When speaking last week I mentioned the stress on individuals of the cost of drugs and medicines and their claims on the whole of the health service. With modern living stress becomes greater and the expense of curing or curbing that stress becomes all the greater, involving an additional drain on the health services. If, in the field of preventive treatment we could reduce the cost and, at the same time the health of the patient, that would be a very worthy ideal to pursue. I wonder if the Minister has thought of the cost of drugs to those people who do not have medical cards. Could the Minister evolve some system under which the whole of the pharmaceutical trade might engage in bulk buying from manufacturers, when the ordinary chemist shops could sell such drugs and medicines bought direct from the manufacturers at bulk prices, in that way helping to reduce their cost. I am convinced that the cost of the ordinary proprietary drugs and medicines means that people who suffer stress deny themselves treatment because they cannot afford to pay. To emphasise the point I have here a container with 50 tablets many people use. In a centre city shop I bought this container for 45 pence. In the south east suburbs where I live exactly the same tablets were bought by another person for 34 pence. Surely there is something wrong when, in a matter of one and a half miles, the cost of tablets varies as much as 11 pence for 50. They were not bought the same day. In fact, the dearer container was bought less than a fortnight after the first. Even with the present rate of inflation surely 11 pence on 34 pence is far too much. The Minister might well consider what he might do to control that type of thing. I will give him the full details of the two shops involved. The cheaper container was bought from my own chemist, who sells things reasonably enough.
Vote 50: Health (Resumed).
There is a convention that names of persons or, indeed, firms are not mentioned, nor should they be mentioned in such a manner as to be identifiable.
I am taking care not to mention any names. However, I can give the Minister the full details if he feels he can do anything about the matter.
The point I am stressing is that the cost of medicines and drugs constitutes an added health hazard for people who need them and that we should consider bulk buying from manufacturers in order to reduce their cost. The tablets about which I speak were manufactured in England but that should not prevent us doing a deal with a manufacturer through some central agency and then allowing the chemist arrange the retail channelling. I do not want to interfere whatsoever with the legitimate trading of chemists. We should let them conduct the retail distribution. But, when a chemist has to buy in small quantities, no doubt the price is higher.
Let me pass now to another problem which increases in gravity practically every week. I refer to our old people. I appreciate what is being done at present and I appreciate also that there is a shortage of money. However, I do suggest that we might have smaller homes for old people because it is, indeed, sad to visit some of the larger geriatric units of some hospitals and see so many old people there. I do feel that so many of them in one ward is not good. Today, when so much emphasis is being laid on local communities, we could have more local community homes in our suburbs. We should buy old houses in such suburbs and set them up as homes for the aged of those areas, encouraging the local people to take such homes to their hearts. The local people could then visit the old in such homes, undertake small jobs for them, making the old people feel they are still part of the community. They should not be cast into homes until such time as God calls them. We have got to show that we do care about these old people. In many cases it is far too easy just to put people away and forget about them. But, if such homes were located in the heart of local communities, they could not be forgotten about because their very existence would bring home to the local people that in there were some of their senior citizens and that they had an obligation to join with the State in ensuring that such people received the best possible treatment.
I mentioned the shortage of money and one has got to face the fact that it is scarce. I understand that the Cheshire Homes which do such great work—and there are quite a few of them throughout the country now— were paid certain capitation grants. They now find that that is not the best method of financing the homes. They would like the Minister to look at the debt on them and to give a subvention more in keeping with the size of the debt, because with the rate of inflation it is very hard to control an institution whether it be a home for handicapped people, a training hospital or a Cheshire Home for disabled people. We must ensure that the work in the Cheshire Homes is not inhibited in any way. If we have to make economies we should make them elsewhere. We should ensure that the dedicated people who run those Cheshire Homes are able to continue their work. We should show them that we are very conscious of the great work being done in those homes. The suffering of those people inspired the founder of the homes to establish them in many countries. The State, with the help of the community, should ensure that those homes can expand all the time until we reach the stage that any disabled person will be sure, if his domestic circumstances do not allow him to stay at home any longer, that he has a place in one of the Cheshire Homes or some other home like that where he will receive the best possible treatment. If there are sufficient places in such homes and they have no financial worries those disabled people will not have the nagging fear that the future of those homes is not safe and that they may have to return home again to less prepared circumstances.
In relation to general hospitals, I briefly mentioned the last day the delays in admittance to hospitals. The Minister reminded me of the people waiting for hip operations. More and more people are attracted to have this treatment because our surgeons have perfected this operation. Last week I mentioned a well-known footballer in the city who played with the leading teams and was a brilliant footballer. I met him recently and he could hardly walk even though he is a comparatively young man. He is waiting admittance to one of the hospitals which carry out this operation. He asked me if I could do anything to get him into hospital. He said he was almost useless as he tried to hobble around. When I inquired on his behalf the hospital told me the position. I sympathise with them. This man knows that he will eventually be taken into hospital. I know they will do a good job on him, but it is a very long waiting period. The man cannot work and he, like many others in the same position, is suffering great mental stress.
People awaiting eye surgery have to wait for very long periods before they can be admitted to hospital. This generally affects people in the older age groups. When those people go to eye surgeons they are told: "You have to have surgery. We cannot take you in yet. Even if your eyes were in the condition we want them in to operate we could not take you in." Those people cannot read and cannot look at television. They suffer great mental stress by having to wait day after day until some morning a letter arrives asking them to go into hospital that afternoon. We should inquire how we can shorten the waiting time for people who have to go into hospital for specialised operations. The suffering of those patients must be our primary concern but there is also the cost to the State of those people who cannot work because of their disability while awaiting operations. They become almost a burden on the State. If the admissions could be speeded up those people could return to perfect health because they would have excellent treatment from the nurses and the staff generally in those hospitals.
When the Minister is replying I would like him to tell us when he intends to extend the school health examinations. They should include every child going to school whether he is in the primary, secondary or comprehensive school. We should start at the earliest possible age. Many a child has been saved from needing even greater treatment because in the school examination the doctor suspected some ailment and was able to get the parents to bring the child for treatment. In many cases the small minor operation or treatment has obviated years of treatment the child might have had to suffer later on.
Our school health examination service is understaffed. I do not know how many times a school is visited in a cycle of seven years. I imagine it is not very often. The school population changes every year so we can well see how fortunate were the children who were at school on the day the medical team came. Even though it may have been bad news for parents to hear that their sons or daughters had some ailment they were very thankful afterwards when their children received treatment and were cured. But what about the thousands of other children who did not have the examination and who continued growing with their ailments also growing? I know of a girl who had some spinal trouble which was spotted at the examination. She received treatment and she is practically 100 per cent fit again. If the people who detected this ailment had not done so that child could have suffered irreparable damage to her spine and perhaps be almost a cripple for the remainder of her life.
The same also applies to dental inspection in schools. The Minister will admit that things are not very good in the field of dentistry. I do not suggest there is any simple solution to the matter and I do not accuse the Minister of neglecting the problem. However, the problem is far from being solved and we will have to give much more attention to our dental services and the provision of a new dental hospital in Dublin and, if at all possible, in other parts of the country. The Dublin Dental Hospital has been the same size as long as I remember and there is not much room for expansion on the present site, but we can find another site. We cannot ignore the claims of the dental service. We must listen to those engaged in the profession and work out a programme for expansion so that this most important sphere of medical treatment will not be neglected.
Could the Minister inform the House if some grants for handicapped children are being withdrawn? I have not sufficient evidence to prove that this is happening, and although this was suggested in Dún Laoghaire I do not accept, without further proof, that it is actually happening. I know of one case where a former polio victim, now the mother of a reasonably large family, was recently told by the Eastern Health Board that her grant was being discontinued. In reply to me the Eastern Health Board confirmed that this was so. I then went to the Polio Fellowship, as the woman was a member who was still badly maimed from the effects of polio and I asked why the allowance was cut off. The woman's circumstances had not changed. The husband had got an increase in pay but inflation would reduce that benefit to the family. In her own right, I believe the woman should still have got the allowance because her health has not improved. She has great difficulty in walking and will always have. Why, with rising costs, should the health board decide to cut off her allowance? When money is scarce I am not so naive as to think there will not be a cutback in certain aspects of the health service, but I refuse to accept that people like this woman should have a small allowance withdrawn. Had she been cured of her ailment one could understand it, but short of a miracle, she will spend the remainder of her life in her present condition. She will never have the agility of a normal housewife and will have to buy special clothes and so on. We do not want a cutback in health finances to hit people like that.
When in power Fianna Fáil always made health a top priority, as I suppose most Governments do. But there is need for vigilance by the Minister to ensure that both the central authority and local authorities get their priorities right. I say this while appreciating the tremendous demands on the health service. The fact that we are spending £250 million on health this year shows how vast the expenditure is, but when inflation is taken into account we realise that people are suffering. Those fortunate enough to have a medical card at least have a safeguard against rising costs. Why is it so much harder to get a medical card in this city than in other parts of the country? Although I serve on a voluntary hospital I am not a member of a health board and I imagine that there is some formula for the issue of medical cards. I am told on good authority that the percentage of cards in Dublin is much lower than the national average. Yet, the cost of living is no lower than elsewhere.
There is no discrimination between urban and rural applicants in regard to the issue of medical cards. I am a member of a board and I should know.
The Deputy will have an opportunity of making his own contribution.
I appreciate the Deputy's help but despite that the percentage of cards issued in Dublin is lower than the national average. I do not know why this should be.
The right is there for everybody and national guidelines are laid down.
Order. The Deputy in possession must be allowed to speak without interruption.
I appreciate Deputy Coughlan's help but what I say is right. Under the present plan for hospital development in this city many old hospitals will disappear. This is a matter for regret. The federated hospitals, Sir Patrick Dun's, Baggot Street, Mercers—these are great old Dublin institutions that have been performing tremendous things in the field of medicine and treatment in some cases over hundreds of years. While I know we must develop and improve the service we should have another look at this programme for the further federation of city hospitals because many of these are institutions which made Dublin preeminent in medicine and this great tradition should be maintained. Many of the newer hospitals are of equally high standard and in some cases may be even better, but the old voluntary hospitals gave one a great sense of confidence in knowing that the men and women on the staffs were fully proficient in their professions and could offer the highest quality service in medicine or surgery.
The Minister might ask the general nurses working party to examine the possibility of awarding nurses some kind of an honour or degree. A start has already been made on this but I think it is going too slowly. The efficiency of nurses should be recognised. The medical schools and universities should go into the status of nurses in greater depth. The conditions which the nurses enjoy, if "enjoy" is the right word, should be improved in order to ensure that these dedicated women are given the fullest reward for their services.
