The Minister for Health was in possession and he has 30 minutes.
Private Members' Business. - Grants for Mentally Handicapped: Motion (Resumed).
Debate resumed on the following motion:
That Dáil Éireann calls on the Minister for Health to devise a system of differential grants for the mentally handicapped which will take account of the degree of handicap and the extent of home care required; that powers of admission to and discharge from all institutions for the mentally handicapped be under the control of a panel of public health psychiatrists and social workers employed by the Health Boards; that an approved points system be established to decide priorities for admission to residential and day centres for the handicapped, such a points system to take into account (a) the degree of handicap (b) behaviour difficulty (c) disruption of family life (d) family circumstances; and that Health Boards be instructed to undertake their statutory obligations for the care of the mentally handicapped by providing a special annual budget for this purpose.
—(Deputy O'Connell).
In moving this motion Deputy O'Connell made it clear that he was not seeking a system of differential grants in respect of handicapped children as the words of the motion seem to imply. For that reason I do not consider it necessary to deal with that particular issue.
Both Deputy O'Connell and Deputy Boland, however, felt that the present allowance was inadequate. I am aware that there is some dissatisfaction among parents that the rate of the allowance has not increased since it was introduced in 1973. I have had representations about this from various groups and individuals including the National Association for the Mentally Handicapped. I am sympathetic, but any increases in allowances of this sort have to be considered in the context of the budgetary situation.
The motion proposes a more formal method of admission to and discharge from centres for the mentally handicapped. The suggested procedure would involve a panel of health board personnel and the creation of a points system which, it is argued, would ensure a more equitable filling of places in the various centres.
I think I should first explain briefly to the House the manner in which the services for mentally handicapped persons are provided. We have now about 5,000 places in special residential centres and 5,700 in the different day care units throughout the country. All but a few hundred of these places are in centres owned and operated by religious orders and voluntary organisations. The right to take the final decisions as to the patients to be admitted to and discharged from these centres has always rested with the management authorities of the different institutions.
Obviously if the new procedures of the type put forward in the motion were to be implemented, then that right would be taken from these bodies. This would be a serious step with serious implications. It would represent a complete change of approach and, in my view, would be more likely to bring about a disimprovement in the situation rather than an improvement.
An essential element in the general running of most institutions is the capacity of the authorities of a particular institution to decide on who should be admitted to it. It is not very difficult to envisage the effect on the morale and the atmosphere of an institution if that capacity were withdrawn. It would also suggest that the present arrangements are inequitable and that the authorities of the different centres are being unduly selective in their admission and discharge policies. I would question whether that is so.
I am sure that, if there were a general feeling of dissatisfaction among parents and friends of the mentally handicapped about present procedures for admission and discharge, my Department would be aware of it. They are not so aware. Furthermore, I have had inquiries made from the health board officers since the Deputies in question tabled this motion and I find that none of them wishes to have the present position changed.
At present when a centre receives an application for admission either from a health board or direct from a family, the normal procedure is that the authorities of the centre will arrange for an assessment report. This assessment is usually carried out by an assessment team employed by the authorities of the centre. If, on the basis of the assessment, the authorities are satisfied that the patient is suitable for admission his or her name is placed on a waiting list. Admissions are arranged as suitable vacancies occur.
I understand that selections from the waiting lists are made on the basis of the greatest need and not necessarily on the length of time on the waiting list. Obviously, there will be cases in which one person's view of the greatest need will not be another person's. I would not claim that, in every instance, the right decision is made. It is not always easy to balance one family's anxiety against another's and to say dogmatically where the priority should lie.
I know that theoretically a good case can be argued for a points system and Deputy O'Connell and Deputy Boland have done so. However, I feel that, allocating the right priority to a mental handicap person and finding the most suitable and convenient place for him or her, is a much more complex task than the allocation of a house, as some Deputies adverted to yesterday. I agree that the present method is an unsystematic one but I think it works better than a formalised one would.
What is important is that the system of selection should not be snarled up by complicated rules and regulations, by the calculation of points or by notional concepts of what constitutes hardship. It should be flexible, family and personal considerations involved, and the decision should be taken by experienced and compassionate people. That is what is happening at the moment and I have no evidence to justify interfering with that arrangement.
As I have said, the health boards are not dissatisfied with the present admission and discharge policies of the voluntary organisations. In every health board area there is an informal committee consisting of representatives of the health board and of the voluntary agencies providing for the mentally handicapped. These committees meet from time to time and I understand they are a valuable medium for ensuring close co-operation and coordination between the statutory and voluntary agencies. They help to remove problems. They provide a forum for discussing complaints made by the public about the services, including issues about admissions and discharges.
I might mention here that I plan after Christmas to convene a meeting of senior administrative and professional personnel in the mental handicap services, both voluntary and health board. This seminar will provide an occasion for a review of our mental handicap needs and our policies and certainly one of the matters for discussion will be our admission arrangements.
