Dáil Éireann debate -
Thursday, 6 May 1976

Vol. 290 No. 6

Vote 50: Health (Resumed).

Debate resumed on the following motion:

That a sum not exceeding £249,983,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1976, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants, and certain grants-in-aid.

—(Minister for Health.)

Mr. Hussey

When I reported progress before Question Time I was drawing the attention of the House to the cutback in the services provided by health boards in order to fit within the allocation by the Government. I was highlighting the frustration this cutback was causing not alone to the health boards concerned but also to the general public. I shall relate my remarks to the Western Health Board area where we have a number of institutions which have been unable to open during the current financial year because of the cutback in money. One which immediately springs to mind is the St. Francis Home at Newcastle, County Galway. This home was built at a cost of £180,000, is fully furnished and a matron has been appointed for the past few months. Up to now, because the Minister for Health was not prepared to make the necessary money available to the health board for the running of this home, it has been lying idle even though there is a very great demand for this kind of home in the western region.

I am glad to say that because of the efforts of some local volunteers it has now been found possible to open this home and the official opening is to take place on 29th June. I would like to compliment the people who are volunteering their services free of charge. I wish them every success in their undertaking. It was a cause of great concern to everybody to see this home lying idle with such great need for it. It is hoped before the end of the year that it will be working to full capacity.

We also have a psychiatric unit and an intensive care unit in Galway Regional Hospital. The same position obtains; there is no money available to extend these services. We have a geriatric assessment unit at Merlin Park and a family guidance unit at Salthill which are also affected and, as far as I can see, there is no hope of opening any of these units during the coming financial year. This is a great worry to all of us. The estimates this year for the Western Health Board services amounted to £32 million and the board's allocation is short by about £2.6 million. They must try to work within their allocation and naturally it would not be possible to maintain services provided during 1975 and they have had to start cutting back drastically on those services.

I want to mention the Galway County Association for Mentally Handicapped Children. We appreciate the tremendous work this group are doing for mentally handicapped in our area. The group represents 24 branches throughout the county. They are in a very serious financial position and for the end of the year they have a projected deficit of about £66,457, a very high figure for any organisation to try to meet. They have tried their best to secure funds from voluntary subscribers by organising collections and so on and the Western Health Board made contributions to the association over the past two years. This year the health board, because of the restraint imposed on them, cannot give all the assistance they would like to give and, accordingly, the health board's contribution has been cut back. In 1974 the health board agreed to pay the association £27,000. They actually paid £15,000, a shortfall of £12,000. In 1975, the health board agreed to pay £28,000. They paid £20,000 leaving a shortfall of £8,000, making a total shortfall of £20,000.

It should be the responsibility of the State to provide sufficient money to ensure that handicapped children, the most disadvantaged section of the community, would be provided with adequate care and attention. It is not right that voluntary associations that are doing such great work to help those children and their parents to overcome their terrible cross should be expected to go out to church gates and collect funds to provide services or keep existing services going. It is time the State came to their assistance. I am only speaking of the County Galway association but I would like to list some of the schools for which they are responsible and the number of children for whom they provide care. First, there is St. Joseph's School for Moderately Handicapped Children in Galway, accommodating 75 children. There is the Care and Activity Unit, Galway, for severely handicapped children, where the number cared for is 22. We have St. Dympna's Centre, Portumna, for severely handicapped children, where eight children are accommodated. The Tuam Centre for severely handicapped children has 12 children and St. Joseph's Training Centre, Galway, which provides occupational training for school leavers has 20, making a total of 137 children.

Those people are to be congratulated on the efforts they have made to provide services for those children. They have tried to extend those services to other areas such as Carraroe and Glenamaddy. A deputation from the north-east Galway area which includes Glenamaddy, Mount Bellew and other areas, met departmental officials recently in an effort to get funds to open a school near Kilkerrin, Ballinasloe which has been offered by His Grace, the Archbishop of Tuam. I ask the Minister to take a very sympathetic view of the proposals put before him by the deputation which met his officials some weeks ago and, if possible, ensure that the service sought is provided.

We are fortunate in having so many dedicated and enthusiastic people providing care and treatment for our mentally handicapped but the State should play a greater part in providing money to ensure the efficient running of the services required.

One issue that confronts every public representative whether or not he is a member of a health board is the question of medical cards. In the past few months we have seen efforts made by the board to curtail the number of cards issued. I do not agree with these efforts and I do not agree with the method of assessing people's means in connection with their applications for medical cards. I am not sure if this applies to other areas but we found in the Western Health Board area that farmers have to supply warble fly certificates or blue card certificates to health board officials to show the numbers of stock they have at the time of application. On this basis their entitlement to a medical card is decided. This system is very unfair because there is great variation in the price, the type, the weight and the age of cattle and, to my mind, having to produce warble fly certificates for all stock on a farmer's land at a given time is entirely wrong. This system should be scrapped. Not alone is it encouraging farmers not to have their cattle dressed properly for the elimination of warbles, but because of the variation in prices at different times of the year it is a wrong system for deciding entitlement to a medical card

We know that the loss of a medical card is of great concern to people because of increased hospital charges and the increased cost of drugs. People are worried about the possibility of having to go into hospital and not being able to pay their hospital charges. The amount of social welfare a farmer is in receipt of is taken into consideration in assessing his eligibility for a medical card. Two reasons given for refusing medical cards are social welfare benefits and farm income. Again, this is very unreasonable. There is no point in the Government boasting about the payments they make to social welfare recipients if those social welfare payments are helping to deprive people of medical cards. When a person is entitled to unemployment benefit he should automatically be entitled to a medical card.