There is no shortage of applicants for nursing in Ireland. Each year when the hospitals start recruiting for nursing staff most girls apply to every hospital in the hope that they will be accepted by one. The Minister should set up a bureau for applicants. This would mean that a central body, in consultation with the authorities in each hospital, would be able to allocate positions. This would save applicants the expense of writing to hospitals and it would also save hospitals the expense of replying to applications. In non-teaching hospitals where they look after chronic patients there is always difficulty in recruiting staff. One city hospital which treats people for chronic ailments can get staff to stay only for a while. Nurses generally prefer teaching hospitals because they have the satisfaction of seeing a patient being treated and discharged in good health, whereas in non-teaching hospitals patients are generally long term. We would do well to appreciate that a fully trained nurse would prefer to be in a hospital where people are being cured and discharged frequently. Therefore non-teaching hospitals should be given extra help in recruiting the best possible staff.
Another point which the Minister should consider is the training of hospital cooks. The preparation of hospital food calls for greater care than the preparation of food in the home because the people who receive it are ill. It might be possible to have a school of cookery set up by the vocational education authorities. Some start may well have been made along these lines. I spoke on this subject a few years ago but I do not know whether it ever came to fruition. We very often hear of patients complaining about the standard of food in hospitals. While we must not accept such criticisms without examination, hospital patients may find the food that is being offered not very tempting to their palates. I suggest that it would be a source of added confidence to patients if they knew that the food they were getting had the approval of the staff of the hospital and had been cooked by a person who had been trained in the special art of cooking for people who are ill.
I would ask the Minister to look at the points I have made, particularly those in connection with some grants which were being paid to handicapped people being withdrawn. The efforts of the people who worked for the handicapped can never be praised sufficiently. The parents and friends of the various institutions for the handicapped are finding the going very tough indeed. The public respond to their appeals for voluntary subscriptions and the State, in fairness, contributes quite a large amount of money, but if some of the grants are being withdrawn then we must examine our priorities and ensure that the most deserving causes get the best possible consideration and financial backing. Some years ago the Members of this House, including Deputy Coughlan played a football match——
It was not a political match.
It was not. I thought it was a very good match. It brought home to us what we had to do then to raise money for St. Michael's House. What the Members of this House did was small in comparison with the never ceasing efforts of thousands of people who give their time and expertise in raising funds for institutions for the handicapped. The provision of house mothers and fathers ensures that these handicapped children will have a permanent home when their own parents have passed on. They look after these children, even when they have grown up. These houses are being established among families in the suburbs and are being accepted as a normal part of the urban or suburban scene. This is a great breakthrough but it all costs money. To buy a suitable house today would cost at least £9,000 and alterations would need to be made. While voluntary efforts can help, because of the enormous cost involved, the State must be the main source of help. The people as a whole would never begrudge money spent on alleviating the suffering of the handicapped. I have other suggestions to make but I realise that my time is almost up. I hope the Minister will deal with the suggestions I made this morning.
I want to add my voice and experience to this debate. I congratulate Deputy Moore for organising the historic football match which was played at Croke Park. It showed his great organising ability. Because the people of Dublin came out to support the match we contributed generously to the support of the handicapped children.
The health situation at the moment is critical because the Minister was left a legacy by his predecessor which was beyond the resources of the people to finance. Before the name McKinsey was heard here—it was a pity it was ever heard—we had our own methods of dealing with our health problems, through mental hospital committees, local health authorities and then the local health boards. Considering how much it cost, I do not think there has been such a vast improvement in our health services. On the introduction of the health boards, which united different regions, we sought the advice of people who were dealing with problems many times more serious than ours. We brought experts from America to solve our health problems. In my view that was absolute lunacy. It was a waste of taxpayers' money to get this group to recommend to us, as members of a health authority, a local authority or a national authority, how our health services should be run. Demands could have been handled in a less expensive manner while giving the same results. We went to great expense setting up boards, offices for boards, extensions to hospitals and other things that could have been avoided and which, as we now see, were brought into line to conform with the finances available and without inconveniencing or withdrawing any of the present services. In a way, it is a good thing that we had this recession, because it made health boards realise the amount of waste and duplication which was going on.
When the Minister took over the position was, as I said, more or less lopsided. It was not as we wanted it. It was not as human as it should have been because of the distant manner in which the McKinsey report was presented to us. Having been a member of these boards for almost 25 years, I realise what this has done and the gravity of the situation. I would go so far as to say that the whole system of the health services needs a thorough investigation. I would go all the way in recommending that a committee of Dáil representatives only, but with an independent chairman, be set up, and that these members should have experience of the Department and its administration. They could ask for and accept the advice of anybody who wanted to give evidence.
I have reservations about a group of individuals or professions because I know from experience that some, not all, of these professions on the board on which I sit, dig their own ridge. They do not see the wood for the trees. Naturally every man looks after his own, but it is left to the public representative who has no axe to grind to take the broad view of what exactly health boards are set up for, that is, the good of the patient. Everything else follows. For that reason I want to impress upon the Minister the necessity for making investigations and making recommendations as to what should be done in regard to the health boards and the administration of the health services.
Not so long ago we had statements coming from the Press and from different sources in regard to mal-practices in the issuing of drugs. We all know that in any region drugs are freely available. There are cases in my area where people exchange drugs or tablets: "I have this and you have that". This is what is going on. There was a case in Cork which got national publicity where something like £5,000 worth of tablets was found in a house. That may be the extreme, but speaking from experience I can say the amount of drugs prescribed for patients is unwarranted. The result is that abuses have set in and the abuses have cost the State a great deal of money.
Any of us who have experience of the health services and of the working of the health boards know about abuses in regard to travel vouchers, school vouchers and the many other things that are given. They are all given on individual application, but there is room for curtailment of the wastage that is going on. I am not one for cheeseparing on any patient, but at the same time in some of our large hospital units there is gross wastage in regard to heating, lighting, food, detergents and so on. These are things that should have been investigated long ago. However, it is not too late to do it now, and for that reason I want to impress on the Minister the need for the setting up of this advisory committee.
I want to state the position in regard to the board on which I have served since its initiation in March, 1971. Prior to that we had the health authority which was formed in July, 1970. Before that we had the mental hospital committee and the different voluntary hospital committees. When we worked as an authority which confined itself to the city and county of Limerick the number employed, including the professions, craftsmen and others involved, was in the region of 1,400 people, and our medical card average was about 30 per cent of the people. Since the board was regionalised in March, 1971, we have 3,000 employed in our board services. That is a good thing. They would not be employed unless the demand was there, and there are 104,000 people in our region covered for medical card services.
On top of that, I would like to give details of the expenditure during the health authority period from 1962 to 1971. For the year ended 31st March, 1962, our gross expenditure was £1,294,000; for 1962-63 it was £1,326,000; 1963-64, £1,415,000; 1964-65, £1,686,000; 1965-66, £1,804,000; 1966-67, £2,004,000; 1967-68, £2,100,000; 1968-69, £2,398,000; 1969-70, £2,895,000; 1970-71, £3,584,000. Therefore, a steep increase can be seen all along the line during the period of the health authority, which confined itself to Limerick city and county.
I shall now give details from March, 1971 onwards when the board took over: 1971-72, £7,618,000; 1972-73, £9,274,500; 1973-74, £12,130,000. In the 12 months for 1975 our Estimate was £16,865,000 and our Estimate for 1976 is £24,109,000. That gives a clear indication of our expenditure with regard to given services in the region which I represent, but we must side by side with that take into account the conditions and circumstances which raised this figure up to £24,000,000. The answer is very simple. It all lies in the fact that we have a Minister for Health who is on top of his job, who has come down to the basics and realities of the position as they are presented and who takes his advice from experience rather than from theory. We are glad we have such a man in the Department which we had not in the past. Let the weeping and moaning and ochoning and keening come from all quarters but the facts must be faced and this I presume I am doing during this debate this morning.
We must remember that since the Minister has taken over the Department of Health we have improvements in this Department which were unseen and could not be forecast or would not be by the previous Government. They stuck their heads in the sand like the ostrich and refused to face up to the reality of the situation. Let me briefly state some of the improvements that have been achieved since the present Minister has taken over his Department. We have brought in the choice of doctor scheme which was not there in the past, where now a medical card holder has his choice of doctor on the panel and can opt for whatever one he needs.
That is not true.
It is true in my region.
No, it is not.
Would the Deputy prove it?
That was introduced by our cabinet.
He can opt for a doctor on the panel provided the doctor is not already oversubscribed with medical card holders. That is the only thing that will stop him.
The Deputy's own side are looking at him in amazement for making that statement.
Are they? I think they are looking at me with awe and appreciation for the information I am giving. Some Fianna Fáil people come in here speaking on health and they are as divorced from health as the North Pole is from the South. It is as simple as that. I am speaking from 25 years experience of these issues. I know what I am talking about.
Deputies' contributions are limited to an hour and they should be allowed that time.
Yes, but it is obligatory at times when making statements to put manners on certain people. That is what I am trying to do now, with due respect to Deputy Briscoe.
With due respect to Deputy Coughlan, he will know that the choice of doctor scheme was brought in by Fianna Fáil, not by this Government. I can correct him on that.
I said that the choice of doctor scheme was introduced in a haphazard fashion. It has been extended and greatly extended.
Would the Deputy tell us how?
Does the Deputy know anything about it? I am allowed to speak, and if he comes in to filibuster me and filibuster the House he will be second best as far as I am concerned.
I know that the Deputy is an expert on filibustering.
I can handle some of the pink-feathered Fianna Fáil politicians on that side of the House who have not yet shed their pink feathers. We have given something that is there for everybody to see to which Fianna Fáil turned the deaf ear and the blind eye. That was the care of handicapped children and the provision of care for parents which is in the region of £25 per month. Fianna Fáil did not bother, good, bad or indifferent, to think of the handicapped children and how they could be cared for. This is something the Minister has to be congratulated on. We introduced the health contribution scheme that was never there before. We catered for the hardship cases, particularly in regard to the refund on medical services, with regard to drugs and tablets that are prescribed, the refund of the amount paid between whatever is spent in monthly account between £3 and £5, half of which is being refunded and which has been increased since. The amounts of over £5 have been refunded. These are things that Fianna Fáil and previous Ministers for Health never thought of and if they did they neglected them.
We have choice of pharmacist, which was never there, introduced by the present Minister for Health. We have the home help which I can assure the House has been a great acquisition and a great help for old people being cared for at home. The home help is provided, visits are made, domestic work in the home is done to give these people all the practical comforts to make life pleasant. These things were absolutely neglected under Fianna Fáil, and they come in here screaming their heads off: "Do this" and "Do that" but they forget that these unfortunate people who suffered for health reasons were completely neglected by them.
When we made the improvements that Fianna Fáil neglected to carry out, certainly we incurred expenses, details of which I have already given, and they have to be taken into account. We do not get the money from the clouds as Fianna Fáil would have the people believe but the people are not fools. These services have to be provided for financially.