The local committees and conferences of this sort are a better way to iron out any inconsistencies in the policies of the voluntary organisations than waving the big stick at them. I am not claiming that every decision taken by the voluntary bodies is the correct one. While there appears to be general satisfaction with the present arrangements, I have no doubt that it will be possible to point to individual instances when a handicapped person has had considerable difficulty in securing admission or has been discharged contrary to the wishes of his family. I know this happens from time to time.
When Deputy Boland concluded, I asked him a question but time did not permit him to answer it. He was talking about a points system and he indicated that he would favour a points system if he could be assured that it would work. I posed the question whether the points system he had in mind would be of national application, or whether each individual centre would have its own points system. These are important issues. I could not see a national points system working because then children could be allocated from the convenience point of view to most unsuitable centres.
I cannot see any points system working. I was dealing with the terms of the motion.
I see. Sometimes a centre will feel it has not got the staff or facilities to cope with a handicapped child or an adult who is very disturbed. Or it may be found in regard to a child in a children's centre that, when he reaches a certain age, the problems of caring for him are so great that it may be in his interest and that of the other patients that he should be discharged. I am aware that there are difficulties of this sort but I think, in general, decisions are taken in a fair and humane way. If I had evidence that the position were otherwise, of course I would have to intervene.
In that connection it is important to try to decide what we are really after in this area. Surely the primary objective must be satisfactory homes rather than some mathematically accurate points admission system. If some points system or other system would result in the destruction of a home or interfere with the management's guidance and control of the home, I do not think any of us would wish for that. It is the atmosphere and the quality of the centre which is important. That should be our primary consideration. The capacity to determine admissions in particular is very important from that point of view.
One of the main factors which gives rise to suspicion is that when a vacancy occurs in a centre the authorities are often forced to choose a patient of a particular sex, age, or degree of handicap who will fit into the ward or unit where the vacancy has arisen. This could, for example, give rise to a situation where a moderately handicapped child would have to be given preference over a severely handicapped child, but I think that is inevitable in any system. We must keep in mind the situation prevailing in the centre. The authorities of the centre must have the right to take certain decisions in that regard and sometimes, because of the different factors involved, this may result in taking a moderately handicapped child before a severely handicapped one.
I would hope that nothing said during this debate will give rise to the impression that we are not conscious of our great debt to the religious and lay organisations working in the field of mental handicap. Previous speakers have all been at pains to emphasise that we are greatly in debt to these organisations. Voluntary organisations take a notable part in many aspects of our health services but their role in mental handicap is outstanding. I do not have to remind the House that the task of caring for the mentally handicapped, particularly those who are severely handicapped, calls for very special personal qualities. It is difficult work and calls for a very high degree of commitment. It requires a great deal of patience, endurance and compassion if the patient is to be well cared for.
The voluntary bodies, and particularly the religious orders, have set standards in this field which make our services the envy of other countries. It is well to appreciate and understand that. Long before the State began taking an interest in the handicapped there were voluntary bodies with staff working interminable hours on limited resources providing the nucleus of the service. We have built on that service and on the knowledge and experience which these bodies established. We must not forget what they have done and are doing. I share what I think was the unanimous view of the Deputies who have contributed to this debate that we are greatly indebted to the voluntary organisations. I do not agree, however, that we have been unfair or ungenerous to them.
Deputy O'Connell appears to have the impression that the State is, to some extent, prepared to leave to these voluntary and religious organisations the job of providing this difficult, demanding service and that it is not prepared to make adequate financial provision for them. Clearly, an impartial examination of existing services would readily indicate this is not so. Almost all the capital projects undertaken by the religious orders and lay bodies in this field of mental handicap are financed 100 per cent by the State. Where running costs are concerned, the larger residential centres have their total expenditure recouped direct by my Department on the basis of annual estimates submitted by them. Sometimes there may be minor disagreements as to what is recoupable but I understand that the voluntary bodies in general are satisfied with the way they are being treated. Some of the smaller residential centres and many of the day centres receive their grants from the health boards and again I am not aware of any general dissatisfaction with their treatment.
It is possible that similar sized centres may get different grants. Deputy Boland has referred to this and very rightly indicated that there is sometimes confusion in the public mind as to why this should be. I assure the House that there is nothing discriminatory in this. Grants are related to running costs and these vary for a number of reasons. It may arise from the nature of the buildings, the particular category of handicapped person maintained, the proportion of patients who attend on a day basis, or various other considerations. But we try to be as fair as we can and we certainly would not wish that any voluntary body should feel that it was being discriminated against. While the State provides a large part of the cost of running centres for the mentally handicapped today, the religious orders and other voluntary bodies make their own special contribution in the quality of services, in commitment and dedication and in my view that contribution is beyond price and something for which the State could never substitute. It is important that that should be clearly said and understood by all concerned. The commitment, the service, the dedication, the compassion and the humanity of the orders and voluntary bodies is beyond price.