Another matter which causes concern is the availability of doctors at weekends. There is no point in the Minister telling this House of the improvement that has taken place in the health service when a sick person cannot get a doctor. We have seen the recent controversy in Dublin over the child who could not get a doctor and was dead on admission to hospital. We could all instance similar cases in our own constituencies of people who had to make four or five calls to try to get doctors to come out during the night. The Department and the health boards may say that doctors have no responsibility other than to people who are the holders of medical cards, but I think there is something radically wrong with our health service when a person cannot be guaranteed the treatment he requires as fast as possible, whether he is a medical card holder or not. We should aim towards that kind of service.

In regard to the availability of doctors at weekends, we should encourage group practice. This has been suggested by other speakers and I have suggested it before when speaking on the Health Estimate. In the west of Ireland, particularly, doctors find it hard to get locums. We realise that doctors cannot be expected to work 24 hours a day, but I think the development of group practice would be an answer to the problem.

One must view with great concern the recent report of the working party on the rising costs of medicines and the pattern of prescribing. One statistic which emerged from that report is that 65 per cent of the total cost of the choice of doctor scheme results from the supply of medicines and appliances. This aspect of the report should be examined very closely to ascertain whether there is overpre-scribing of expensive drugs. How many of those expensive drugs are being used by the patients concerned? Quite an amount of expensive drugs are wasted by patients. It is true to say that expensive drugs are left lying around in many houses. They are useless to the patient and a danger to people who might take them in error. People should be encouraged to return unfinished drugs to a doctor or public health nurse because the cost of drugs is one of the reasons for the cancellation of medical cards. We are slowly creating in Ireland a situation where the cost of being sick is the cause of illness for many. Perhaps there is some merit in the Swedish scheme mentioned by Deputy Dr. O'Connell. Under this scheme essential drugs are free and a contribution is made towards the cost of nonessential drugs.

In conclusion, I should like to ask the Minister to impress on his colleagues the importance of providing an adequate health service for our people. We now know that the health service for 1976 cannot be maintained at the 1975 level. This is to be regretted. The Government must accept responsibility for this situation, which is due to their inability to generate sufficient wealth to enable health boards to provide the service to which the people are entitled. I hope the Minister and his colleagues will do everything possible to provide that the health service is improved as quickly as possible.

Dr. Byrne

I am pleased that the percentage of moneys allocated from the Exchequer is similar to that of last year, giving recognition to the most unusual economic circumstances of the Exchequer at present.

I note the attention the Minister has given to the allocations of money for grants-in-aid. I should like to mention the Cheshire Homes organisation which has made application for grants. I refer particularly to the Cara Cheshire Home in the Phoenix Park. This home, which opened two years ago, depends on a grant from the Department of Health of approximately £100,000. The rest of the money is raised through voluntary channels. The patients are subsidised by the Eastern Health Board by an amount of £3.30 each, the same rate they would receive in a rural Cheshire Home. There are 36 patients there suffering from physical disabilities. Bearing in mind that the criterion for entry to a Cheshire Home is that one must have a physical disability, be poor and be young, certainly under the age of 45, I appeal to the Minister to allay the anxiety being experienced at present by the Cheshire Homes and other voluntary groups. The total amount of money requested by the Cheshire Homes, £76,000, could be provided through grants-in-aid. At present they are not allowed cash any cheques, pay bills or their staff because the banks have foreclosed on their overdraft facilities. The situation is very serious. The patient ratio is one staff member to every patient. I would ask the Minister to pay special attention to this and see if his Department could act swiftly.

One thing that upset me was the way in which the percentage number of medical cards throughout the country has been rising, from over 60 per cent in the north western area to just under 30 per cent in the Eastern Health Board area. When this figure, averaging at 37.8 per cent, reaches 40 per cent of the population, the agreement between the IMU and the IMA must be discussed again. The most pertinent figure I saw was that quoted by a previous Minister for Health, Deputy S. Flanagan, who mentioned that in 1968-69, the last year he held office, it was £26 million and has now escalated to £249 million.

The standard of care at patient level has not to my mind gone up in proportion to the increase in allocation. One of the problems is that some health boards are too large to function efficiently. At one time, one could ring a health board and get an answer but now one can get on to eight officials. It would be no harm if the Minister had a look at what programme managers are doing. This is a new term which was introduced into medicine since the establishment of the health boards. I do not think their function has ever been properly defined. At some time in the future the Department will have to give very serious consideration to the division of the Eastern Health Board—the largest health board in Europe. It attempts to cater for people living in high rise flats and people in the Wicklow Mountains and on the farms of Kildare. To my mind the combination of Wicklow, Kildare and Dublin is not logical. I suggest that at some stage the Department will have to start dismantling the Eastern Health Board.

I have tremendous admiration for the officials of that board who are trying so hard to make it work. When one looks at the budget one sees an enormous expansion in bureaucracy, the vulture that is feeding on the money needed for improved care. Other health boards have a more practical ratio and would not all need to be disbanded. The Eastern Health Board will have to be examined and, having proved that it is ill, treatment will have to be prescribed. In this case, treatment would be a form of amputation, dividing the board into at least two sections, one for the greater Dublin area and another for Kildare and Wicklow.