These demands have been increased. Our estimates have been increased and so our expenditure has been increased. I want to give one brief example in the medical field. In 1962 the minimum nursing salary was £420 a year and the maximum £450. I do not know who was in power but somebody will give me the record, Deputy Briscoe perhaps. In 1964 the minimum at entry was £520 per annum, maximum £670. In 1968 it was increased to £620 minimum, maximum £879. In 1975, the minimum was £2,145 while the maximum was £2,697. In December, 1975, the minimum was £2,287 while the maximum was £2,737. At 1st March, 1976, the minimum was £2,351 while the maximum was £2,933. The maximum when Fianna Fáil were in power was £450. That is one of the reasons why the cost of the health services has increased. The Minister has taken the situation completely in his own hands and treated the health services in a humane and realistic manner.
The nursing vocation was treated in a miserable manner by Fianna Fáil but we have uplifted it to a standard that it rightly deserves because of the dedication of these people. Anybody who has been in a hospital for a term appreciates the great work the nursing staff do for the comfort of patients. In our region there are 1,500 nurses employed. For the number of vacancies in our nursing schools in Limerick or Clare we have ten times too many applicants. The vacancies are advertised in June and September and the interviews are held on a group system, something of which I am not completely in favour. It is very difficult when there are more than ten applicants for each vacancy for anybody to succeed. A similar position prevails in the other regions. That is a good thing. The figures I have given do not include the voluntary hospitals. I see no reason for Deputy Moore to be critical of the fact that applicants for the nursing profession must apply for three or four different posts. That shows that those who apply are determined to get a nursing post.
Some of these young girls are so determined that they work in the hospitals during the summer holidays. They do domestic work in those hospitals in order to be au fait with the running of a hospital. This also shows the great demands on the Minister who has many problems because of the legacy left by Fianna Fáil. Fianna Fáil are now keening and moaning and asking for things they know they would not dream of introducing if they were in power. We must decry what happened in the past.
In our region there are 4,500 beds to be serviced. This means a big demand on our finances. We also have 110 general practitioners in the region and that also means a big demand on our resources. For the benefit of those who think they know it all as far as the cost of health is concerned, I should like to give them a little insight into the cost of maintaining patients in our hospitals. We have 944 beds to service in our general hospitals—not taking into consideration the voluntary hospitals —and in the psychiatric hospitals we have 1,600 beds to be maintained. For long-stay patients we have 1,582 beds and 170 beds in welfare homes. Bearing in mind the number of beds that must be serviced in that region is it any wonder that our Estimate for 1976 was £24 million? The cost to the board of a bed in a public ward occupied by a medical card holder is £17 per day. In a private ward the board's contribution to a patient is £3.90 per day and in a semi-private ward it is £3.25 per day. That is the contribution of our board to those we help.
Since the National Coalition took office we have done many other things to improve the health services. We have done many things to help the unfortunate people Fianna Fáil neglected. With regard to welfare homes, an area which Fianna Fáil completely neglected, we opened four such homes in my region. We opened one in Kilrush to serve the people of west Clare, where we thought they were most needed—one in Newcastle West, County Limerick, where it would be of more service than anywhere nearer the city of Limerick, another in Roscrea and another in Nenagh, County Tipperary. We have applied ourselves to providing the care which had been grossly neglected by Fianna Fáil in the past.
What were the dates of the opening of these welfare homes?
I have not got the dates.
All last year?
I did not say last year. I said since the National Coalition came in and took over health. Do not try to put wrong boots on my feet. I will not change my position on this issue, because I am telling the truth. I can appreciate your embarrassment. I am sorry for you, because we are personal friends of long standing and I want to keep it that way.
I am not embarrassed. I am delighted that our plans were implemented by the present Minister.
I must tell the truth. The welfare homes cost us in the region of £700,000 for the care of those unfortunate people. We have 50 beds for paediatric patients and another 50 for psychiatric patients, which Fianna Fáil had completely neglected.
We have six Cheshire Homes throughout the country at the moment, which are doing much good. There is one in Wicklow, one in Cork, one in Limerick, one in Carlow and two in Dublin. They are voluntarily organised and they deserve every sympathy from the Department of Health. Unfortunately at present they are in financial difficulty because of the fact that to date they are only getting something in the region of £19.8p weekly capitation fee from the Department. I stress that, although this is a purely voluntary body, the Minister and his Department have given it recognition. At the moment they are in debt to the tune of something like £75,000 for 1974-75. I appeal to the Minister, in view of the good work the Cheshire Home organisation is doing for these unfortunate people who have multiple sclerosis or parkinsons disease, to give sympathetic and urgent consideration to their problem. Due to the debt of £75,000 the Cheshire Homes cannot issue any more cheques because they will not be honoured. I know there are many demands on the Minister and his Department at present and that the Minister has spent to the limit of the amount allowed him, but this is an emergency and even if something has to be curtailed something should be done. This again is something that Fianna Fáil never thought of recognising. In England the contribution to the Cheshire Homes varies from £38 to £73 weekly. All we have here is an average of £19.
In Limerick there has been erected through the Brothers of Charity a complex which was opened by the Minister for Health two or three years ago, which is now fully completed and which will cater for the rehabilitation of about 100 handicapped children. Unfortunately this complex will not be finally equipped this year and maybe well into next year because of the demand and the cost of the equipment. I know it is expensive. We set out with the best intentions at that time when we turned the sod on that complex in Limerick, but we were living in normal times. Our attention then was absolutely beyond reproach. Unfortunately, we are now in a valley period. Luckily, the worst has passed and we are now on our way out of it, because we stuck together, gritted our teeth and fought together on this issue. Some recognition should be given to this complex, because if it is lying idle for 12 or 18 months its value will not be enhanced. It should be heated and maintained in good condition. It will have to be protected against the vandalism that is rife all over the world today. If even some small approach were made to get things moving on this complex it would be a great help.
I should like to direct the Minister's attention also to the work being done by the associations of workers for children in care. These are voluntary bodies set up to handle children of families which have broken up for one reason or another. There are two such bodies in the city where I come from. They keep, feed, clothe and send these children to school. Their ages range from two to 17 years. The Good Shepherd Convent in Limerick cater for about 40 boys and girls in that age group from broken homes. There is also the Convent of Mercy where 50 of these children are looked after. Between those two institutions alone there are almost 100 children being accommodated. There are also the voluntary bodies such as Adapt, made up of people who, of their own volition raise money and help in various other ways.
Much credit is due to those people. They need all the encouragement and help we can give them. However the capitation grant of £15 per head in the institutions in which these children are cared for is not sufficient. We know how much food teenagers, for instance, require. I recall that when I was at that stage the legs of the table were not safe. At that age children rush to the table and eat everything on it. The capitation grant is not adequate in terms of today's cost. We are lucky to have the various religious institutions who without any payment whatever for their work devote their lives to caring for these children. But since there are not enough religious to do all the work in this area we need to employ people from outside. Every effort must be made to bring the services into line with the recommendation of the report issued in 1968 on the question of the care of these children. I ask the Minister to give his attention to the points I have raised. I am aware fully that the matter is not entirely one for him because it must involve also the Departments of Justice and Education.
In the limited time at my disposal I intend dealing with the question of hospitals generally and to endeavour to take a broad view of the situation as I know it from my experience in this field. Deputy Moore reminded us of the desirability of preserving some of the older hospitals in Dublin. That is a laudable sentiment, but we must be practical and forget our emotions in this sphere.
In Limerick we have two voluntary hospitals but they are limited in many ways, limited in regard to the complexes they occupy, in regard to the potential for extension and in regard to income. There is far too much duplication in those hospitals in relation to equipment and the provision of services generally. Because of the expense involved in bringing hospital services up to present day requirements I suggest that there be coordination of services whereby one hospital would specialise in one area and another in a different area. I am not advocating the abolition of voluntary hospitals, but the type of coordination I am suggesting would cut out much of the duplication not only of equipment but of specialist and consultant services.
The Deputy has seven minutes left.
I shall never get through all I have here in that time. Whoever ordained this time limit?
The Committee on Procedure and Privileges.
It does not make sense that those of us who come here in an effort to be helpful and who know what we are talking about are given only the same time as those who waste the time of the House talking through their hats and in some cases trying to be destructive.
Another subject to which I should like to refer to is the question of alcoholism, of which we have been reading and hearing much in recent times. We are told of the effects of this disease on the families of the sufferer. I believe that matter has not been tackled as it should. It has been tackled in a way that is most demeaning. I refer to the situation whereby if a person is not in a position to go to a private institution for treatment, where the fee is about £20 per day, he must go to a unit within a psychiatric home, which may not be the place one would wish to seek treatment. This is the case in Limerick where there is such a unit within the grounds of the psychiatric home.
The Minister has taken advice from some of us in regard to Limerick, and the result is that we are to have an extension to the regional hospital in which alcoholics can be treated. While this is a start it will not be possible to cater there for the demands being made for this treatment. We all know the stigma that attached to mental illness in the past. That situation exists to a lesser extent today, but it is still there. The result is that people are reluctant to present themselves at a psychiatric hospital for treatment for alcoholism. That is why I stress the need for a thorough investigation of the services in this area. The problem should be tackled immediately. The Minister should set up a committee consisting only of public representatives who because of their experience in the field of health services generally and because of personal detachment from the problem would be the best people to investigate the services. I know of instances in which there is much wastage and extravagance in these institutions. McKinsey has caused much damage to our health services.
I want to ask the Minister a question. Why do we have to have health advisory bodies? They are the greatest nonsense and the greatest waste of time. They provide a platform for budding politicians, for grousers and grumblers who know nothing about what it means to serve on a health board. The tragic thing is that no official or administrator of the board is responsible. They do not even have to attend. Members of those bodies yap all day about the services. Think what it costs to call them together. I cannot see why the health boards are not allowed to carry on like vocational committees or agricultural committees. The then Minister for Health took Mr. McKinsey's advice against our recommendations. These bodies say we should give medical cards, extend hospitals, get a wheelchair for this person, get this, that and the other thing. They all talk through their hats. Think of the damage they are doing. Unfortunate people read their extravagances in the use of language. They say: "I read in the paper Councillor So-and-So said this and Councillor So-and-So said that. Why can I not get it?" I implore the Minister to let the abolition of these advisory bodies be the first step. I do not know who they are advising.
The Deputy's time has now run out.
I am sorry about that. We will have another day. I want to say how grateful I am and how happy I am about what has happened in the Department of Health since the National Coalition took office. I am sure the achievements I have enunciated delighted some of my Fianna Fáil colleagues. Why did somebody not inspire them to try to give some of the services we have now achieved? There are more to come.
Having listened to Deputy Coughlan talking about the family table I can now understand his behaviour sometimes in the House. I welcome the Minister's statement. I appreciate the difficulty he finds himself in. He is very restricted by the financial state of the economy. There are many things he would like to do to make progress and I have no doubt about the sincerity of his approach. I hope my contribution will be constructive.