Deputy O'Connell referred to "50 odd years of indifference to the mentally handicapped" and he spoke about an attitude of "benign neglect" which he said had governed the State's attitude to the problem. In fairness to my predecessors as Minister for Health I cannot accept that this was the case. Neither can it be said that, because the voluntary organisations have provided the bulk of the services, the State has reneged on its responsibilities in this vital area. The State has allocated an increasing amount of resources over the years to the voluntary bodies in this field. Their involvement has been consistently encouraged by the State which felt the special needs of the mentally handicapped would best be met in voluntary-run institutions. There are many who would rightly maintain that this marriage of State and voluntary organisations is probably the best possible approach to this very difficult and sensitive area of caring for the mentally handicapped.
The commitment of the State to the development of the mental handicap services can be clearly seen in the substantial build-up over the years of places in residential and day centres. For instance, in 1950 there were less than 1,200 places in residential centres and only a few hundred places in day centres and day schools. Today we have about 5,000 places in residential centres and about 5,700 places in day centres and day schools. Few areas in our health services have developed in such a rapid way over the years but in saying this I do not wish to appear or to sound complacent because I recognise as well as any Deputy that a great deal remains to be done. We have a big problem and it must be overcome. It will demand a real, positive and definite effort to reach a satisfactory position in this area. If I outline what has been achieved and the number of places available at present I do so only to rebut the argument that nothing has been done, that there has been what Deputy O'Connell described as "benign neglect". I admit that for many years there was neglect but I also feel that the efforts of a number of my predecessors in this area should be recognised. Now, it is a matter of going on from there and trying to achieve as near perfection as we can as soon as we can.
A lot of disappointment, frustration and anger that arises over admission policies is because there are not enough places. Probably a great deal of the irritation and frustration about admissions will disappear if we have a completely adequate number of places. I understand that some families could feel annoyed and impatient at the delay in finding places for handicapped persons. We have not enough places, particularly adult places, in residential institutions. Deputy Boland spoke very cogently about the necessity in some centres to retain young mentally handicapped persons long after they should be passed on to other institutions. That is undoubtedly a bottleneck in a number of areas. I assure the House that this Government have committed themselves to improving the situation and I hope that we will be successful in honouring that promise. This year about 490 additional day and residential places have become or are becoming available. Almost 900 other places are in planning or at the building stage. Furthermore I have under consideration new schemes which will provide over 1,000 further places and I shall be giving very sympathetic consideration to starting the planning of as many as possible of these schemes next year. The House must realise however that the capital resources at my disposal are limited and there are very great demands on them. Nevertheless I intend to ensure that there will be a steady improvement in the availability of places for the mentally handicapped, especially for the adult mentally handicapped.
Deputy O'Connell has been critical of the number of mildly handicapped children in residential care and has suggested that they are occupying valuable places unnecessarily. It is general policy to look after mildly handicapped children in a community setting and this is being done in the vast majority of cases. Nevertheless there are mildly handicapped children from broken homes who live in the harshest conditions. Their environment and the lack of love and care has created their handicap as much as anything else, and there is no choice but to remove them from that environment. I am sure that Deputy O'Connell would not wish it otherwise. There are other mildly handicapped children from remote areas for whom attendance at day centres is not practicable. Like practically everything else in this area, this is not an open and shut case. Quite a number of mildly handicapped children are maintained in residential centres, but there is no other solution. People involved in this area will explain that very often these mildly handicapped children are the most harshly treated and that they are the children who need the most attention and care because of their family backgrounds, environment and so on.
The motion asks that health boards be instructed to undertake their statutory requirements for the mentally handicapped by providing a special annual budget for them. The boards at present set aside a certain amount each year in their budgets to cover the running costs of services for the mentally handicapped. They also decide what priority to give to new buildings for the mentally handicapped in the allocation of their limited capital resources. Since the cost of the health services is now met entirely from central funds the boards themselves are not the final arbiters of what should be spent on a particular service. Decisions in that regard lie with the Minister for Health. This year about £13½ million will be spent on the operation of special residential and day care centres for the mentally handicapped. It is estimated that about £8.3 million of the expenditure on mental hospitals is in regard to mentally handicapped persons in those hospitals. An additional sum of £4.3 million will be paid to mentally handicapped holders of the disabled persons allowance and to mothers of mentally handicapped children who are eligible for the domiciliary care allowance. This brings the total estimate of expenditure this year on mental handicap service to £26 million. Last year it was £21.23 million and in 1975 it was £17.93 million approximately. During the past year hundreds of additional new posts were created in the mental handicap services which will provide additional doctors, nurses, physiotherapists, occupational therapists and others. The full financial impact of those jobs created in 1977 will not be apparent until next year when they are likely to give rise to increased expenditure of about £2 million.
The policy of establishing community workshops for the handicapped in general will also serve to alleviate the pressures for mental handicap places. I fully support the concept of community workshops. They are, as Deputies know local based workshops providing a range of work for various categories of handicapped persons. The aim of these workshops is to fit as many handicapped persons as possible for a working life either in open employment or in continuing sheltered work. The workshop will provide the sheltered work for those who are suitable for it and for whom open employment is not a realistic alternative. Such a local centre will contribute in an important way to our mental handicap needs. It will help to maintain some of our mentally handicapped in the community and give them some degree of independence. I recently had the very rewarding experience of opening such a workshop in Clonmel and I have no hesitation in telling the House that I was very impressed with everything about that workshop. There are many more like it throughout the country. I intend to set aside some of the capital resources at my disposal for this type of development. By so doing I hope to get increased support from the European Social Fund, which is now making substantial grants available towards our handicap services. It is always very encouraging to know of the number of people in the different local areas throughout the country who are prepared to give their time to this work. Indeed, it is one of the most encouraging features of this whole problem area.
