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Seanad Éireann debate -
Wednesday, 14 Jan 1970

Vol. 67 No. 9

Health Bill, 1969: Second Stage.

Question proposed: "That the Bill be now read a Second Time."

The Health Bill's Parliamentary career up to the present has been unusual. Introduced in Dáil Éireann at the special session on 21st January, 1969, commemorating its fiftieth anniversary, the Bill has passed its Second Stage, after a long and informative debate, by the time the Eighteenth Dáil was dissolved in May. The Bill was reactivated in the Nineteenth Dáil in July, when a resolution was passed directing that it should be taken up again at its Committee Stage. It was then, of course, that I became directly involved with the Bill.

During the Committee and subsequent Stages in the last session of the Dáil, we had very constructive debates on the Bill and several useful amendments were made arising from points raised on all sides of the House. I venture to say that the Bill as now presented to Seanad Éireann has been considerably improved in several respects as a result of these debates.

Much more is contained in the Health Bill than one would infer from its moderate length: it is a highly-compressed instrument for the development of future policy on the health services. The Bill has, indeed, been criticised because of the inevitable appearance of vagueness which is a consequence of this, and for the extent to which details are left to be filled in by Ministerial regulations, orders and directions. I think, however, that when one looks to the nature of possible future developments in the health services, the kind of flexibility which the Bill will permit is highly desirable.

I should point out too that, in the provisions of the Bill allowing for subordinate enactments to be made by the Minister, there are adequate safeguards for Parliament. In particular, this Bill uses to a rather unusual extent the device whereby the more important regulations—such as those dealing with the establishment and constitution of the new health boards—must be presented in draft form to the Dáil and Seanad, and approved by both Houses, before coming into effect. I would, indeed, point out that, as far as the Seanad is concerned, this right to veto such regulations is greater than their powers in relation to Bills; for those the ultimate power of the Seanad is, as you know, merely to delay.

The provisions of the Bill fall into two categories. First, there are the provisions in parts II and III dealing with the reorganisation of health administration and, secondly, there are the remaining provisions, in parts IV and V, which largely codify the law on the major health services and make provision for a number of improvements in those services, to which I will be referring later.

Each county is at present a separate administrative unit for the health services. Except in Dublin, Cork, Limerick and Waterford, where joint local authorities operate the health services, the county council acts as health authority. Under section 4 of the Bill, it is intended to establish larger administrative units, counties being grouped for this purpose. For each such group of counties, there will be a health board. A majority of the members of the health board will be appointed by the county councils concerned. County borough councils and the Dún Laoghaire Borough Council will also appoint members to the appropriate boards. Membership of the boards will also include persons elected by the medical and ancillary professions in the area and some Ministerial appointees.

It has become clear that for many of the services provided in hospitals, and for the general organisation of hospital services, the county is too small as a unit. This conclusion derives not only from studies in this country, but from what we have learnt of similar studies in other countries, notably Scotland and Denmark. By co-ordinating the hospitals for a group of counties, and by concentrating expensive specialised facilities in the larger units, I am confident that a much more economical and effective hospital service can be organised. The needs of the hospital service in this respect are preponderant, as over three-quarters of the total health expenditure is for services in hospitals.

Hospital services employ large numbers of professional and technical staffs of different kinds, some of which — for example, radiologists — are in short supply. By organising the services in units more suited to the requirements of hospital administration, better value will be obtained from the available facilities.

Many county councils now send hundreds of patients each year to hospitals in other areas. This does not, however, give such a county council any say in the operation of the hospital services in that centre. An important attendant advantage of grouping the counties as proposed in the Bill will be that, with few exceptions, the organisation of services for a county's patients will be in the hands of a body on which the county is directly represented. Roscommon and Mayo, for example, can have a direct say in how the specialised services in Galway are organised and Kerry can have a similar say as respects Cork.