I should like to bring to the Minister's attention something which is happening in certain hospitals and which I cannot accept. I do not know if it is happening in all our hospitals but it is happening in a number of hospitals. A medical card holder is sent by a GP to see a specialist because the GP is not in a position to diagnose accurately what the ailment is. It has been happening that housemen in hospitals have been seeing these patients. I was speaking to some consultants not so long ago and one of them explained to me that the maximum number of people he could see in a three-hour session was 12 allowing one for every 15 minutes. There were 30 people waiting to see him and he was booked up for months ahead. This was why the housemen sometimes saw the patients, although most times it was the registrar.
I am sure the Minister knows that a houseman has just come out of the university and knows less than a GP. At a meeting of a hospital board of which I am a member I asked if this was happening and I was told it was for the reasons I have given. I do not want to say this to alarm people. We must be very responsible about the way we state these things. There should be an instruction from the Department that no housemen are to see patients referred to hospitals by a GP. Registrars yes, but not housemen. If the GP feels the patient should see a consultant he should not be seen by a houseman. I can assure the Minister this is happening and I believe it is wrong. I am quite sure the Minister agrees with me. Perhaps his departmental advisers could try to find a way around this and check with the various hospitals where this is happening. This would be a worthwhile achievement.
The last speaker referred to alcoholism. Only yesterday, I think it was, a reverend gentleman said no reference whatever had been made in this House to the problem of alcoholism. That is not true. When the Minister for Justice introduced a Bill last year dealing with the new licensing regulations we dealt extensively with alcoholism and its problems. I suggest that in the Department's advertisements against drinking, and the rounds system in particular, drink should not be used. A thirsty person who is trying to kick the habit and who sees three, four or five pints of beer on the television screen, with a reference to the vicious circle, is actually seeing drink. The advertising agency should try to find a way of advertising against the rounds system and excessive drinking without using drink.
If we hope people will stop drinking we are living in a fool's paradise. What we should be preaching is moderation in drinking and moderation in smoking. If we are trying to get people to cut out drinking and smoking we will not achieve anything. Young people take example from adults and adults are not prepared to give that example. Deputy Gibbons is here beside me. I often complain that in these debates the doctors take over and not the laymen. Any doctor will tell you that a man smoking five or six cigarettes a day is much less likely to do himself harm than a man smoking 40 or 50 cigarettes a day. We know this to be true and our aim should be to preach moderation
In regard to drink, our aim should be the same. It should be to discourage people from drinking to the same degree. There is a bit of joking going around to the effect that the Minister for Finance has done more to cut out drinking than was done by Father Mathew. I think the Minister has aggravated an already serious problem. I understand the small whiskey is now cheaper than the pint. That means people who drank pints because they could not afford spirits will switch to spirits. This is a dangerous situation.
I heard a recent figure on alcoholism in this country. Of course it is difficult to find drinkers who will admit that they are alcoholics and therefore figures may not be accurate. The official figure is that one in every 25 drinkers is an alcoholic. I am satisfied that this is accurate in so far as it goes, and I will not disclose my source which says that one in 15 drinkers is unfortunately an alcoholic although many of them may not know it. That is the studied estimate of what I regard to be a very responsible body. When the figure was given to me it was stated it would cause pandemonium but it is important we should preach moderation. I am in favour of moderation rather than total abstinence.
In this country in regard to drinking and in regard to round-buying we have always felt a sense of meanness if we do not buy our rounds. We have all heard about somebody: "The mean so-and-so, he never buys anybody a drink." I have seen sensible people going away and leaving as many as seven whiskies on the counter. It serves the person who bought them right although his family may be going without a lot of things.
One thing I get very angry about is finding children in pubs, even if they are drinking only orangeade. It is something that should be discouraged vehemently and this should be brought to the notice of publicans. The majority of people do not like children going into pubs. There are people who leave children outside while they are drinking and I do not have any respect for them. Other people leave children at home with a babysitter while they are out drinking. However, no matter how good the customer is, a publican should say to him: "Mr. X, I value your custom but it is embarrassing for me to have children in my pub—I get criticised about it." It is something about which the Department should disseminate information.
I hope the Minister will take my point about preaching moderation rather than abstinence both in smoking and drinking. The Minister for Health is in the peculiar situation that the Minister for Finance tries to raise as much as he can from tax on tobacco and drink and the Minister for Health has to try to finance discouragement of both by spending the tax from both.
In relation to welfare homes, I am disappointed that the homes planned for this year will not be built. The Eastern Health Board were recently given a present of an acre of prime land in a Dublin residential area where I understand the value of land to be about £40,000 an acre. The Department know what I am talking about. We have prevailed on the Eastern Health Board to put up a notice saying that this land has been acquired by the board, even though this is not so officially. The nuns in the convent were very kind. They had about nine acres, eight of which they sold for building houses and they literally gave a present of £40,000 to the health board. When these houses have been built the people in them will say they want recreational facilities and there is no way in which pressure to build the welfare home will exceed that to provide recreational facilities on this acre. Everybody knows I have been foremost in advocating the provision of recreational facilities, but we must have welfare establishments. The building of this home would cost the health board £156,000. It is a large senior citizen centre and the home would not just be a place where old people could stay but it would also enable them to come together and get a community spirit going. The delay here is a source of great disappointment.
I have stated before that there are matters on which the Minister is not fully informed. One of them is the trepidation of some hospital boards about making rows, as it were, to get their entitlements because they think they would be upsetting officials in the Department. They are assuaged sometimes by senior officials saying: "We recognise the need for your intensive care unit and you are in the first four or five when money becomes available." The hospital authority then get the feeling that if they create a row they will be put far down the list. They have the "do not rock the boat" feeling.
The intensive care units, particularly in children's hospitals, should be of the highest quality. We read recently of a dispute between the board of governors of one hospital and the Irish Medical Times for printing an article in relation to a deputation which was going to see the Minister. The board denied it. In fact, the board were inaccurate when they denied it. They denied that they were going to see the Minister about a particular subject, but they were going to see him about a number of topics, one of which was this particular one. They were splitting hairs. That arises, out of a sort of fear. I am sure the Minister knows the hospital about which I am speaking. He has visited it and seen for himself. I have spoken to doctors working there and they told me that the facilities are less than adequate. The cost about which we are speaking is £146,000. I am not saying that a person who has lived his life should be regarded without compassion but I have greater compassion for an infant given new life than for a person who has been lucky enough even to reach 50 years and had the wonderful gift of life. But children must always be at the top of our list of priorities.
One area in which I sympathise with the Minister—because whatever decision he takes he will be abused and attacked by people from both sides of the House—is that of the siting of the regional hospitals. Whatever he may do, he cannot win there. In a sense that places him in a very strong position. He can site the hospitals where he believes they should be, being satisfied by the advice given him, having considered all of the recommendations and listened to all of the submissions made to him. And he has been very patient and taken a lot of trouble to do so. The Minister should site them where he believes they will do the most people the most good. Were I Minister I would act accordingly, and to hell with the abuse. One cannot be a Minister of Government without getting abuse, particularly on a subject like this where everybody is out for their own area. That is understandable; they are elected to represent their people.
It is unfortunate that the Minister has to operate on such a restricted budget this year. There is an old saying that out of evil comes some good. Perhaps out of the evils of our times in relation to lack of money people will become more cost conscious, as was pointed out by the Minister in his statement when he said that he is not without some compensation in so far as it has made everybody more cost conscious and aware of the need for economies. This is needed and may be a salutary lesson for a lot of people. I still believe that the health of the nation is an extremely important area. I know how hard the Minister has to fight his corner, just as has every other Minister. Very often it depends on the tenacity of that Minister how much he will get for his Department.
We have been speaking about increases in expenditure. That does not mean anything because we are living in times of unprecedented inflation. When one talks of, say, £600 in 1961 and about £2,000 or £3,000 in 1976 there is no comparison.
Another matter which concerns me, and which the Minister might examine, is the terms of eligibility for medical cards. For instance, a man earning £6,000 or £7,000 a year, with a very large family, may have very large payments on his house and find it difficult to meet medical expenses. I have always been happy about the way in which the Eastern Health Board dealt with hardship cases. The Minister said in his speech:
For the third category—other non-insured people—the present limit of £1,600 a year goes back to 1971. For these, entitlement is related to the income tax year and a continuance of eligibility after the income limit has been exceeded does not operate as it does for the insured. Because the present limit for these people has so clearly gone out of date, the chief executive officers——
This is the part.
——of the health boards have been applying the "hardship provisions" liberally so that in reality the fixing of a new limit of £3,000 a year would but formalise a situation which has been largely established by administrative practice.
Taking the pattern as a whole, the proposed change in the limits will not give rise to any substantial change in the proportion of the population which has been traditionally eligible for these services, which is about 85 per cent. In effect, this change will maintain the limits at its traditional level in real terms. Discussions have been held with the medical organisations, so that they will be fully aware of what is involved in this change. What is involved here is a "holding operation" to maintain the existing levels of eligibility. I hope the House will see its way to approve of the draft regulations before it.
I hope the Minister is not implying that the various health boards would be told: "Look, hardship provisions are out" or "You are being too liberal." I can speak only for the Eastern Health Board whom I am satisfied do not apply the hardship provisions too liberally. I do not think they apply them liberally at all. They exceed the limit for hardship but the word "liberally" is the wrong one to use here. It is either hardship or it is not, and even a man earning £6,000 or £7,000 annually can have a real problem paying his bills. Thank God I am in the VHI. That is one service Deputy Coughlan forgot to say was inaugurated by a Coalition Government.
It was, yes.
Were it not for the VHI I would be in a lot of trouble because I would be outside the limit for a medical card and nobody would believe that I could not afford to pay for medical treatment. The VHI is very good value and I wish more people made use of it, although probably the more people that make use of it, the more money they lose. It is certainly getting that way.
With regard to rates of inflation, take-home pay is something that should be examined rather than gross income. I know deductions are allowed from gross income for outgoings on a house but there are certain other costs for a family such as education, clothing, food, the running of a car. People in that category will find it very difficult to make ends meet. Most people of that type who run cars will be subscribers to the VHI, but many will not, many who work in factories, particularly in rural areas.
It may be said that because I represent a suburban constituency I could not understand the problems of a rural area but I have had quite a good deal of experience of the hardships suffered in rural areas while working in by-election campaigns. I understand the hardship involved for people living three or four miles from a town in which they are employed. These are the things that must be taken into consideration when assessing a person's right to a medical card. I hate the term "medical card". There are people who should have some assistance, assistance something like the waiver of rates, when they require medical attention. The person who cannot pay is in the best position because, if a person has no money, it cannot be taken from him.