I again assure the House that I am very conscious of the needs of the mentally handicapped and I fully realise that there is a major job to be tackled in this regard. I am glad that Deputy O'Connell and the Labour Party put down this motion because, while I do not agree with what they are suggesting in a number of respects and while we will have to vote against the motion, this discussion has been worthwhile. It has helped to focus attention on this area. I hope it will encourage many more people throughout the country to take an interest and to give of their time and energy and join those very dedicated committed people who are already engaged in this area.
I join with my colleague Deputy O'Connell in initiating this debate. I appreciate the points made by the Minister for Health. We had a discussion within the parliamentary Labour Party on the services available for the adult mentally handicapped and we received a number of representations in relation to placement procedures. We felt that the best course of action was for the House to debate it. If my memory serves me right this is the first time since I entered the House in 1969 that we had an exclusive debate on the mental handicap services. It is not the intention of the Labour Party to be contentious in relation to this matter. We feel that this is something on which we must sit down and talk—in the Department, in the health boards and with the voluntary organisations both lay and religious—and work out a system for the future.
I strongly hold the view that existing arrangements either for accommodation or for servicing or for placement are not adequate. In about five to ten years unless we review now the current arrangements we may find ourselves in a fairly critical situation. I welcome the fact that the Minister intends to have a seminar in the New Year with responsible administrative and other organisations. It will be welcome because that form of consultation between the Department, the Minister and these organisations is always to be welcomed. I also hope that in the terms of reference of the proposed all-Party Oireachtas Committee on Health, which the previous Minister for Health decided to establish and which I understand the present Minister intends to re-establish in the very near future—and on which we will be nominating Deputy O'Connell and Deputy John Ryan—very special attention will be devoted to a review of the services for the mentally handicapped.
My concern for the future is the extent to which the voluntary organisations, both religious and lay, will be capable of dealing with the growing problem. I have the utmost admiration for the voluntary organisations. My sister teaches mentally handicapped children. In my constituency I have a fair degree of contact with the St. John of God Order and I have the utmost admiration for their work. But repeatedly more and more representatives of the voluntary organisations come to me and say "It looks as though in about five years' time, particularly in relation to the handicapped, we, despite our work, are going to be in trouble". We have seen the signs of that, where pressure has been brought to bear on parents, on families, on individuals and on organisations.
At the stage where children reach the age of exit the pressures are there for alternative residential accommodation for the adult mentally handicapped. I am concerned about the extent of such accommodation and I am not entirely reassured by the Minister's indications here in relation to capital expenditure for 1978-79. I brought great pressure to bear on the former Minister last year and this year. Deputy O'Connell remembers the pressures we brought to bear on our colleague for a greater capital and budgetary allocation generally. There was a measure of improvement. The Minister has indicated that this grew from £21.23 million to £26 million in 1977. We had various other improvements such as the percentage increases in the disabled persons' allowances, mentally handicapped allowance and so on.
These improvements more than kept pace with inflation. However, I know the pressures which will face the Minister for Health in the next 12 months and in the budget discussions which he will be facing in the next two months with his colleague. These pressures tend to push out the legitimate demands for increased expenditure in this field. The pressures in the Department of Finance for economic and social development in other areas push the demands into the background. I know the capacity of the Minister to have an entrée into the Department of Finance in terms of demanding more money, but I want to express a worry that, notwithstanding the moneys which he will manage to get from the Department, they will still not be sufficient in 1978-79. These are our prime concerns in this debate. I am sorry that, despite guarded references by the Minister to the projected capital works for 1978, he is not being explicit in that regard. He may elaborate in January and we may get more information in the budget.
I bear in mind the principle point which is made to us by many of the organisations involved. A number of them, including religious orders, have been coming to us over the past few years and saying "We never envisaged having the problem of adult mentally handicapped facing us in addition to our work at present. We will not be capable of controlling the situation, we will not be capable of dealing with it". On that basis, despite their outstanding work, their concern is something we have to take cognisance of in this debate. As a result a degree of acrimony, emotion and parental frustration can build up in relation to the placement system and can build up to such a degree that the pressures evolve around the formulation of an alternative placement system. It would be far more productive and far more conducive to better services if we could have additional money spent on the extension of residential facilities, both day and fully residential. On that basis we could meet the growing needs.