One cannot, perhaps, see as being quite as clear-cut the case for having larger administrative units for the other health services. There are, however, important advantages to be derived in the operation of these services from enlarging the administrative unit. If one looks at the map of the country, it is striking to note how many of the towns are on or near county boundaries. Examples are Limerick, Waterford, Drogheda, Carrick-on-Suir, Ballinasloe and New Ross. Centres such as these are going to be increasingly important as foci for the organisation of all the health services. Clearly therefore, for the organisation of the new general medical service with choice of doctor — to which I will refer later — or the public health nursing service, or the child welfare clinic services, there will be considerable advantages to be derived from a combined administration where the facilities can be used without much reference to county boundaries. The larger administrative units wil also permit the more economic employment of social workers and other staff for the child care and geriatric services.

The future pattern of health services will be based on the 1966 White Paper and on the four reports published in recent years on the general hospital services, on mental illness, on mental handicap and on child health and will involve both decentralisation and concentration of resources. Clearly, decentralised facilities should be used as much as possible: this will be more economic and more satisfactory for the patients. Hence, running through our future planning, there will be increased emphasis on the development of the role of the general practitioner, the extension of the public health nursing services, of domiciliary care for the mentally ill and the mentally handicapped and of the pre-school and school health examinations. Out-patient diagnostic facilities will also be provided by visiting consultants at many centres.

These services should reduce the need for intern hospital care and the length of stay of patients in hospitals. In particular, the provision of more out-patient specialist services will enable diagnoses to be effected without hospital bed occupancy in many more cases. The involvement of most general practitioners in the country in the services for the lower income group will help considerably in the full co-ordination of the general practitioner services and the hospital services. The admission of general practitioners to hospitals, on the lines recommended in the FitzGerald Report, will also mean that many patients can be looked after in the smaller local hospitals by their own doctors.

Concentration of resources in fewer centres will follow from the needs of highly specialised medical and surgical procedures, which can only be organised in large units. The development of new techniques, the requirement of complex laboratory equipment and the needs to have highly skilled teams of workers for such procedures has inevitably led to the conclusion in this and in other countries that there must be a concentration of acute surgery and specialised medical care in larger units. For this kind of care, therefore, we must accept that there will be a concentration of resources.

This increased specialisation in medicine is reflected in the recommendations of the Todd Report on medical education in Britain, which will provide for increasingly specialised training for medical practitioners in different fields. We are examining the implications of that report for us. It seems inevitable that, if we are to maintain our present close connections in medical education with Britain which means that our medical graduates are free to practise there, we will have to make corresponding adaptations in our present medical training.

Looking ahead, we can see a pattern of health services in which the increasingly specialised and well-equipped larger centres are closely connected with the smaller units, through visiting consultants and through the involvement of general practitioners in hospital work. The various centres will, of course, have to be properly integrated through the use of better-equipped ambulances travelling on improved roads. It is only by pursuing the policy on these lines, for interconnected specialised and smaller units that we can make available to the people the full benefits of modern medical developments. What I have just said, therefore, must be the essential basis of our future policies.

A further significant justification for taking health administration out of the ordinary local government pattern lies in the ever-increasing State financial assistance to meet the cost of the health services. The Government, by the 1966 White Paper, committed itself to an acceptance that the cost of specific further extension of the services would not be met in any proportion by the local rates and, since 1966, the fraction of local health expenditure met by payments from the health services grant has risen from 50 per cent to about 56 per cent and is likely to rise further as services are improved and extended.

In addition, for rural areas, the State, from the agricultural grant, makes a further substantial contribution to the cost of the health services through relieving farmers from paying rates. As a consequence of this, State funds now meet, over the country as a whole, almost three-quarters of the total cost of the health services and this is a proportion which can be expected to increase in the future. These financial considerations, with the administrative factors which I have mentioned, provide what I think is a complete justification for the change from the present administration by local authorities to administration by health boards representing, as the 1966 White Paper stated, "a partnership between local government, central government and the vocational organisations".