Some time ago I was approached by a doctor who told me he was being examined very closely by the Department of Health because of the number of patients he had. He believed he had been loaded with elderly patients who were passed on to him by other doctors. These others were being selective and they would tell an elderly patient that this man probably had vacancies on his panel with the result that he had to cope with a preponderance of elderly people. He was suddenly told he was making too many calls. One way to reduce the cost of treatment for elderly people would be by providing other facilities. The National Social Services Council was set up by the Minister's predecessor and it establishes community information offices and through these offices many services could be offered. In my own area a community information office will open on 20th June and there will be two officials from the Department of Social Welfare there. The accommodation was acquired by the community with a grant of one-third of the cost from Dublin Corporation and a loan from the bank.
When talking about child health services the Minister referred to public health nurses. These nurses could operate from these centres. There are many other services which could operate from these centres. The centres are manned by voluntary workers who undergo a course of training. I congratulate the Minister on the staff with which the council is manned but I believe it is grossly undermanned. I believe the National Social Services Council should operate under the Department of Social Welfare rather than the Department of Health. The kind of services to which the Minister referred could be operated from these centres. I believe there are over 50 such community centres now registered all over the country. There are quite a few in Dublin. The idea is excellent because people know where the community information office is and they can go straight there for assistance. If the Department of Social Welfare would put in two officials perhaps once a week or once a month that would be of tremendous benefit to people seeking help. In the same way the ESB could supply some personnel to answer queries and discuss difficulties. That is the kind of use to which these centres could be put. There is scope for an expansion of the services. The amount of money involved is small in relation to the total budget and, if the Minister accepts my suggestion, the relief could be quite phenomenal.
I find myself somewhat concerned about future planning. The Minister says the analysis of the census has now become available and the results can be examined. There are other aspects involved because every single Department, including the Minister's Department, will be at a disadvantage in regard to future planning because of the reluctance on the part of the Government to carry out a national census this year. Without that I cannot see how the Minister can plan for the future. The next census will be taken in 1981 and the figures will not be published until 1982. There will be no information in the meantime about population movements. Every Department and every local authority will be adversely affected because of this failure on the part of the Government. The Minister and his Department will be working in a vacuum.
Tributes are paid from time to time to voluntary organisations, such as the Central Remedial Clinic, the Cheshire Homes and so on. No reference has ever been made to the Variety Club of Ireland and the excellent work they are doing. They have contributed many coaches to various children's hospitals. They specialise in providing coaches for children. St. Joseph's Hospital and the St. John of God Hospital, who do such wonderful work for handicapped children, have received coaches from this voluntary body who receive no State subsidy whatsoever and do not ask for it. It is a fund raising effort. I am glad to put on the record of the House the wonderful work of the Variety Club of Ireland.
I am pleased that the Minister has arranged with AnCO to take in an increasing number of handicapped trainees. We are in a situation of high unemployment but any undertaking should have to take a certain number of handicapped people able to do a good job. I have seen many excellent people who because they are physically handicapped cannot get a job; yet they are saner than many of us in the House. Many of them are more capable than some Deputies. A well-known restaurant in Dublin employs a blind telephonist and I have never seen anybody work as fast as he does. He is a magician. It does not bother him that he has no eyesight.
There are two ways one can encourage the employment of handicapped people. We can say that employers must take a certain percentage, as was done in England after the war. At that time, because many people had lost limbs during the war, it was compulsory for firms to take in a certain number of disabled people. Cash incentives can also be given to firms to encourage them to employ handicapped people. I know there are cash incentives given to firms to take on so many people through the Department of Labour. I am talking about giving a cash incentive to get a handicapped person capable of working back to work. I hope that AnCO will not have any difficulty in placing those people when they are trained. I would like to see AnCO taking on some handicapped person to train other handicapped people. There is no reason why they should not do that.
I want to refer to medical examinations in schools. The Minister stated:
As regards school examinations, it was envisaged that, in addition to annual testing of vision, posture and cleanliness carried out by public health nurses in all national schools, all national school entrants should undergo a comprehensive medical approximately when they were approximately one year at school...
Many of the problems with young adults started when they were at school because their teachers were not astute enough to know that particular children were slightly deaf or that they were having trouble with their eyesight and could not read the blackboard. Consequently, because such children could not make head or tail of what was going on around them, they lost interest. Thank God my children go to a national school where the teacher observed that when my little boy was five years of age his eyesight needed correction. The teacher was able to spot this difficulty. Before that he went to a Montessori School where the teacher spotted he had difficulty in hearing. He was brought to a specialist who immediately diagnosed the problem as some fluid in the ear. He went into hospital and had the ear cleared out and he can hear now as well as anybody else. Those are little problems which, if neglected, would become permanent. The child would then develop a permanent defect for the rest of his life.
The emphasis is not on nurses going to school and dealing with thousands of children but careful scrutiny by teachers who notice that a child is not making progress. The work of the public health nurse is very important but this is also a very important aspect of the matter. If those faults are not picked out at the age of four, five and six years they may not be noticed until much later on when it is too late to do something about them. This work will have its rewards because a lot of handicapped people under treatment today would be completely cured now if they received treatment when they were young. Many young people are vandalising the city every day of the week. Perhaps some of them had little problems when they were at school and did not do well. If those problems were spotted by astute teachers or public health nurses they would not be drop-outs today. Those are very important areas and are non-contentious. As I said at the beginning, I hope my speech will be taken by the Minister to be constructive and not destructive.
The Minister, when dealing with public health nurses, stated in his speech:
The public health nurse is frequently the first point of contact between families and the health services; as a locally based nurse she gets to know the famalies in her area, and is available to provide advice and nursing care ranging from that required by the expectant mother or pre-school children to the sick nursing care of the aged and chronic sick.
The community information office can serve as a base because the staff there are local people and are aware of local problems. We are creating greater community awareness, something which is very important. We often talk about a time, which Deputy Dockrell would know very well, when in Dublin everybody knew everybody else on the same street. Today you do not know your next door neighbour, never mind the person who lives across the road from you. Community development will help to overcome this. The Department of Health and the Department of Social Welfare can play a very important part in this. I should like to see much more work and investment in that sector.
The local authority in Dublin are prepared to give a grant of £4,000 in the case of premises which were acquired by the Lower Crumlin Community Development Association for a community information office. The local authority are also prepared to guarantee the bank the loan of £7,000 which the association obtained. The association had £1,000 in the bank which they put into the development. The repayments of the bank over three years were £75 a week but because of the community involvement and awareness they are clearing something like £100 each week in 10ps and 5ps. This shows in a catchment area of between 10,000 and 15,000 people the amount of good work which can be done. They have the community support in that area. It is no use giving money out if it is not appreciated. The community must be involved.
I should like to see the State participating a little more in that direction by encouraging local authorities to put up community information offices. The Minister could say to them that he relies on the advice of the National Social Service Council as to who will be registered and who will not, that a local authority can give a grant towards the purchase of premises and that the Department would then give a grant, pound for pound, or something of that nature. This would be very successful. It is something I would love to be able to say in a political manifesto but it is too important a matter for making political points.
We are talking of how to reach people and cut down on the excessive use of drugs, of the loneliness of people. Older people, when their families go away sometimes have nobody to look after them. It is said that one mother can bring up ten children but ten children cannot look after one mother. This very often happens. Such lonely people need to talk to somebody. I am sure many doctors would agree that the problem of many patients is loneliness. Some of the drugs are prescribed to give the patients a "lift", to ease depression which is a form of mental illness. Money can be saved through community development on the issue of drugs if the people concerned are absorbed into the community and feel they belong to it. This can be and is being done. It needs effort and dedication but it is well worthwhile. I hope the Minister will give some time to studying what the National Social Service Council are doing. He will be very gratified to know that they are doing an excellent job but are very restricted for want of funds.
When a new community information office opens they provide a filing cabinet and a typewriter and so on. They give lectures and teach the personnel how to interview people. It takes time before the people of an area will go to the centre because they do not want everybody knowing their business. Personnel are taught the need for confidentiality. When they opened these offices in England they did not expect to get perhaps more than 16 or 17 inquiries in the first six months and hoped that in the second year it would begin to improve but expected that it would be two or three years before it really got going. Actually where these centres have opened inquiries have been pouring in and people have been coming in three or four times. Gradually the centres are becoming known and people know where to get access not only to all the State services and be told of their rights—there was that famous discussion in Dún Laoghaire on "The Right to Know"—but they also find out how their public representatives can be reached.
I have told public representatives of all parties in my area that if they leave stamped addressed envelopes at the community information office anyone who is looking for them can put a letter into an envelope which will be posted to the appropriate representative with the message that such a person wants to see him or her. The facilities are for everyone, and of course it is non-political; it is not a pressure group and it is developing. This is the type of thing to cure the present ills of society, the pressure of maintaining standards of living. We are told that we must take a lower standard of living. We can all say we will accept that so long as we have enough to eat and a roof over our heads, but it is the struggle to maintain that standard which is driving many people into a state of depression which leads them to go to doctors and the whole situation is escalated. This gives rise to many of the bills.
People who have been out of work too long are afraid to work. Their confidence is lost. I know the feeling of somebody seeking work who meets refusal after refusal and the effect that has. The result is so soul-destroying that it has to be experienced to be understood. I experienced it once and I know what it is like. You have the fullest confidence that you are the person everybody is waiting for. Then you get the first "No", the second and the third. There is a tremendous problem in this regard.
The Deputy has five minutes left.
Did Deputy Coughlan take some of my time?
The Chair is meticulous in matters of timing.
I have made most of my points. Tribute was paid by the previous speaker to the nursing profession and, as a former patient, I should also like to pay tribute to them and the wonderful care they give patients. Nursing is one of the finest professions. Many nurses have had difficulty due to the increased cost of food and car expenses, as many of them must use cars for travel to the hospitals. They have had to meet tax and petrol increases and when the last increases were announced the nurses were very active in trying to get something done. I hope the Minister will be able to provide some form of expense allowance or help them in some way in regard to transport. My colleague, Deputy Gibbons, would probably know better than I the kind of problems they have.
In view of the Local Government circular recently sent to all local authorities saying that all subsidies would end on housing for certain repairs and so on I would like to know what the position will be. The Minister referred to the fact that there would be no charge for health on the rates for 1977. Will he suddenly say: "Yes, but any additional expenditure will have to be borne out of the rates"? Will he renege on the Government's stated policy to take health charges and housing subsidies off the rates? The housing subsidy promise has already been reneged on. Will health charges be next? Will this be the last year in which these subsidies will come off? Will we be told that in future all increases in wages, which is very often the major expense, or any additional services will have to come out of rates? I predict on today, 6th May, 1976, that that is what will happen.
I conclude by congratulating the Minister on presenting a very comprehensive document. I have tried earnestly to be non-political in my remarks. I hope they have been constructive and that the suggestions I have made will be taken up by the Minister, particularly in relation to having a closer look at community information offices and the uses to which they can be put.