These are the only comments I wish to make in support of Deputy O'Connell. The word used by him, "indictment", is legitimate. Over the years we politicians have been quite happy to pass the buck of the care of the mentally handicapped to the lay organisations. We have been happy to pass the buck to the religious organisations and they do the administration and we provide State funds. But otherwise we tend to be reluctant at departmental level to get too deeply immersed in the overall formulation of a national policy. That is not going to hold good for the late 1980s and 1990s. These organisations inevitably have their limitations. They have their staffing problems. Areas of duplication, overlapping and inter-organisational conflict tend to develop which can be resolved in the final analysis only by the Minister for Health of the day. I think he will be surprised at his seminar in January to find the extent to which these organisations will be looking to him and his Department for guidance. We should not withhold that guidance.
In the Dáil, unfortunately, we get little opportunity of talking about these issues. We perhaps have a Health Estimate once a year or a Supplementary Estimate now and again, a Private Member's Motion occasionaly or a few intermittent Dáil questions. The proper forum for a discussion of issues of this nature would be such as we had in the Select Committee on the Misuse of Drugs Bill where there was direct discussion between the former Minister and the present Minister, and on that basis we could tease out the issues.
On that basis we can tease out the issues in a frank and open way with the exchanges recorded formally and published in the Official Report. I would hope that the many Members of this House who have a deep interest in the problems of the mentally handicapped would have an opportunity of participating in the All-Party Committee on the health services the Minister will establish, when he may be assured that the Labour Party and my colleagues will contribute fully.
Since I wish to hear the views of other Members of the House who have far greater knowledge than I on matters of this nature and since I can have only a lay politician's involvement I shall confine my comments to that extent.
I have listened with very considerable interest to the discussion on this motion in relation to the provision of adequate care, treatment, training and accommodation facilities for the mentally handicapped. It is right that we should have a discussion of this kind here. Having listened to the debate I feel sure that the views expressed by the various Members who have contributed will be helpful to the Minister in the formulation of his future policy in this area.
I should like to commence my short contribution by commending Deputy Dr. O'Connell for having put down the motion. It is worthy of very serious consideration and, at this point in the discussion, it is right to say that it has received very serious consideration.
I have been most impressed by what the Minister for Health had to say to us here this evening; it coincides almost exactly with what Deputy John Boland said last evening; his views, I believe, represent those held by Fine Gael in this respect. However, this is not a party matter. It is a matter about which the House generally is concerned, one in respect of which all of us want to arrive at the right decisions and always want to do the maximum for handicapped people of whatever grade, or from whatever part of the country they happen to come.
It is very unfortunate that what has come through the media and the publicity we heard and read of today gives the impression that Deputy Dr. O'Connell did nothing but criticise what was being done up to now, and that in fact he said nothing was being done. I suppose people, when making their case, often overstate it. There has been an element of over-statement in the circulars we have all received. I am not criticising people who want to do the right thing but who are quite deliberate in overstating the situation in order to draw people's attention to the matter in which they are interested. I know that these people are well-intentioned; I know that Deputy Dr. O'Connell is very well-intentioned in putting down this motion. I do not agree with everything he says in the Motion. Indeed, were there a vote on it I would not vote for it; I could not vote for it with the experience I have in this field, and I have some little experience. I have had some responsibility for the setting up of at least one unit for moderately mentally retarded people and I am a member of the board of another institution with a large number of seriously retarded people. Therefore. I have had some opportunity of seeing at close quarters what is happening. It is altogether wrong to say that nothing has been done. An immense amount has been done in recent years. The Minister was quite correct when he said that, for a considerable time, there was neglect in this area and very little done. But, in the last five to ten years, there has been considerable progress made; after all, Rome was not built in a day. We must have some little patience if we are to do the job properly.
From time to time over those years excuses have been offered—I say that deliberately—to cover up the fact that money was not readily available. What was being said was that we had not enough trained personnel, but that is not a sufficient explanation of why there is not more provision. I will give the House an example of an experience I had some years ago. I called to a house where there were ten children, the eldest of whom was aged 14. The father had a job that kept him away from the home for the whole week, returning only at the weekend. The mother of that family had to contend with a child of five years of age, a very troublesome, mentally retarded child, and there was no place that child could be got into. To tell me there were not trained people to take care of a child of that kind is not acceptable. Any nurse with general training—and there are sufficient of them in the country— would certainly have been able to do more for that unfortunate child than a mother who had ten children to look after at the same time. There are quite a number of these cases. If our people were brought face to face with them I believe they would be very much concerned. But we have the case of the institutions that are suitably equipped to deal with children; we have the institutions suitably equipped to deal with severely handicapped patients. We also have those equipped to deal with the moderately handicapped. I agree entirely with the Minister when he says that the decision as to what type of patient is suitable for a given institution should be left to that institution.