The Central Remedial Clinic has done and is doing tremendous work. It is, I believe, amalgamating with the Mater Hospital whose funds have also dried up. One never likes to see an independent functioning unit being slowly taken over by another body. One must have tremendous admiration for the lady in charge, Lady Goulding, and her committee for the wonderful work they have done for the clinic. The Mater Hospital will be combined with Jervis Street and the Richmond Hospitals. Once again the Minister may be moving into an area of great bureaucracy. There is an optimum number of hospital beds at which a hospital can run efficiently to the benefit of their patients but when the number of beds is too large human and clerical errors can occur.

I would like the Minister to have another look at the projected expansion of population in the Dublin north city area and to give consideration to the erection of a hospital on the land he owns under the 1943 St. Laurence's Hospital Act—and at Cabra Cross. This land was originally purchased for the erection of a new St. Laurence's Hospital which was to take in the Richmond. Whitworth and Hardwicke units. Unfortunately, that hospital was never built. The board exist under the Minister's appointment and they run the Richmond, Whitworth and Hardwicke complex for the Minister.

In the future projected hospital service we should give consideration to what have come to be called "pay beds", that is, a British term for private beds. There are two aspects of this: first, if a person is paying for himself, has invested in a health policy or voluntary health insurance and wishes to pay for himself, that can be embarrassing in a ward of six or eight people who need special food. Small wards of the four to six variety should be built where private and semi-private patients can go if they have the money to pay for it. At present a bed in St. Vincent's Private Hospital costs £20 per day, and this is an indication of the escalation of health costs.

One other aspect of the Minister's proposed hospital services is that there should be introduced in hospital budgeting a system whereby outpatients' costs and expenditure on outpatients for X-rays, blood tests, and so on, would be isolated from the capitation costs in the hospital. As I understand it, the total cost of running a hospital is divided by the total number of beds. There is no provision for taking the out-patients' costs into account, and these are added to the bed costs for accountancy purposes.

I should like to refer to the directive which was issued recently regarding the withdrawal of free transport for patients. Recently doctors in the Eastern Health Board area were given approximately two week's notice in a letter accompanied by a small display card to be put in the surgery to tell patients that from 1st April onwards they could not order taxis or ambulances, the taxi being an auxiliary ambulance when no ambulance was available. This has caused much confusion. This was unacceptable as the notice was very short notice. Furthermore if a patient is sick he has to be taken to hospital, and though the directive was clearly set out in English, it still was not workable under any Act, least of all the last Act under which the health boards would be obliged to look after the health of those people in the health board area.

Some very interesting figures can be obtained in respect of the cost of the general medical service. The Minister and his Department are extremely fortunate in that at least an accurate visiting rate and an accurate patient demand based on a one-month restriction can be obtained. He is the only Minister in these islands who can obtain that figure now for 37 per cent of the total population. This gives a tremendous amount of information to the Medical Research Board as regards the morbidity throughout the community, as regards the type of drugs prescribed, the type of illnesses that occur. Provision could be made under the GMS—it would take some specially trained staff—for a symbolised index of illnesses, which would relate back to the number of people who suffered from heart disease, arthritis, lung disease and other system-type illnesses. In this matter I would encourage the Minister as much as possible, knowing that he of all the Ministers throughout the world has the best facilities with which this can be done.

Allowing for statistical inaccuracy, you could have a breakdown of figures for 37 per cent of the population. Even take the visitation rates for doctors. The British can only estimate; the Minister can be exact. The British rate of 4.5 per year is only an estimated rate based on what the general practitioners would have thought the visiting rate was. On a fee per item basis, the Minister has an exact figure that cannot be contradicted. He will have to make allowances for what is to my mind one of the greatest flaws in the choice of doctor system, that is the amount of the prescription. One school of thought, quite correctly I think, has advised that prescriptions should not be given for too many drugs at the one time. However, it is wrong that a patient suffering from a long-term illness such as epilepsy should have to return once every month for the rest of his life to obtain a prescription which the doctor of a private patient can give for a year. This is adding extra cost to the service. We are speaking here on this Estimate of a sum of £250 million, but if we must keep a close eve on the pennies as well as on the millions of pounds, this is one way of doing it. The Minister should negotiate with the chemists to get some form of repeatable prescriptions for GPs. These patients should not have to make 12 visits a year, as distinct from the 4.5 that was projected for the service, without being sick, to get tablets repeated on prescription.

Another matter which has seldom been referred to by the Department of Health is the loss arising from the two-tier price system in the changeover from the dispensary service to the choice of doctor scheme which came in in April, 1972, under the Eastern Health Board. This two-tier price system is something the Department should re-examine. They should try to buy in bulk and distribute to the health boards and let the health boards distribute to the chemists.

When one bears in mind that in these islands the average expenditure of a drug company on each general practitioner is £35,000 just for advertising and drugs promotion, the total expenditure can be visualised. This figure was arrived at by a subcommittee of the Labour Party in the House of Commons in Westminster about six months ago, and a further committee will be set up to see the justification of the cost of drugs. As the Minister realises, one drug will cost so much but another drug with practically the same strength and composition could cost double or treble that. It is purely a promotional section of business. Admittedly many of the drug companies, not them all, put plenty of money into research of such a standard that could not be financed at State level.