Sir, I wish to add my congratulations to those of other Deputies to the Minister for Health. His Department is one of the most comprehensive and all-embracing that we have among our great Departments of State and he has filled the office with great tact and energy. The two do not always go together, but in his relationship with the doctors he has shown that he understands their difficulties and that they understand his. Certainly he has served a great deal better and much more smoothly in that particular area than many of his predecessors.
St. James's Hospital, which lies in the centre of the city, is a vast hospital. I understand the Minister has made a decision to extend the ramifications of that hospital, and that is something which will be greatly welcomed by the citizens of Dublin. We can all remember when the area occupied by St. James's Hospital was the old Dublin Union. That was what the ordinary Dubliners called it. It is a vastly changed hospital from what it was in those days, covering many acres of beautifully laid out grounds which certainly have altered the whole concept of the type of hospital that is there.
I find it very interesting to go back over a few years for the purpose of looking at what is accepted by the Minister and his Department as being part of the day-to-day working of his Department. He has set up all sorts of boards which work in with other ones. One to which he has referred is the Medico-Social Research Board. He and his Department are in close touch with that board and with the World Health Organisation, at which point something comes into my mind in connection with 'flu epidemics. There has been a scare. It is very hard to tell, when you read something in the papers and are not yourself a medical person, how far these statements are founded on fact. They sometimes are, but sometimes they are not as medically or statistically correct as the announcement would lead one to believe. There has been a scare about the danger of a 'flu epidemic coming from the Far East analogous to the swine fever which attacks swine. I should like to ask the Minister what are his views on that and whether vaccines are readily available here if the occasion arises? However, that is a digression.
The field of preventive medicine is one which a remarkably short time ago was not held to be within the purview of the Department. It was held to be something the public themselves would deal with. While no Department of State can enter into that field in a personal way, they can and do give great encouragement and help to bodies which are interested in that enormous field of medicine. We all recognise that the cheapest way of dealing with any illness—and the larger the scale the more money is saved—is to prevent it over as wide a field as is possible. In that large field lies the question of physical fitness, the training of children in school and the lecturing of teachers and pupils on the value of physical fitness. That is something quite separate from the therapy which takes place after illnesses.
All that side has been touched on in the Minister's statement. He made a comprehensive statement from which one can see that the health of this country is not as bad as we sometimes like to think it is. We sometimes think we should do better—and of course there is always room for improvement —but if you study the statistical information in this very fine booklet you will see that Ireland, from the point of view of longevity, the health of women and children, is well up in the Western European league of health. The Minister and the Department are to be congratulated on that aspect of medicine and for producing this very fine booklet, which is a mine of statistical information. Clearly set out in that mass of documents and figures are the figures for the health of this country, which, I am glad to say, is quite good.
The question of alcoholism has been touched on by various speakers. The Minister referred to it at some length in his address. It is a problem in this country. Nobody can say how far Departments of State can help in alleviating it. I believe alcoholism is a medical matter. People not only become medically and often mentally unfit through alcoholism, but often they have medical or nervous complaints. No layman can lay down hard or fast rules on that. Even our judges when dealing with culpability in our courts have, in some cases reluctantly, been forced to grant a certain degree of medical leniency or alleviation of the problems which come before them. I say "reluctantly" because there is a school of thought that all crime has its medical roots and that everybody who commits a crime is, to a greater or lesser degree, sick. Obviously, there is a great deal of truth in that.
The Department of Health should keep an open mind on the very wide aspects of medicine relating to the physical and medical health of the population, how law-abiding are our people or how far juvenile delinquency has its roots in what are essentially medical problems and sometimes also Department of Health problems.
From my experience in this House. I would say that the Department of Health are wide open to the examination of that area of their responsibility. There was a time when people, both inside and outside the Department, said that that was not their concern, that it lay with lay bodies or the courts of justice and so on. Now that whole aspect has changed. If one were pushing the Department to interest themselves and to gather information on those subjects, one would be pushing an open door.
I would like to touch briefly on the very large and unique contribution which is being made by private citizens, many of them religious, who run hospitals and so on. They are a tremendous help to the work of the Minister and the Department. They take a great load off the backs of the public, both in expense and in the quality of the service they give. The Cheshire Homes were referred to and there are many other bodies which deal with other aspects of health. Alcoholics Anonymous and so on. The religious provide hospitals and training places for sick and handicapped people.
I congratulate the Minister on his speech and on his work in the Department. He is carrying on a great tradition in which this House and the country are interested, to help the sick and improve the health of our people. In spite of high costs and the difficulties involved in this enormous all-embracing Department, we can be very proud of the work the Minister and the Department are doing, for which there is a very sympathetic body of public opinion.
The Minister stated in the opening of his financial policy that he hopes to keep the medical services in 1976 at the same standard as they were in 1975. Unfortunately, I do not think he will be able to do this because already signs are appearing of cutbacks in the services, particularly in the service on the public health side in relation to public health nurses. One fears that, unfortunately, further cutbacks may have to take place to meet the financial situation which constrains the Department of Health and all Government Departments. However, it will have to be stated and admitted that down the years each Minister for Health and each Parliamentary Secretary have made great efforts in advancing health care throughout the country and making provision for illness of one kind or another.
Firstly, I propose to deal with one aspect to which the Minister has not made any reference, that is, the obstetrical and maternity sides. It is accepted that a reasonably good indication of the standard of health services is the reduction in the death rate of both mothers and infants. With this as the standard, it is easy to see that down the years there has been continuous progress.
The Irish Medical Journal of December, 1975, contains a report of the maternity mortality committee of the IMA. They give a resumé of the ten years from 1964 to 1973. It is as well to point out that this is a committee which was organised by the Irish Medical Association. It consists of their own members, the people who are working in the maternity or obstetrical speciality. Each year they come together and investigate the number of maternal deaths which have taken place throughout the country. They try to establish the reasons for those deaths and, naturally enough, to take precautions and to instruct themselves as to how they may be avoided in the future. It is well that the public should know this, because I do not think there is any other professional group in the country that perform this exercise of self-examination and, to a certain extent, self-criticism, and that is in the interest of their patients.
The figure for the maternal death rate in 1964 was .64, and this, in 1973, was reduced to .31, and in 1974 was down to .28—in other words, the figure has been more than halved. Unfortunately, most of the deaths took place in the lower income group. The number of deaths is about 20 each year, but most of those take place in the lower income group. In the past reference was made each year to the occupations of the people concerned, and at that time the people of the itinerant class seemed to have a larger share in it than others. The more recent report does not seem to refer to this.
However, these figures provide some basis for the suggestion of the Bishop of Kerry that mothers who are expecting babies should get extra financial help. I do not think anyone would agree that people in the higher and middle income groups or, indeed, all of the people in the lower income group would need this; but there are certain sections of the lower income group who could well do with this extra help. One would have to think about the form in which it should be made available. Making it available on a financial basis would probably not be the best thing for the itinerant, in particular. One would think of protein food or something on those lines, and, naturally enough it would need some supervision. Some effort should also be made to get people like itinerants into the hands of doctors somewhat earlier, as there is a tendency for them to wait until the latter months of pregnancy before they present themselves to doctors.
One interesting observation that must be made about these statistics is that in 1972 the higher income group had seven deaths, and most of those were due to infection. I do not recall the details of the IMA group's findings on the 1972 deaths or what explanation was given for this, but looking at it without the extra information I think it is extraordinary that this could happen in a time when we have so many antibiotics available to us to deal with infection.
There are other interesting items in this book of statistics which was made available to us by the Minister, a fact which has been commented on and on which I add my thanks to the Minister. It contains a great deal of information. One of the things I observe in it is that the Galway maternity unit has a bed occupancy of 125 per cent, and this suggests to me that it is grossly overcrowded. Its neo-natal unit has a maternity occupancy of 114 per cent. Therefore, from the purely statistical point of view this unit is not large enough and it is certainly overworked. It must be admitted that such a unit of itself is not the best in which to conduct first-class maternity services. On the other hand, I observe that other maternity units around it also seem to have a fairly big bed occupancy, being in the 90 per cent category, with one exception which happens to be the Roscommon County Hospital maternity unit.
In arranging for priorities and organising the medical services in a body such as the Western Health Board, when it is seen that one unit is overcrowded, those concerned should see that the beds that are available in the non-crowded unit become available to the public. This could be done by availing of the beds in the Roscommon County Hospital. The Western Health Board have asked to have the Roscommon County Hospital staffed as a proper obstetrical unit. Unfortunately, Comhairle na nOspidéal in advising the Department and the Minister, fulfilling their statutory obligation, have not gone along with this recommendation of the Western Health Board. There is something wrong that this situation should obtain in our area. Taking the guidelines which they themselves suggested for the development of such a unit, the unit, catering for over 1,500 births, should be staffed by two obstetricians, a paediatric specialist and have radiological and laboratory facilities.
The statistics revealed that the average duration of stay for a maternity patient in a hospital is six days and in fact many hospitals have a lower figure of 5.5 to 5.6 and indeed down as far as 5.4 Assuming six is the standard, I estimate that the total bed-days in Roscommon County Hospital will provide accommodation for 1,540 patients. Here is a basic theoretical unit making itself available for the standard guidelines for Comhairle na nOspidéal, but when this advice is given to the Minister and his Department they do not seem to accept it.
A further guideline is the density of population in the area of 40 people per square mile. Most of Roscommon and surrounding areas would come into this. Another guideline is the figure of 75,000 people. This would be probably the more difficult one to make up. Nevertheless, taking in the hinterland of the county which includes the towns of Athlone, Long-ford, Carrick-on-Shannon and Ballyhaunis and around there, I have no doubt that this hinterland would go very near to meeting the 75,000 population.
Here is presented a definite case for the establishment of such a unit, particularly in view of the overcrowding that seems to be taking place in the maternity unit in Galway. The assigned birth rate in County Roscommon is 850 births, and probably there would be this difficulty in providing 1,500 actual births within the confines of the county hospital. Nevertheless, the towns which I have mentioned, a patient from which could be allowed access to the county hospital, would go a long way to making up the 750 births that are needed and by doing this they would take the pressure off Mullingar, Sligo and Castlebar hospitals and the Portiuncula maternity unit, all of which seem to have difficulty in providing accommodation for people. I suggest to the Minister that this unit and this area should be re-examined in the light of what I have said, or, alternatively, that the Minister contradict each of the points that I have made to him here and point out to me where it is unacceptable to provide those extra facilities in Roscommon.
There is another aspect to this. Living in north Roscommon at a distance from the regional hospital, one is very perturbed about the disposal of patients on the maternity side. They are sent to Galway and they have to travel something like 80 or 90 miles. This is not a journey that one would suggest to any woman in labour, and this means that to get her there in time even under normal conditions she must be advised to go two or three days beforehand. This again is going to lead to further overcrowding in the Galway unit, whereas if we had a unit more convenient to us in Roscommon, and the unit which I have suggested complies with the outlines of Comhairle na nOspidéal, we would get over this difficulty.