I do not think there would be any serious objection to a points system being set up or to having the panel Deputy Dr. O'Connell described. There may be occasional cases in which there is some little discrimination in favour of somebody, in which there is an immense amount of pressure brought to bear or where there is extra influence but it is a very rare thing. It would be wrong if anybody got the impression that this is the general attitude of people who concern themselves, all day every day, with mentally retarded people, that they would take in patients according to the amount of pressure or influence used. It would be a very exceptional instance. We should not set up a board merely because this occasional thing happens. I would be extremely afraid of killing the interest, initiative and concern of the people who have been so dedicated over the years and who have done so much in this area, if we take this responsibility from them; it is because they have responsibility their interest is alive and will remain so. They should not be surrounded by a set of rules and regulations that would hinder them. I know that is not Deputy Dr. O'Connell's intention; I know he does not want that type of bureaucracy but he is convinced that a problem exists there. He seems convinced that the problem is much larger than it is. I would say it is very small indeed. When he was speaking last evening I was afraid that that was the aspect of what he had to say that would come over in the newspapers and the media generally. Unfortunately that is what happened. That is not being fair to Deputy Dr. O'Connell because, in many ways, his views coincide with those expressed by other speakers in the course of this discussion.
My experience has been mainly in the provision of accommodation and workshops for the moderately handicapped. I should like to say something about this aspect. Deputy Boland made the point that it was important to have these people working with the mentally retarded in, so to speak, the whole of their health. This is very true. There must be a percentage who are not themselves handicapped working with them. I have had some experience in this field. I remember going around with a group looking at what people were doing in this field both here and elsewhere. Generally speaking, these people were producing products no one wanted and then others were being blackmailed into buying these products at sales of work and so on. One of the things we were determined to do was to ensure that these people produced something others had to buy. We were determined to ensure that the products were delivered on time and that we would be able to give that guarantee to customers good enough to support us. The project eventually set up has worked extremely well and quite satisfactorily. Now that I have this opportunity I should like to thank those cooperating in providing suitable work for these workshops and thank also the people who purchase the products produced. In my approach to the latter I was always met sympathetically. The only condition they made was that the goods should be delivered on time and be up to a certain standard. That is understandable because people could not stay in business without a guarantee like that. Workshops will not be successful unless they are run on these lines and there must be enough people in the whole of their health with a suitable temperament working with the mentally handicapped in order to get the results essential to keep the workshops going properly. Experience has shown that it is possible to do that.
In regard to the points system of admission and discharge and the differential grants, I agree with the need for differential grants according to the category of patient. This is already being done. The Minister gave the reasons. They get more, or less, for providing the accommodation, care, treatment and training of patients. I use that word but when speaking of the moderately handicapped I do not think we should call them "patients" and we should not talk about hospitalisation. These people should be treated the same as any other worker and they should go out every day to work at the same time as other workers. They should have comfortable and adequate accommodation. It is all very well to talk about getting those who have worked in workshops out into the community, but that is more difficult than many seem to think. It is amazing how well they seem to be getting on as industrial workers in workshops but the number who can compete outside is quite small.
One of the drawbacks of the fund is that one gets nothing unless one is getting these people out into the community to work in the community. The Minister should use his influence to have this part of the regulation amended because the concept is quite wrong. I have read a good deal of literature from Sweden and elsewhere about the patients' own views and the way in which patients progress because they were kept in certain environments and so on. If patients were able to express themselves in that way they were no longer mentally retarded. My conclusion is that it is someone drawing on his imagination when I read this sort of stuff.
Again, in the assessment of mentally retarded people you get this glib talk about I.Q. What is I.Q.? I think it is a very difficult thing to measure. I believe it is vital to have a variety of jobs. You can take in a mentally retarded person and try him at one, two, three or four jobs and it is only when he comes to the fifth or sixth job that he is attracted. It is very rewarding to see someone, able to do nothing as far as one could judge, suddenly succeed because attention is attracted. The great thing about these people is they do not suffer from boredom.
I agree, with certain reservations, to the setting up of a panel that would look at the system of admission. I do not think there would be any serious objection to it, but I do not think it is necessary. I certainly do not agree that discharges should be regulated by a panel. Discharges can best be arranged by collaboration between staff, parents and guardians. Sometimes urgent discharge is necessary from institutions. The necessity for such a discharge may be apparent only to the staff who are close to the people and who understand the damage that could be done either to themselves or other patients. A distant body regulating such things would be more of a hindrance than a help. Take the case of a patient subject to violent outbursts. Such a patient could possibly be easily managed by his parents but could not be looked after in an institution providing a limited service. We must be very, very careful.
What we should be doing is assuring those who led in providing accommodation, care, treatment and training for these people that we are not being critical of their efforts and, when he is replying, I am sure Deputy O'Connell will do this. I suppose what we are asking for is a general review in the light of our experience in recent years, and it is only in recent years. We should be looking for general review arrangements all the time. We admit that the attendance of a doctor would be a distinct requirement in a discussion of this kind, but even experts should be questioned and that is why I question some of the things proposed and recommended in the motion.
The voluntary people who have worked in this field for a long time should know that we appreciate what they have done and that is why our words here should be words of commendation and appreciation of them. We should let them know we are prepared to support them and I believe the Department of Health are giving them a great amount of support. As the Minister said, the Department are paying the bill, but that is not all. Whenever the Department are approached in regard to a problem they come along and do whatever they can to assist people in those institutions. However, this is not enough. The foundations that have been laid can be built on and progress can be more rapid in the next few years than in the past.