However, I would urge the Minister to extend the free drug system to the whole population because at present a person who spends more than £3.50 per month on drugs can have 50 per cent of that returned up to £5, and 100 per cent returned above £5 for each month. This works out at an average of 15p per day. That is not a great deal. If such people pay tax and if they spend more than £50 on medicines in the one year, they can put that down against their tax. It is not a huge figure for any one to have to pay, but, because of the cost of administering that I would suggest to the Minister that he should form a national drugs pool so that 20 of the most commonly used essential drugs would be purchased by the Department. It might be asked: how can you do this? How would you know how many you would need? Under the new system of prescriptions being programmed and computerised, it is possible for the Minister to find the number of penicillin tablets that were prescribed last year. In this way it would be quite simple to say we would need approximately that number of penicillin tablets for the next 12 months. It is a very simple figure to get, and the same can be done for any other drugs.

We had a saga regarding the nylon stockings. The Department could come out quite simply to say so many pairs of nylon stockings were prescribed. If it can be done with nylon stockings it can be done with penicillin and with any other drug that is necessary because all these drugs are coded, and the code going on to the prescription, they are codable and information is available in exact terms and not in any projected terms. I would urge the Minister to investigate this.

One other aspect of the GMS is that some of the drugs are available on prescription. Since I came into this House I have always, as a practitioner in the health services, argued against some drugs being available. For example Dettol is not a medical compound. I have never seen it used apart from washing floors and maybe for an odd cut or wound. There is no reason why, for a bottle of Dettol which can cost 50p in a supermarket, the eastern health board should have to pay a GP £1.35p to write a prescription and the chemist another £1 to fill it. This applies to Dettol, hair shampoo, sun tan lotion, certain toothpastes and also to baby cream and baby powder. These are items which, if the Minister and the health boards think them necessary for hygiene or whatever reason medically, should be given out by a public health nurse. Do not be taking up the GP's time and the chemists' time by having this system abused in an objective and subjective fashion. A person queues up, taking up the time and taking up the recorder, and everyone, at a cost of much more than the £2.35. These could easily be given out by a public health nurse in the same way as Ostermilk and baby milk are given out in the clinics. It was possible at one stage to write a prescription for Ostermilk and baby milk, but that was during the milk strike. It should not be necessary, if a health board say a person is entitled to free Dettol, for the doctor to be brought into that transaction. Let the health board give the patient the Dettol. The same applies to hair shampoo. These are things that can be used regularly. They are consumable and do not relate in any way to health improvement. For many other things such as calamine lotion and calamine powder there is no need for a doctor to be brought in. This is one of the reasons why the cost of the choice of doctor service has gone up. One other aspect, is that a GMS doctor in any health board area cannot refuse to see a patient if a patient calls. He can refuse to see a private patient but not a GMS card-holding patient, nor can he refuse to go on a house call to that patient. If that patient rings up the doctor cannot say : "I do not think your call is justified". He cannot refuse. He is obliged by the contract between himself and the health board for 365 days in the year, 24 hours a day, to look after and to provide medical services for that patient.

If the doctor does that then I contend that for each service the doctor gives the health board should be obliged to refund him. Recently I heard of a case of a doctor who had a very low house-visiting rate and yet the health board were inclined to say it was too low, and because it was too low it needed investigation, and the percentage of night calls to day calls was different from that of others. He lost quite a lot of remuneration over it, nearly 25 per cent. This should not go on. I have great sympathy with the previous Deputy who mentioned week-end cover and medical cover.

I would like to see the Minister, the Irish Medical Association and the Irish Medical Union getting together to see that this situation is improved. Suggestions have been made to follow the Swedish, German and French system of pool doctor, but we should have a look to see what we need, where we need it, and what we can do. There is no point in trying to start a group practice on Achill Island or certain parts of the western seaboard where there is the lowest percentage of doctors in Europe, apart from Lapland. This should be borne in mind when we consider the number of doctors we produce and the number who emigrate. Perhaps a greater incentive or an educational grant in return for three years' service in the western seaboard area would be guaranteed.

I refer to the availability of doctors entering the choice of doctor system. If a doctor is qualified to be registered and to see private patients he should be given a chance of entering the choice of doctor system. The restrictions at present are a little harsh, although the Minister did effect some improvement in them.

I would like to refer to the abuse of drugs and to ask the Minister to try to strengthen the powers of the National Drugs Advisory Board and also to have another look at and try to reactivate the Poisons Board and possibly amalgamate the two boards. The Minister will find very good, expert consultation made available to him by those who are interested in that section.

It is vitally important that we have information rapidly available regarding the introduction of new medicines on to the general medical scene. The Minister has introduced legislation in special committee in the Dáil regarding the abuse of drugs. This legislation will certainly be an improvement on the previous legislation. I think the Minister is doing a very good job. The Bill might need to be strengthened a little and not too much liberty be allowed for the perpetual, repetitive abuser. If the Minister wants to compare, I came across recently in the Channel Islands, a health system where everybody was treated and if one had not got the money to pay and could not afford to pay a general practitioner, the bill was sent to the local town hall. This is something the Minister should possibly consider in that grey section of our population who are not covered by medical card and who run out of money during the week and cannot pay a doctor. They are probably the greatest section of the community that are deprived in regard to health services. They wait too long because the money is not there.