The Bill does not go into detail as to the number of health boards or as to their constitution. In accordance with section 4, these will be determined by Ministerial regulations. However, before making these regulations, the Minister will be required to obtain the views of the relevant local authorities and the Minister for Local Government and, as I have said, the House of the Oireachtas must approve of drafts of the regulations before they can come into effect.

The formal processes for the establishment of the new administration must await the enactment of the Bill, but the House will be aware that I have been formulating my tentative proposals in this respect, so that there will be no unnecessary delay in setting up the health boards. In September last, I circulated a memorandum giving tentative details of these proposals. Copies of these were sent to Members of this House.

This memorandum proposed the division of the country into eight areas, each to be served by a health board, the population served to range from 921,000 for the Eastern Health Board down to 178,000 for the health board for the midlands. The memorandum also set out a proposed constitution for each of the boards. After its circulation, I arranged a series of meetings for each of the eight groups of counties to explain the proposals and to test, informally, local reactions to them. I would here like to express my appreciation of the helpful and constructive attitude of the local members and officials who attended these meetings. They have been most useful to me and I am now having what was said at these meetings digested, so that I will be able to put out formal proposals for consideration by each county council and other local authority concerned as soon as practicable after the enactment of the Bill. When considering these proposals, each county council will have before them a report of the meeting attended by their representatives. All the members of each council will thus see what representatives of other counties in the area have said and the views which I expressed at these meetings on the many points made. In this way, each county council when sending me their views, should be able to appreciate their implications for their neighbours and for me. After the formal local consultations the House will have the draft regulations before it for its consideration.

At this stage I do not intend to say anything more on the details of the establishment of the health boards. These boards will be the basic administrative bodies for the health services in the future, but the Bill provides for a number of other bodies at different levels which will have specific functions. For each county, or for a part of the county in some cases, there will be a local committee whose functions will be mainly advisory. Local councillors will be in a majority in the membership of these committees, it being intended that there will be a number of councillors from each of the county electoral areas. It is my intention that these committees will be live factors in the new arrangements and that their meetings will be properly attended and serviced by the officers of the health board.

These local committees are included in the new administrative structure because of the importance of maintaining local contact with the operation of the services. This, indeed, has been one of the major problems in the design of the new administrative arrangements — to combine the establishment of units large enough for efficiency and economy with local humane personal contact between those engaged in the day-to-day operation of the services and the people using the services. Not only is it intended that the local committees to which I have referred will be involved in this, but it can be expected that the new boards will, in the day-to-day operation of the services, act to a great extent through officers stationed in county centres and other towns.

At the level of the health board itself, there might, indeed, be some clash between the particular interests which the members — and particularly the local authority representatives — will have towards the services for the people from the local area which they represent and the broad interests of the board. It will be important that each member of the board, in acting on the board, will regard himself as part of a corporation with the wide responsibility of providing comprehensive health services for the whole area which the board serves. The members should, I think, become accustomed to looking at their problems in this way; they should eschew too much concern with minor issues and should be prepared to leave the management of the services to their staff. The Bill, I should mention, does not apply the details of the present county management system to the health boards, but its provisions are flexible so that the chief executive officer and his subordinates can be given sufficiently free play in the exercise of management functions.

The balance between what the members, sitting as a board, do themselves and what they leave to their administrative and other staffs will, I think, vary from board to board. In the case of the proposed Eastern Health Board, which will include Dublin, I am told that the experience of those on the Dublin Health Authority indicates that anything less than a delegation of the functions now given to the manager under the Management Acts could lead to difficulty. The smaller boards may not need such a widespread delegation to their administrative staff. I propose, before the boards are set up, to have a study made on the best administrative structure and administrative techniques for them, so that each board will have this available before they become responsible for operating the services.