Under abnormal circumstances the situation is aggravated and indeed under abnormal circumstances of acute onset the situation could be absolutely disastrous. I am thinking of one such case in the last fortnight. Here where we are dealing with the maternity death rate, of, fortunately, about only 20 people, at least one death would add substantially on the percentage side. However, statistics in this case do not matter. One life is just as valuable as another. It is only fair to say that as far as the Minister, the Department and the health boards are concerned every facility as far as is reasonable is made available to avoid those deaths.
I am suggesting to the House that Comhairle na nOspidéal, who have this statutory duty to see further into those matters, are creating a situation in the Western Health Board that they could obviate by making different recommendations to the Minister and to the Department. Another aspect is the question of paediatric services. This would mean an extra person on this side, but that would not be as absolute as the two obstetricians properly trained. Naturally enough they would cater for the acute emergency which can arise in obstetrics. In that case a long journey will add to the difficulties.
The Minister also mentioned that the priorities of the Western Health Board are an extension of Castlebar Hospital and an extension of the maternity unity in Galway, but of those Castlebar takes priority. I would be inclined to question that in the ordinary course, but the fact that those extra beds are available in Roscommon to my mind justifies taking Castlebar as the priority until they make some further reference. To provide 25 extra maternity beds in Galway, assuming they get down to this priority—at present prices I am told the cheapest hospital bed costs £9,000 under the cheapest circumstances—this is going to drive us into a fairly large figure. Assuming the interest of the capital outlay on those 25 beds is only 10 per cent, this means a cost of servicing that capital debt of £22,000 a year. This would adequately pay a consultant staff in a maternity unit or an obstetrical unit in Roscommon. In fact it would more than do so. Here is another reason why a new look should be taken at the accommodation that is available in Roscommon because, as the Minister said, it is most unlikely that this extension to Galway maternity unit will be provided in the very near future, despite the fact that it appears to be the second priority on the Western Health Board side.
In my view there is a greater priority at the moment for the Minister's money in the Western Health Board, and that is the extension of the orthopaedic theatre unit in the Merlin Park Regional Orthopaedic Hospital. We have been told that the Western Health Board are seeking extra theatre facilities which would involve equipping a new theatre. If this were developed it would provide a very good service for us, reduce the extraordinary waiting list we have and reduce numbers of unfortunate people who are waiting for this newly-developed hip operation. The last time I was told about the waiting list for this it was something like 220 patients, and with the present available theatre space in Galway, only God knows when they will get through this. There is something wrong in suggesting that the maternity side be developed when beds are available, if proper use is made of them within the health board area, instead of providing this necessary service for the people at the other end of life who need it very badly and which would provide a great deal of comfort, mobility and sleep for those people advanced in years who unfortunately need this operation more than others. That is not taking into account all the other orthopaedic difficulties awaiting solution.
I have dealt at length with this and analysed it to the best of my ability. I sincerely hope the Minister will have another look at it and present the figures and facts as I see them, and at some time take the opportunity to point out to me where I am wrong or where what I suggest is unacceptable to Comhairle na nOspidéal, the people on whom I place the most blame. The Minister, and the Department, in the past seem to have had a more humane and sympathetic approach to those problems. I accept that there is this constraint on money, a matter I have already dealt with. The interest which would be paid for the minimum unit by which Galway could be extended would go a long way towards paying a properly equipped obstetrical unit in Roscommon, even with two obstetricians.
I have heard a suggestion that some of the county hospitals will eventually be designated as community hospitals. The main suggestion in this regard is that they will be made available to general practitioners where they can look after their patients before they enter hospitals or after they are discharged. This is acceptable. Indeed, general practitioners through their medical organisations down the years have asked for this facility but, on the other hand, to offer it to all patients and all doctors as a facility is not on. Many general practitioners live a distance from the hospitals and they could not serve them.
The nearest hospital to me would be Manorhamilton and it would be impossible for doctors in Carrick-on-Shannon, Mohill or Ballinamore to travel to Manorhamilton to look after their patients. They could only do so by neglecting the patients they have at home. That would mean that there would be a number of patients in the community hospitals for whom other medical services must be provided. Those services can be provided by the general practitioners living adjacent to the hospitals and this would mean increasing their workload but how would they be paid? They would have to be paid extra and if that was not agreeable somebody else would have to be appointed to run the hospitals. What qualifications would the person appointed need to have and what would he be paid? If it was necessary that he should have high qualifications and be highly paid should we not go further? That is the difficulty I see.
I do not know how much thought was given to this matter. We were circulated with a document by Comhairle na nOspidéal but that document did not advert to this side of the problem. Having thought about it, I considered it to be an exercise like that carried out by the Department of Education when they decided to close rural schools and tried to induce parents to send their children to the other schools by offering transport. One gets the feeling now that transport is being tightened up also. I believe that this aspect of a community hospital scheme will eventually create administrative difficulties. I do not know how the problem can be solved without appointing a medical officer to be attached to the unit. It may be said that a medical officer could be appointed to the unit and that the general medical practitioners could work the unit also and that is a solution to the problem but what would the financial involvement be?
It should be remembered that specialists will have to travel a distance to attend those community hospitals. It is 20 miles from Sligo to Manorhamilton and 40 to 50 miles in the case of Roscommon. Are those highly skilled and highly paid men to be asked to spend up to three hours of their day travelling to clinics? Is that a wise investment of money? The main reason for suggesting the re-organising of those hospitals is that units are costing too much but I wonder how does one interpret this cost-benefit analysis of running an hospital. This has been written and debated but I do not think there is any agreement on it. It would appear to be a great waste of a great skill to suggest that a man should spend up to two hours per day travelling to his work. That is not making good use of that man's time, particularly when one considers the length of waiting lists in the health board regions.
Waiting lists are getting longer each month and this is a tribute to the development of the health services. It shows that the doctors and patients are agreed that they will get the same service at the local clinic as they had to seek further afield and pay a lot more for in the past. In this regard the Minister and the Department are deserving of congratulations but, nevertheless, the length of the waiting lists creates a lot of anxiety for patients. It has been suggested that the bed occupation of an hospital can be reduced by employing extra staff. A report to this effect was published in the Irish Medical Journal of March, 1976. That publication stated that such an operation took place in Crumlin children's hospital and listed a number of reasons why that hospital succeeded in reducing the bed duration. The first was that there was a commitment by the staff to do this and the second was that the number of staff was increased. In the summary the latter seemed to be the main reason why that hospital was successful in having their bed occupancy reduced. Here is a lesson for us on the other side. It is obvious that we can reduce the waiting lists by employing extra people.
In this regard the question that must be considered is whether the employment of extra people would involve as much money as the provision of additional beds. Seeing that the cheapest estimated cost of providing a hospital bed is £9,000, and the dearest is £18,000, one must be forced to the conclusion that a lot of thinking should be done before extra bed accommodation is provided without firstly providing the personnel. In this way the overhead costs of the health services could be reduced substantially.
I should like to give some idea of what a conscientious consultant considers necessary at outpatient clinics. That consultant feels that a clinic with a waiting list of more than three weeks probably does more harm than good. He stated that the bottleneck in service comes from the actual interview at the clinical examination. The nature of the problems takes something like three-quarters of an hour per new patient and he mentioned that some of the assessment clinics in England were seeing as few as four or even two patients a week. He said it was not possible, unfortunately, to save time on apparently trivial and obvious cases since one must go through the full examination or else be held liable for the inevitable "mispathology". From that one gathers that those people have their difficulties also. In my view the only way to get over this difficulty is by appointing extra personnel. Until there is adequate service of consultant, specialists and ancillary grades available to meet the requirements of the general handicapped and disadvantaged those difficulties are likely to continue.
That gives an indication of the amount of time that has to be spent on this. The Minister has dealt with the general medical services and the amount of money that is spent on that. Everybody who is responsible for the introduction of the general medical services into this country on a fee per item basis should be congratulated because they have done more for the development of the medical services at that level than has been done down the years and have provided a much better relationship between doctors and patients. Unfortunately, some doctors are inclined to abuse the scheme but these things have to be dealt with. We must accept that they must be dealt with and investigated as necessary. Something that strikes me is that we read about and hear on radio of admonitions to the general service for the reduction on expenditure. It is not made so public when other services are asked to reduce their expenditure. However, this is probably done by writing but, unfortunately, the media seem to point the finger more at the general medical services than at the hospitals. Eligibility is increasing all the time and I have no doubt that if the money were available it would increase much faster.
There is, I understand, an agreement between the medical associations and the Department to the effect that when the total eligibility for medical cards throughout the country reaches 40 per cent the whole system will have to be reviewed. Eligibility in the west of Ireland has gone up to 50 or 55 per cent. One would think that we should be entitled to a review now on our own. Another point in relation to the Western Health Board's figures is that it has the lowest number of attendances both from the point of view of surgery and domiciliary visiting. In view of the large number of old people in the area this is a surprising figure. I suppose it is because of the fact that the people are so far away from the doctors that they are not inclined to visit them so often or the doctors do not visit the patients as often as they do in other health board areas. Another aspect is that the patient must choose the doctor who lives within seven miles of him. If he chooses a doctor who lives further away, the doctor will not get the extra fee for going over the seven miles. Some of these people live in very difficult places to get to and they should have their choice of doctor the same as everybody else. That is something that should be looked into and done away with. It seems to apply more in the Western Health Board area than in other areas and doctors are inclined to take on the patients even though they know they will not get the extra fee which they would get if the patient was living in some other place.
Much has been made of the cost of drugs and the amount of drugs that have been given out by doctors. A statement was made in the House that £5,000 worth of drugs were found in a house in the south of Ireland. I did not see that in the papers. It is extraordinary that that should happen. Doctors are criticised for giving out drugs. The are criticised, on radio in particular, for giving out tranquillisers. I do not know why tranquillisers should be picked out more than anything else. Is this a basic indication of our attitude to mental diseases and emotional disturbances in that we do not understand them as well as we understand pain? In the case of ordinary mental diseases if a patient is seriously ill he is sent to hospital but in relation to emotional diseases people say: "He just gave me a tranquilliser and sent me home". In these cases our critics suggest that we should sit down and talk to the people and not give out any medicine or very little medicine over a short time. It is quite true that this is probably the proper approach and it is a lucky doctor who has the time for that approach and, indeed, the patient is twice as lucky if he has a doctor who has such time. If he has such time he has not a very big income from medicine. Nevertheless, there is a lack of understanding among our critics if they suggest that we see those people and treat them solely by talking to them. This is not acceptable.