One of the biggest problems in the practice of medicine nowadays is the cost of drugs to the patient. With the private patient one has to look up a book to see which is the cheapest drug to make sure that patients do in fact get it. They may endanger themselves by not getting it.

The Minister and his Department have made great strides, in some directions far too great and bureaucratic—I mentioned the Eastern Health Board—but they have made tremendous strides in technically alleviating the hardship for the provision of general practitioner services, but not everybody knows that the special free drugs relief system is available to all. I would be surprised if very many claimed.

I should like to give all the praise possible to the nursing profession and the para-medical professions, the technicians and those who work behind the scenes in hospitals. They are totally dedicated and they are doing great work, sometimes under harsh conditions. Sometimes they do work which many other ladies would not be allowed do by organisations. I should also like to compliment the orders and groups who have provided so often the money necessary for the building of homes and the provision of equipment. It is sad to see that the Minister's own hospital, St. Laurence's Hospital—the only hospital in the country for which he has direct responsibility—is being deprived still of the new X-Ray machine for diagnostic purposes. This machine which would cost £250,000 would re-volutionise diagnostic procedures in the field of neurology as it has done in other countries. I am surprised that the hospital is still without that most revolutionary piece of equipment for the sake of that small amount of money. It is said to be the greatest step forward ever taken in diagnostic medicine since the invention of the X-Ray. I should also like to give due cognisance to the work done by the staff of the Irish Hospitals Sweepstake, for the fund-raising which they have done and the relief the moneys they provided in the past for many hospitals. I should like to plead with the Minister to give as much consideration as possible towards the Cheshire Homes which are in terrible trouble. Those homes provide an excellent service and I make a special plea to the Minister to help them out financially. I know that if the money was easily available the Minister would have no hesitation in making it available.

Mr. Leonard

The Minister, and Government Deputies, in the course of the debate spoke about possible alterations in the structure of health boards but we must be realistic about this matter. The defects in the health services at present are practically all related to a shortage of money. It is my view that this sudden interest in considering how health boards could be restructured is, to some extent, a red herring to divert attention from the restrictions in the service. The Minister said it was only to be expected that the general economic climate brings in its wake tensions and frustrations over and above the normal and I agree with that statement. There is a great sense of frustration about the hospital service at present and this is not due to the economic crisis but to the cutbacks. The Minister should agree that cutbacks have taken place. The best way to deal with that type of frustration is to be frank about it.

Cutbacks were also experienced in the North Eastern Health Board in 1975. That board in 1975 prepared a five-year priority ranking plan which it was estimated would cost more than £5 million. The plan provided for rewiring, the provision of fire escapes, lifts, and other emergency measures. At the last meeting of that board the cost of providing those emergency services —one of them was a fire escape at Monaghan County Hospital—had to be met out of funds secured by the sale of surplus property of the board. The cost was met out of the sale of dispensaries, the sale of land purchased by the joint Cavan-Monaghan Mental Health Committee when they had charge of St. Davnets Hospital. It is a serious situation when such a board must depend on the sale of that type of property to finance projects which are essential.

The Minister asked us to note that the health share of overall non-capital Exchequer allocation was not less than 1975, a statement which is typical of the whole approach of the Government to health. The Minister should have told the people that the non-capital allocation to the health boards in 1976 would be substantially less in real terms than it was in 1975. Allowing for inflation, the amount being allocated is not adequate. We have heard of restrictions in the scheme for the transport of people to institutions and I have found in my area a peculiar situation in relation to the payment of disabled person's maintenance allowances. That allowance is available to those who had no stamp record and were unable to avail of unemployment benefit or assistance or disability benefit. Their only allowance was the disabled person's maintenance allowance but, in line with the small increase in benefit granted on 1st April, the health boards re-examined the incomes of people in receipt of those allowances. In many cases the increase amounted to about 5p per week.

In many cases the increase was not given while others discovered that their allowance was discontinued. If money is scarce and health boards must revise their budgets, they should first look at other areas such as consultants' fees. Any normal person would be inclined to use the knife in other areas before he would touch the disabled person's maintenance allowance which is the easiest one to chop. I know of a man who was in receipt of that allowance, and whose wife, who also had to look after their three children, worked their 32 acre farm. They were in receipt of £11.16 per fortnight. On 1st April, 1976 that disabled person's maintenance allowance was discontinued. I intend to ensure that at least people will be given an indication in advance before that sort of thing can happen. That man's income from his farm was estimated at £24 per week and that was related to what he would receive if he was in receipt of social welfare benefit for himself, his wife and three children. That was in the region of £22.

In a case where there is a wife attending a completely disabled husband her family and a farm the Minister should recognise the need for additional funds. The Minister should examine this situation and tell health boards to have another look at it, especially those cases who are hard hit in their income because of this reduction in the disabled person's maintenance allowance. This brings to memory the time of another Government in this country who when faced with cash restrictions curtailed the old age pensioners. I hope this is not the beginning of the curtailment of incomes of people who are least able to stand against that type of operation.