At this stage, I would like to refer to another issue which has arisen in the Dáil and elsewhere — that is the possibility of having representatives of the administrative and other staffs of the boards included among the membership. This would be quite a novel departure in the field of health administration. An officer of a local health authority is by law debarred from becoming a member of it.

In relation to the health boards, I had already indicated that this rule could be set aside in the case of a doctor or other professional person who would be elected as a member of the board by the doctors practising in its area. It has been represented to me that this would be an unfair discrimination against the other staffs of the board, including the clerical and administrative staff and the manual workers. Accordingly, it has been proposed to me that these should be entitled to elect representatives to the board.

I have carefully considered this issue but I do not think that it would be desirable to make this change Firstly, the professional officers who might get on to the board will not be there as officers, but as doctors, dentists, nurses or pharmacists Secondly, administrative and clerical staff will be in a somewhat different position in the management hierarchy in the board and I do not think it would be right that, say, a staff officer working up to the chief executive officer in his administrative capacity should then, as a member of the board sit in judgment on the chief executive officer's actions, or the actions of any other member of the staff. Accordingly, in the passage of the Bill through the Dáil, no amendment of this kind was made.

I do agree, however, that it is important that the members of the staff at all levels should become involved in the generation of ideas on the better administration and operation of the services. Perhaps some form of joint council between the staff and the management would be the most appropriate thing for this. I intend that this should be studied in conjunction with the plan for the management of the new boards to which I have already referred. I think it is not necessary to make statutory provision in the Bill requiring health boards to establish such councils. I considered this but concluded that, as the success of such councils depends on the willingness of management and staff to go into them and work in them voluntarily, a compulsory statutory provision for their establishment would be psychologically unwise, at least at this formative stage.

The day-to-day operation of the services and the general planning of the future services will be in the hands of these health boards. They, therefore, will be the essential nuclei of the new health administration. However, as I have mentioned, there will be subordinate local councils under them and, above the health boards, it is intended that there will be, for larger areas, three regional hospital boards to coordinate the planning and development of hospital services. These are provided for in section 40 of the Bill.

The health boards will be responsible for the administration of the hospitals which are now owned by the local authorities. It must be remembered, however, that about 44 per cent of all the general hospital beds in this country are in voluntary hospitals, the ownership of which will not, of course, be affected by the Bill. Most of these voluntary hospitals are in Dublin, but they serve a region extending into the areas proposed for at least four of the proposed eight health boards. In the south there is a connection in medical teaching between Cork and the Limerick hospitals.

It is clear that none of the health boards could thus be entirely self-sufficient in the provision of hospital services and co-ordination must be exercised over wider regions. Hence, section 40 of the Bill provides for three regional hospital boards based in Dublin, Cork and Galway with functions, as section 40 states, "in relation to the general organisation and development of hospital services in an efficient and satisfactory manner in the hospitals administered by health boards and other bodies in its functional area which are engaged in the provision of services under the Act."

One half of the members of a regional hospital board will come from the health boards included in its area and the remainder will be appointed by the Minister as representing others involved in the provision of hospital services and in medical education. The co-ordinating function of these three bodies should be highly important. They will have devolved on them work now done in my Department and will take over much of the work of the Hospitals Commission. The regional hospital boards will play a large part in integrating the services of the voluntary hospitals with those of the health board hospitals by arranging for appointments of consultants with responsibilities in both types of hospital and by organising common services.

Section 40 of the Bill provides also for a body, to be known as Comhairle na nOspidéal, which, at the national level, will regulate consultant appointments, and thus the development of specialties, in the hospitals providing services under the Act. The proposal to establish this body was generated by the FitzGerald Report which pointed out that there is a danger of uncontrolled proliferation of specialties in the various hospitals which are, of course, under independent managements. It is highly important, both for the quality of the services and for ensuring the best use of resources, that there should be control on the creation of new specialties in hospitals and the appointment of new consultants. This will be the main task of Comhairle na nOspidéal.