I would issue a word of warning, from the little experience I have had. I would warn against the building of large units because I think it would be a bad thing to do. People would become numbers. This kind of care and treatment must be fairly intimate and I would say that units to cater for between 250 and 300 patients should be the biggest. I suggest that it is wrong to put units in psychiatric institutions or close to them, but it is a good thing to have such units close to hospitals because though the patients are not sick in the usual way they will have the ordinary ailments from time to time and it is better to have treatment facilities and doctors to prescribe for them as close as possible.
However, there is still the stigma, the distinction between the psychiatric and the mentally retarded patient. Therefore a psychiatric institution would be the wrong place in which to set up a unit for the mentally retarded. I have looked at this problem in the constituency I have represented for a long time and I know the feelings of the people there. Far from being dissatisfied with the way members of their families are being treated in existing institutions, they could not be more grateful or appreciative. On many occasions I have had discussions with these people and they have expressed relief and pleasure at the way members of their families were being treated. There are mothers among them who almost weep when they see members of their families who come home for weekends almost crying in their anxiety to get back. This is not a reflection on their families but the company and the little element of excitement in the institutions.
What we need are more places, not additional rules and regulations. Far too many people are critical. Many of the people who do all the talking do damn all else. There are people who criticise and condemn everybody but if you ask them to buy a ticket for a cause they will not put their hands in their pockets to give a bob. I do not pay much heed to the people who do all the talking because they do not take hand, act or part in improving the situation. I again add my voice of appreciation for the people who have led the field in this area and I can assure them of my fullest co-operation and help.
Although I do not agree with everything in the motion, I compliment Deputy O'Connell for introducing it because it has led to a discussion on the mentally handicapped which has been at a high level. Because of the brief time at my disposal I do not intend to go right through the field, but there are a few points I should like to make. In the care of the mentally handicapped we have a combination of the State, through the health boards, the voluntary organisations and the National Association for the Mentally Handicapped. As well, there are the religious.
I do not agree with Deputy O'Connell that the State has failed. Last year the State spent almost £26 million, a fair amount, which proved the State has not failed. Indeed it has played a very big part, particularly since the commission reported in 1965.
The most important point to remember in planning services of this kind is assessment, and it is therefore important that in every health board area there should be an assessment team under a director of community care or a director of mental handicap. Such an assessment team should have a psychiatrist, a psychologist and a social worker. I should like to see such teams standardised so that they could work in harmony and at the same level, so that priority lists in different areas would indicate the children with prior necessity to be in care. In my constituency there are nine different methods of assessment.
We need to have priority lists to ensure that those who need care will be in care and the recommendation of Deputy O'Connell, I suggest, would not work as efficiently or to the same extent as having assessment teams within local communities. The benefit of the advice of assessment teams has not been available to school managers and this should be standard practice in the interests of the children concerned, because this is necessary for the benefit of the education of the child.
Another point on which I do not agree with Deputy O'Connell is that all moderately mentally handicapped people should be in residential care. We have ample proof in our communities that moderately handicapped children are very happy at home and their parents are happy to have them there. They can travel to schools and in my own area they travel 20 miles a day to a school and it works very well. There are some children who are difficult to handle at home or perhaps home circumstances are not suitable and these children should be in residential care.
The number of sheltered workshops throughout the country is growing, mainly through the efforts of the National Rehabilitation Board and the Rehabilitation Institute. In rural Ireland there is a transport problem and the Minister might look at this at some stage. Obviously there cannot be a sheltered workshop in every town but where there is a distance to be travelled it is important that transport should be available. The same would apply to children attending day care centres in schools for the mentally handicapped. I gather that while the Department of Education have an agreement with CIE to transport children to the educational facilities in the schools, this facility does not extend to children attending the special care units, health care units, because the Department of Health do not have this sort of agreement. They are carried on the bus if——
The Deputy has one minute left.
The point on residential care is an important one. It has to be looked at very carefully. It would appear at present that there are a number of people in residential care who would not have been there had there been day care facilities in the past. I believe the emphasis in the future will be on community care and because of better day care facilities there will be less and less need for these people to go into residential care. In this context, if new beds are created for residential care, rather than thinning out the population within the residential care units some children should be taken from the community. Two great problems are the waiting list for some severely handicapped children and the overcrowding of residential care facilities for adults.
I must now call on Deputy O'Connell to reply.
This has been a very interesting debate and certainly the contributions have been very helpful. If it has done nothing else, this motion has highlighted the fact that we must examine very carefully the whole problem of mental handicap.
The Minister for Health must bear in mind that he and his Department do not have a monopoly on wisdom. We in the Opposition have a role to play. We must not be destructive in our approach or in our contributions to debates. If any motion or suggestion emanates from the Opposition there is an obligation on the Minister to weigh it up seriously and not to reject it out of hand. We have a lot to contribute. Last week when amendments of mine were tabled the Minister rejected them but put them down under his own name. We must put a stop to that petty, party-political approach. We must be statesman-like in dealing with Bills in this House and the Opposition have an important role to play. There will be other motions. The Minister should consider whether the Opposition might be right. The same thing applied when the Coalition were in power. Many useful contributions came from Fianna Fáil when they were in Opposition. I earnestly ask the Minister to take this into consideration so that the Opposition may play a useful role in the governing of our country.