In one paragraph in the Minister's speech, in Volume 290, column 355 of the Official Report, the Minister deals with the hospital provision for the North Eastern Health Board area. The short skimped way in which the Minister dealt with this is typical of the Minister's approach to the problem. What he said was:

In the north-east, the health board have designated Cavan Hospital as their priority. Discussions have been held with officials of the health board on the catchment area for the new hospital and on the number of departments and beds which would be needed to serve the projected population of that catchment area. Since the general hospital plan was produced on 22nd October, 1975, the Minister has caused frustration, fear and alarm by his indication that Monaghan County Hospital is to be downgraded to the role of a community hospital. The people in that area have been protesting since then. They have appealed to their advisory health committee and through the county council. An appeal was made in December to the North Eastern Health Board, because the Minister had claimed that the health board had made the decision. They had made a very hurried decision but when members of the health board, the advisory committee and the public representatives of Monaghan met the health board in December and made a case they admitted that they had made a mistake and recommended to the Minister that Monaghan hospital should not be downgraded. The Northern Standard which is the local newspaper, initiated a campaign to save the hospital. They inserted an advertisement which appeared weekly under the caption “Help to save our Hospital”.

That advertisement said that, in common with the vast majority of the people of this county, the Northern Standard was opposed to the downgrading of Monaghan County Hospital. The combined efforts of the public through their elected representatives could advert this retrograde step. People could help by signing an attached petition and sending it to their TD or local representative or alternatively sending it to the Northern Standard offices, The Diamond, Monaghan. Support for and co-operation with the TDs would strengthen the case when the matter was raised in the Dáil.

On 21st December the Hospital Retention Committee sent 4,779 "save our hospital" signatures, to the three TDs for that area to present to the Minister for Health. When the hospital Retention Committee met the health board and when the health board unanimously agreed to ask the Minister to change his decision to downgrade Monaghan County Hospital we advised them that it would be better to give the Minister an opportunity to examine the case. At that stage the retention committee discontinued their campaign. However, since then many thousands of signatures have come in. All these signatures give an indication of the concern of the Monaghan people in relation to the downgrading of their hospital. Over the years a large part of the cost of hospitals and health services was borne by the ratepayers. The people of Monaghan made certain to maintain and develop their hospital. They were willing to pay extra to maintain and extend the facilities in Monaghan. That development continued until it was the second largest county hospital in the country. I would have expected that the Minister for Health would have shown some appreciation of what had been done. He has shown no appreciation. In that area at that time there were discussions in terms of the Fitzgerald Report, in terms of four regional hospitals and 12 general hospitals but, on 22nd October, 1975, the Minister changed that to 23 and we felt that to victimise four hospitals was very unfair. The wish of the people to retain this hospital has been put to the Minister by the three TDs for the area, by trade unions, by voluntary organisations and by three separate deputations.

Recently the figures produced at an estimates meeting of the North Eastern Health Board give an indication of how efficiently the hospital is run in regard to maintenance. The figure given per bed patient in respect of lighting and heating was the lowest for any hospital in that health board area. While this is a different matter from that of the cost factor for medical attention, it indicates the efficient lines on which the hospital is run. The figure given was only a little more than half that of another hospital, the status of which is being upgraded and not downgraded as is the case in respect of the hospital I am talking of. Since the whole curtailment in the health services is based on cost factors it is no harm to bring in the question of efficiency when there is talk of downgrading.

In December, 1973, when the decision in regard to the hospital was taken, the chairman of the North Eastern Health Board was asked to request the Minister to state clearly the role of county hospitals in the area which would not be developed into general hospitals. Monaghan and Navan were mentioned specifically in this regard. At the end of 1975 there was circulated a discussion document on the role of smaller hospitals. The Minister had from 1973 to late 1975 to discuss the question with the interested bodies. But in his speech here he could not have been more vague when he said that there has been a certain amount of misunderstanding as to the precise role of these hospitals. He went on to tell us that on a number of occasions here he had spelled out in some detail the probable functions of community hospitals. He told us that the part which they will play is not yet appreciated fully and he went on to give us a general outline of the service which, as he said, will probably be available at these hospitals. There is the continual use of the word "probable", whereas if he had consulted in 1973 with the medical association and with the health boards he would be in a position to give us something definite in that regard.

I do not propose to repeat all that has been said in regard to Monaghan hospital, but there are a few matters I should like to bring to the Minister's attention. This hospital, with 174 beds, is the second largest in the country. We have been hearing a lot about the 30-mile radius. This yardstick was used when it was found suitable to use it, but it was ignored in other cases, such as in Monaghan. A radius cannot be measured as the crow flies in those areas because the territory is made up of winding roads. A journey from north Monaghan to either Dundalk or Cavan entails going through portion of Northern Ireland, through south Armagh in travelling to Dundalk and through south Fermanagh in travelling to Cavan.

There are 15,000 people in north Monaghan who, because they are outside the 30 mile radius from Cavan, are not getting any cover. The northern part of Monaghan is 45 miles from Caven, 50 miles from Dundalk and 76 miles from Drogheda. Another aspect of this is that the route involved is the national primary road on which there is very heavy traffic. In the 11 months to September, 1975, there were recorded 53,746 crossings of heavy vehicular traffic at the Border. That is an indication of the volume of traffic on this route.