If a patient goes to a doctor with a stone in his kidney and the doctor sat down and talked to him about the stone and how it came and told him the pain would eventually go if he put up with it long enough, and if he does this, that, and the other, and then sends him home without doing something to relieve the pain this would not be accepted. The patient would feel that the doctor was neglecting his duty. If a patient comes with some emotional disturbance, and having explained the situation to the patient and pointed out to him what he should do, surely if you can help him further there is nothing wrong with making medicine or drugs available to that patient. Not alone is there nothing wrong but I feel there is a duty to do something for them, because after all, their pain or discomfort more often than not is much greater than the person that has an actual organic pain. The media do not understand this problem. I feel that this is basically because we as a people do not understand mental or emotional problems most of which are referred to as nerves. The suggestion that a person suffering from nerves should be able to just shrug it off is a completely wrong approach.
In relation to the question of inoculation or immunisation against whooping cough, I feel that the Minister was a bit remiss on this when the controversy was hotter than it is now and when it was getting so much publicity. As far as I recall, there was no definite statement made at that time about it. Many people had difficulty in deciding for themselves whether or not to immunise their children. Unfortunately, there is a tendency among some people to say that what they hear on television or radio is much more important than what the doctor tells them. We will have to put up with that I suppose. The silence from the Department on this issue created an amount of anguish for some young mothers who never saw whooping cough as the last generation saw it. It is only in the last while that medical organisations pointed out that in the better interests of patients it should be continued.
A matter of priority is the waiting list on the orthopaedic side, the ophthalmic side and the dental side. I feel that some effort should be made to get these waiting lists reduced. It should be a first priority because there is something hopeless about telling a person he or she will have to wait three, four or five months for a service. I appreciate that there are difficulties in regard to personnel but one would be inclined to the view that if the money offered to aspirants was attractive enough they would be willing to come into the service. There is the alternative that for a period of a year or two the patient would be given the option of attending private practitioners. This would entail arrangements with the private practitioners to take up the backlog that exists in respect of dentures and spectacles. A GP is in a difficult situation when he is confronted by a child who is studying for an examination and who is having difficulty with his eyes because the GP does not find it easy to tell the child that it will not be possible to have him fitted with glasses before his examination takes place. The doctors concerned go out of their way to meet the situation but it is an unenviable task when there are so many requests and such a long waiting list. This sort of situation should not obtain.
To get back to the question of Roscommon County Hospital, the federation proposed is intended to be a solution to the problem but I do not know how it will work. However, I shall not say very much about it at this stage.
The re-organisation of hospitals as announced by the Minister seemed to lack one major advance. I refer to the need in the midlands for a unit at which victims of road traffic accidents could be treated. Either Tullamore or Mullingar would be an obvious choice. In the centre of the country there are the main arteries to the south, the west and, to a certain extent, the north since much of the Donegal traffic goes through Mullingar. Therefore, the provision of a unit for dealing with accident cases should have been a priority in the re-organisation structure. I have in mind a unit at which the various specialist services would be available, including a brain unit. To all intents and purposes there is no brain unit outside of Dublin so the provision of one in the midlands would eliminate the problems involved in having to send patients to Dublin, both from their point of view and the point of view of visitors. It should not be necessary to send to Dublin every case requiring brain treatment.
Most speakers have referred to the problem of alcoholism. I have not much to add to what has been said already. The problem seems to be increasing although I do not know whether drink consumption is at the high level which existed before the last budget. Deputy Briscoe was under the impression that this subject was not mentioned in the House before but I think I must have been the first here to suggest that the rounds system contributed more than anything else to alcoholism. I suggested that we should get away from that system as this would be a big factor in preventing an extension of alcoholism.
The voluntary health insurance scheme is invaluable to its many members. It is worth recording that the IMA were the first body to suggest the basis of this scheme. Indeed, they have suggested that it be extended to include the remainder of those to whom medical services within the social welfare schemes are not available. I understand that the suggestion is being presented to the Government and we wait with interest the result of the move.
On the question of the smaller hospitals I should like to quote from the Annals of the Royal College of Surgeons of England—the April, 1974 issue—in which, at page 198 Rex Lawrie had this to say:
The little hospitals are friendly places closely related to the group they are designed to serve.... It is sometimes argued that these civilised and friendly conditions are less important than the medical care and that the advantages of the highly equipped district hospital will compensate for long travelling times, loss of personal attention, and perhaps less efficient and changing personnel. But in fact 80-90 per cent of all medical and surgical conditions do not need specialised units and can be treated in small hospitals quite as well as in large hospitals, and this also applies to emergency situations.
If it should prove necessary to transfer a patient to a special unit, this can easily be arranged.
For these reasons—good patient care and patient preference—I believe the closure of small general hospitals to be unjustified and contrary to the best interests of the community.
This is the opinion expressed by a reputable man in a reputable journal and it should be available to those concerned here because there are many factors in this sphere which must be taken into account, a very important one of which is the question of visiting and also that of travelling to out-patient departments. It is hardly fair to tell somebody that he is entitled to free medical services if, in order to avail of the services he must pay, perhaps, £10 to £20 to hire a car to take him to the institution concerned. However, I expect that this question will arise again and that we shall have more to say on it.
I should like to quote, too, from the British Medical Journal of October 26th, 1974, in which there is a review of the book The Soviet Health Service—a historical and comparative study by Gordon Hyde:
Two facts will surprise most readers. Not all medicines are free, charges being maintained because they cause no hardship to the patient and contribute towards the pharmaceutical industry. Private practice is not illegal. Patients can go to "pay" clinics and get a second opinion from a senior specialist....
Therefore, even in that state which is represented to us as being the last word in so far as social services are concerned, there remains room for private practice.
Finally, I would summarise what I consider to be the priorities in medicine. The first is that general practitioners be easily available to the people. This can be achieved fairly easily in built-up areas but it is not always possible to achieve it in rural areas. On the hospital side one would like to think that a patient on arriving at a hospital would be attended to immediately if he is acutely ill and that there be competent consultants for this work. The purpose of advocating that there be two consultants in the smaller hospitals is to allow for reasonable time off for each. But when what is required is mostly a matter of investigation, one would like to think the laboratory facilities and the radiological facilities would be convenient, and there would be reasonable clerical staff available so that the consultants would be in a position to get out their reports in reasonable time to the referring doctors.
In regard to the radiological services, in case I do not get an opportunity of saying this again, and in reference to the community hospital idea, it is no service just to have a radiological unit in a place unless there is somebody there to interpret the results within a reasonable time. Sending a patient there with, say, an injury to a bone and having to wait three or four days before you get a result of the X-ray is not a medical service, to my mind. To write on paper that a radiological service will be available some place is not a service.
The Minister referred to the auditing of health board accounts and said he intended having copies of the audited abstracts of health boards accounts for the years 1971-72 and 1972-73 laid before each House of the Oireachtas. I should like to make one or two comments on that before I go on to speak on the general Estimate. The health boards were set up by the Health Act of 1970 and have been operating since 1st April, 1971. Section 28 of the Act provides, in effect, that the accounts, like those of local authorities, shall be audited by a Local Government auditor. Section 29 provides that the audited abstract of accounts shall be published by the boards and that copies shall be sent by the auditor to the Minister and to the local authorities who appoint the members of the boards and that the Minister, in turn, shall send copies to the Minister for Finance and the Oireachtas.
The present position is that the boards have been slow to produce final accounts and for this and other reasons the audits are in arrears. In the case of all boards the two years to 31st March, 1973, have been audited. The abstracts of accounts for those two years are now ready, I understand, and will be laid before both Houses of the Oireachtas in the very near future according to the Minister's statement. For the three years accounts to 31st March, 1974, 31st December, 1974, and 31st December, 1975, the audits have either not been completed or not started. In most cases, the completed audit reports on the 1971-72 and 1972-73 accounts are believed to have been uncomplementary. There are indications that advantage may be taken of the literal wording of the Act to limit their publication.
The abstracts of accounts only, it seems, are to be sent to the Oireachtas without the reports, although some of the reports are believed effectively to qualify the auditor's certificates. Certain boards which had the combined abstracts and reports printed in booklet form have been asked to have a supply of abstracts only without the reports specially prepared presumably for submission to the Oireachtas. To my mind, this raises the question of respect for the Oireachtas and the principle of accountability. I would ask the Minister to ensure that, as well as abstracts of accounts, the reports also are placed before both Houses of the Oireachtas.
By comparison with county councils who formerly administered the services, the new boards are highly geared in the matter of staffing particularly at the finance and accounts end. The McKinsey model which was adopted provided for a finance officer, a financial accountant and a management accountant, compared with a financial accountant only for the county councils. Union pressure made it difficult to recruit professionals to the new accountancy posts and com-puterisation and staff mobility have created their own problems. Even so, the posts have been filled and the accounting performance, to my mind, should be better.
Public notices of the audit or local authorities and arrangements for public inspection of their accounts are provided for by the public bodies order. These orders do not seem to apply to the health boards. Even though the boards, to date, have followed procedures similar to those of local authorities, there appears to a layman to be nothing in the Health Act either to prevent a departure from present practice or to ensure uniformity of practice between one board and another.
In discussing the Estimate for the Department of Health one cannot but be overawed by the amount of money set aside for the administration of the health services. The figure of £250 million approximately which the Minister is asking for this year is the biggest demand ever made. To the ordinary person it would seem it was more than enough to provide an adequate and efficient general medical service for all our people. Unfortunately that is not the case. For the past six months or so, health board officials have been engaged in a pruning operation desperately trying to maintain existing services and to contain those services within the financial allocations made to the boards.
One cannot but agree with any efforts being made by health board officials or members to eliminate wastage in the administration of the health services. I am afraid in the present situation they are going far beyond the limit. There is confusion not only among the health board officials but among the general public at the extent of the cuts it has been found necessary to make in order to work within the financial allocation made by the Department of Health to each board. Schemes which have been in operation for a number of years, such as the home help scheme, have been severely curtailed. No longer is it possible for a relative of of an aged or disabled person to qualify for this allowance.
Even though it amounts to a few pounds a week only to the person getting the allowance, nevertheless it often helps to provide the additional nourishment which the elderly person needs. People who are non-relatives of the old or incapacitated person have had their allowances cut. This is one area where I believe the savings effected as a result of this cut will not have the desired effect of saving money for the health boards or the Department of Health. It will mean more of those people will be institutionalised. In the long-term this will cost the health boards much more money.
When this Government took office in 1973, they committed themselves to improving our social services. If we take the administration of the health services as an example, I am satisfied the Government have not honoured that commitment. It is no good telling people the Estimate for the Department of Health has been increased by £X. People base their judgment on the type of service they get. They are not getting a good service at present. Hospitals are over-crowded and there are long waiting lists for certain types of operations and for dental and ophthalmic treatment. Geriatric patients and those suffering from strokes are being discharged from hospitals. This is not progress or an improvement in the general health service.