Concerning the mentally handicapped, the Minister has said that perhaps I have been a little overcritical of the facilities provided. I went to visit St. It's a few years ago and I saw a temporary building erected in 1902 for the workmen involved in constructing the main building. There were 96 mentally handicapped women in one dormitory with two open toilets. The Minister for Health was a member of the Government which tolerated that. I am not exaggerating about this and when I wanted to highlight it they banned me from attending again. The Department of Health stand indicted. When I said that it was benign neglect it was much worse; it was criminal complacency. They played ducks and drakes with me in my appeals to have action taken. One of the Minister's predecessors laughed scornfully when I told him about the situation, but he would not visit the hospital and see for himself. I would ask the Minister to visit a few of these places before he says that everything is all right with the facilities for the mentally handicapped. These people are human beings and we must treat them properly. What I saw was a disgrace and a shocking indictment of our country.
The points system I have suggested was asked for before. The committee on mental handicap of the Eastern Health Board asked the society of social workers who were involved in mental handicap to consider a points system because they felt that the present system was not satisfactory. I ask for some points system based on the degree of handicap, the family circumstances, the behaviour of the child and the destruction of family life, with a report provided by an independent psychiatrist. Points would be awarded to the child and the mother would know when the child would be admitted. Deputy Clinton said that the voluntary bodies might not like that; they might not. They are not concerned with admission. Their vocation is dealing with children and they are not concerned which child they get. They will care for them all. They are not there to decide whether they like the look of a child. It does not matter.
If they are equipped.
They will deal with the mentally handicapped based on the points so that it is seen as a just and equitable system. It is a flexible system but it may be modified. I am suggesting the principle so that people will know the position of their child on the list. They do not know this at the moment. This should be operated in each health board area. It will also give the health board lots of information about the number of mentally handicapped people in their area. When the points have been allotted they can tell a mother that her child will not be admitted for a year and enable her to make arrangements in the meantime. I have tried to get children admitted and have been told that there was not a hope. When I asked when there was likely to be a chance they told me they did not know. Is the Minister for Health satisfied with that? If he is, then I am sorry that I put down the motion.
The Medico-Social Research Board carried out a survey in 1974 and they found that there were about 1,300 mildly handicapped children in residential care who should not be there. Dr. Michael Mulcahy, who is the chief doctor in Stewart's Hospital, said they should not be there. It is not good for a mildly mentally handicapped child to be put away with moderate, severe and profoundly mentally handicapped patients. Because there is no points system these patients are getting in ahead of those who need residential care. More than 1,300 places have been taken up by these patients and there is no medical need for it.
It has been said that we need more places and that was my reason for saying that we needed a budget for each health board. Now the Minister says his Department decide the budgets not the health boards, but I disagree with the Minister. I was a member of a health board and I thought the health boards decided their budgets and submitted them to the Department for approval. The Department do not decide the priorities as it is the function of the health boards to do so and is the function for which they were established.
The health boards should be given a directive to give priority to budgets for the mentally handicapped so that in eight or ten years' time we will know that we can provide sufficient places from our waiting lists. Surely that is not too much to ask. We must have a target. There is no point in dealing with the problem in an arbitrary way.
I have seen the suffering of mothers of large families with mentally handicapped children. The mothers are not able to cope and they have no hope whatsoever. I accept that a points system can be subject to modifications and that that can be done by consultation with the voluntary bodies. I am not suggesting that we supersede the voluntary bodies.
I do not like bureaucracy in any form. These children should be assessed and points awarded to them on the basis of the assessment, and this should be done in each health board area. The suggestion should not be rejected because it comes from me or from the association for the mentally handicapped. The parents of the mentally handicapped children understand the problem and have asked for this system. The social workers have submitted a set of proposals and have suggested that the scheme could be introduced on a pilot basis. I do not believe we should reject their suggestion on the basis that we know better. I know the Minister's views on this matter and he has decided to reject it. However, something has been achieved.
I promised the Deputy a seminar.
If I achieved nothing else I have got the Minister's agreement to a seminar In that way perhaps there is some satisfaction in tabling a motion. I would ask the Minister not to reject every suggestion from this side of the House.
I do not do that.
I have seen the Minister in action and have directed his attention to it before.
I accepted many suggestions from the Deputy on the Medical Practitioners' Bill.
Deputy Dr. O'Connell on the motion.
I do not object to the Minister's interruptions.
I do, Deputy.
The Minister says he will not accept my proposal but will produce his own, which will be the same as mine. That is not right and I am asking the Minister to rise above that attitude.
That is only drafting. When a Minister accepts a principle from an Opposition Deputy he always puts down his own amendment for drafting reasons.
I am asking the Minister to say that the suggestion need not be rejected because it comes from the Opposition. If we could do this, we would contribute more as a legislative body. We are seeking changes for the betterment of the mentally handicapped.
Question put and declared lost.