A large Army barracks is in the course of completion in the area and this is expected to result in an influx eventually of 1,000 people to that area. I trust that the Minister for Defence, in his concern for the Army personnel, will impress on the Minister for Health the need to retain general hospital services in the area. In the case of Monaghan all this requires is the provision of four additional professional personnel—a surgeon, physician, obstetrician— gynaecologist and an anaesthetist. The provision of this extra staff would be sufficient to render the hospital as fit as any other general hospital to deal with the normal run of cases. Not only does this area require and deserve the retention of this hospital, but by virtue of its location and the inherent dangers of living in a Border area, it is entitled to an expansion rather than a downgrading.

A matter of considerable annoyance is the question of the placement of mentally handicapped children. In this regard I asked the Minister on the 11th of February last the number of mentally retarded children awaiting accommodation in institutions and the proposals he had to provide accommodation for those children with particular reference to the North Eastern Health Board area. His reply was:

In the country as a whole there are approximately 580 children awaiting placement in special residential centres for mentally handicapped children.

This is a serious problem. A number of those children in County Monaghan have reached the stage where they require attention which their parents are unable to give them. They are a real problem for mothers who have to attend to other small children. These people come to members of the health boards and public representatives appealing for something to be done. I have raised this matter with the health board. I realise it is a problem. Some accommodation should be found for them in psychiatric hospitals and former TB hospitals. There is a reduction in the number of psychiatric patients.

There should be some suitable accommodation in the health board areas for these children because children who are mentally handicapped create a real problem. The Parliamentary Secretary should keep that in mind. The building of extensive accommodation for them is not on at present. The total number in the North Eastern Health Board area is 65. When we consider the problem these children are to their parents and other members of the family we realise that they should be accommodated as a matter of urgency. In some places, day centres and day care are provided.

One of the main criticisms made by visitors is the poor level of hygiene particularly with regard to the handling and preparation of food. This criticism has been accepted as being soundly based by various bodies involved in the tourist industry. The best approach to that problem is education, but more could be done to implement the regulations on hygiene. This should be more actively pursued if we are to develop our tourist industry. We will have to reach higher hygiene standards if we want to compete with the other countries in Europe.

The premises used by the health boards should be properly maintained and serviced and properly heated and decorated. Many of the buildings owned by the health boards are from 100 to 150 years old. Buildings which might have been acceptable then are not acceptable now. Even though funds are scarce these buildings must be maintained.

Another matter which seems to be getting the headlines now is the harmful effects of smoking. This has been well established for some years. As time passes, more evidence becomes available of the injury to health caused by smoking. I read lately that an eminent authority on cancer said 80 per cent of cancer was caused by smoking. The Department of Health have been making efforts to get this message across to the public, but more could be done to alert our youth to the dangers of smoking. I do not like to talk in terms of banning smoking, but effective measures will have to be taken to make our young people realise the dangers to their health. I should like to mention a number of other matters but Deputy Callanan has waited very patiently and I should like to give way to him.

Mr. Callanan

I want to start off by making a statement which may be unique. When an Estimate is introduced it is expected that the Government side will praise it and the Opposition will condemn it. I would be the first to say fair enough to that if we had a statement from the Minister which was correct and if he said: "I have got no money". The Minister said he intends to maintain the health services at the 1975 level. All Members of the House realise that is not on. I sympathise with the Minister and the Parliamentary Secretary but we cannot maintain the health services and we are trying to say we can.

The health boards had to bring their officials together. The hatchet will be brought down on the poorer sections of the community. To me it is terrible to have to say this has to be done. We will not admit it, and that is what is wrong. If I were Minister for Health I would say: "I have not got the money. I have to do it". I would issue an order that the poorer sections of the community should not get the hatchet. In the Western Health Board the poorer sections of the community had to get the hatchet. This affects home care, disabled person's maintenance, mentally handicapped children.

The voluntary organisations are doing very good work, as was pointed out by another Deputy. We all got circulars from them stating that they will hardly be able to survive. They were supposed to get a certain amount of money from the Western Health Board but they did not get it through no fault of the board but because they have not got it. You cannot draw blood from a turnip and I cannot see how health boards can maintain existing services when their estimates are being cut. For instance, the estimate of the Western Health Board this year was cut by £½ million. It is well known that I did not agree with the setting up of the health boards but I admit that their officials do a careful job and that they will find it impossible to maintain existing services on their restricted finances. Apart from that, they are supposed to staff and maintain all these new hospitals and homes about which we heard so much today. I would be astonished if they were able to do so.

The Minister spoke about the desirability of keeping as many people as possible out of hospital. I agree with him entirely. But I would point out to his Parliamentary Secretary in his absence that unless substantial sums are paid to the people who care for old people in their homes many hospital beds will still be occupied by such people and genuine cases will be unable to gain admission. It is ridiculous that a non-relative will get an in-care allowance but a relative will not if there are more in the household than the person caring for the in-care patient. I know of a case where a girl returned from England, where she was working, to look after her father but because there was a brother in the household—he was away working most of the time—she did not qualify for the allowance.

If the Minister is serious in trying to encourage old people to stay out of hospitals he will seriously have to consider not only increasing the in-care allowance substantially but easing the conditions in which it is paid. There are many old people in hospitals—I have experience of St. Brendan's in Loughrea which used to be called the County Home—who would much prefer to be cared for in the homes where they had lived most of their lives, but without proper in-care allowances this is not possible and consequently, as I have said, genuine cases who need hospital beds will be unable to get them. The lack of proper provision for caring for old people in their homes is a big cause of those people being in hospital.

I would take a gamble. I would make a substantial increase in in-care allowances and take the chance that this would mean that many people now occupying hospital beds unnecessarily would leave hospitals and return to the homes where they had spent their lives. I would get rid of the condition in regard to relatives and the numbers in the households. Naturally, I would see to it that there would be social workers to supervise the care of old people in their homes to ensure that proper care was being given to them. Then there would be numerous beds available in our hospitals and other health institutions where genuinely ill persons, now deprived of hospital accommodation, could be treated.

The question of home care is not mentioned in the Minister's brief this year. Indeed there is very little forward thinking in that brief. Another point I should like to make forcibly is this—it is only 12 months ago since Deputy Haughey spelled out here what would be our policy with regard to people eligible for medical cards, people who should be in the middle income group. We believed then, and still believe, that we cannot afford to have a free-for-all, much as we would all like to have it. There is not sufficient money in the State for its provision. Deputy Haughey suggested at that time that the income limit for medical card eligibility should be raised. I think the figure he mentioned was an income of £40 or thereabouts, which would bring more people into the middle income group.

This may be wrong coming from me and be regarded as a left wing opinion, but we must remember that private hospitals are doing a tremendous job. If we do not get people who can afford it into private hospitals, we will be putting them all back as a burden on the State. I do not think we have the resources to do so. Even if one could achieve that goal, one would still not be providing as good a service for the people who cannot afford it. and for whom it is the responsibility of the State to provide. That is where an adequate service is required. However, I am astonished to discover that, as a result of shortage of money, instead of raising the income limit of the people who should come into the free service bracket, health cards are being taken from them. At present the income eligibility for a medical card is approximately £28 for a married man. An old age pension at present amounts to approximately £10 and, in order to get that, one cannot have an income of more than £6. But a married couple can have an income of £12. If one adds that to the old age pension, one is over the income limit for a medical card. There is something wrong there. I heard recently that a single person— who could not have been above the income limit—was refused a medical card. The single person's income limit is £19. A single person's old age pension would amount to £10 and, if one adds £6, one still arrives at a figure of £16 only, which is well below the limit. I cannot prove that case because it was related to me and I asked the councillor in question to let me have proof.

That is why I say the guidelines are unrealistic. I remember pressing for a £35 guideline and as far as I remember Deputy Haughey was seeking a figure of £40, which we did not get. There seems to be a difference between the way a pensions officer assesses means for an old age pension and the way the health boards assess means for medical cards. There should be some kind of uniform assessment. The same assessment of means should be placed against a person entitled to an old age pension as is placed against him for medical cards, which is not the case at present. I raised the matter here.

I had a question down to the Minister for Agriculture and Fisheries at one time on this question of looking for blue cards and warble fly certificates for small farmers. The Minister agreed with my contention then. I put a question down then to the Minister for Health. He said he was not aware of it. But this system is still being operated in the Western Health Board. One may be achieving the eradication of disease in one area—it may be only animal health but it is very important to human beings—such as the eradication of the warble fly in cattle. If a man applies for a medical card, he will dress only the cattle he is going to sell if he thinks he will be deprived of his card. Therefore, he will probably keep back cattle and, in that way, it is an interference with the eradication of disease. However, that is still being done. The question arises also that the home assistance officer would need to be a terrific judge of cattle, unless he ascertained how often they had been tested. One would need to understand the value of a cow, and there is a vast difference between the value of a cow and a calf. I do not believe any home assistance officer could be qualified to assess income in that way. That should not be a means of assessing the income of small farmers. It is something we have been fighting for a long time in the Western Health Board.

At present—particularly in the Western Health Board—a review is taking place. Social welfare exists for the benefit of keeping people at a certain standard of living which is the minimum but because social welfare has to be raised to bring them up to that minimum standard, it may be the cause of excluding them from eligibility for a medical card. When one complains about this to a health board the answer one is given is: "The number of medical cards has increased enormously in our board". The answer to that is a simple one, it is because young people over 16 who formerly did not bother applying for medical cards—and who are now entitled to them are so applying. That is what has occasioned the increased. There has been a decrease in the number of workers and small farmers but a huge increase in the number of young applicants. There was a time when we did not have that number of young people unemployed in the west—a lot of them had gone east to take up clerical jobs—but they are now at home and are holders of medical cards. Therefore, that is an unrealistic figure to quote. Though it may be correct the reason that increase has taken place is because of the huge rise in the number of young people in those areas who did not apply heretofore.

I heard recently also of another case about the lower income group— a group nobody seems to look after at all—which astonished me. There are people paid by the various health boards—dispensary card-takers and so on—as low a figure as £50 a quarter. These people have no union or anybody to look after them. Sometimes they are not paid for a fortnight after a quarter has expired. That is a terrible state of affairs for these people. I heard of yet another case the other day which opened my eyes, of a person receiving social welfare who did not understand the position about obtaining a tax-free allowance. Of that person's income of £50, £14 was deducted. I told that person he should not be paying it. When I telephoned the health board they said "It is not our job. Why did the person not send in a tax-free allowance certificate?" That person did not understand the law. That is why I contend that it is the underprivileged person who is being hardest hit. I want to mention also the question— raised here already by Deputy Hussey —of the mentally handicapped.

Debate adjourned.