It is expected that the comhairle will also become involved in selection processes for at least some of the consultants in the hospitals providing services under the Act. At present, consultants in local authority hospitals are selected through the Local Appointments Commission and those in the voluntary hospitals are selected by the hospital authorities or, where teaching appointments are concerned, by joint arrangements with the teaching bodies. The FitzGerald Report emphasised the desirability of having a common corps of consultants, under the regional hospital boards, who would serve in the different kinds of hospitals and who would be selected by common selection procedures. We must aim under the Bill to achieve this.

It will not be easy to arrange common selection procedures for consultants. Such procedures must have the essential features of those of the Local Appointments Commission but must also have regard to the traditions and requirements of the voluntary hospitals and the teaching bodies. I will ask An Comhairle, when they are set up, to give some priority to examining this issue.

I might sum up the essential functions in relation to hospital services of each of these bodies by saying that Comhairle na nOspidéal will control the disposition of specialties and the selection of consultants at the national level, that the three regional hospital boards will be the planning and co-ordinating bodies for the public authority hospitals and the voluntary hospitals and that the health boards will be responsible for administering services in hospitals, and for ensuring a satisfactory relationship between these services and the other health services.

The details of this division will arise more appropriately at Committee Stage, or indeed when, later on, the regulations setting up the various new bodies come before the House. I have told the Dáil that, at that stage, I will circulate an explanatory document setting out the functions of the different bodies so that Members of both Houses, those concerned with the operation of the services, and the general public will have a detailed picture of the general pattern of the new administration.

Lest what I have said should leave the House under the impression that the establishment of these new bodies will lead to a proliferation of public authorities concerned with health services, I would mention that, while 12 bodies will be established under the Bill, it will abolish 13. Included among those abolished will be the Hospitals Commission, the dissolution of which is provided for in section 41. Clearly, with the establishment of the new bodies proposed in section 40, the functions of the Hospitals Commission could not remain as they are now. The very important contribution which the commission make to the health services at present can in future be made by Comhairle na nOspidéal and by the three regional hospital boards. The staff of the commission will be absorbed into these bodies. It has been said in the Dáil, and I should like to repeat it here, that this decision does not imply any dissatisfaction with the way in which the functions which have been conferred on the commission have been discharged by them. Indeed I should like to take this opportunity to thank the chairman and other members of the commission and their staff for the contribution which they have made and are making to our health services.

The establishment of the new administration will involve the transfer of many members of the staffs of the present local authorities to the new bodies. Most of these will, I should expect, find themselves carrying on their duties much as at present, although working to a different and ultimate superior. I have had discussions with the organisations representing different classes of staff on the transfers and I am arranging to set up a special ad hoc joint council to help smooth over any difficulties which arise on the transfers.

I should now like, a Chathaoirleach, to refer to the provisions in Part IV of the Bill dealing with health services. My remarks on these will not go into great detail, as this will be more a matter for Committee Stage.

Essentially, the provisions in this part of the Bill on eligibility for services do not represent any departure in principle from the present law; each service will still remain available only for that group in the population judged to be unable to afford to arrange it from private resources. However, there are some significant changes. In the first place, the definitions of persons with "full eligibility", as referred to in section 44, will be determined on the basis of an assessment only of a person's own means and that of his wife. Secondly, the Minister will have power to lay down standards for assessments of eligibility under this section; at present, each local authority are a law unto themselves in this matter and there are fairly wide differences in the standards followed.

The definition of "limited eligibility" proposed in section 45 is a reenactment of the present definition of the classes entitled to the hospital services, but the new section does provide for flexibility in that the Minister will be able to make regulations varying the limits. Such regulations would be subject to approval in draft form by both Houses of the Oireachtas before being made. A new provision has been introduced by section 46 which will require that each decision on eligibility by an officer of a health board will be subject to an appeal.

The most important change in the services themselves which is provided for in the Bill is that referred to in sections 57 and 58. Under these sections, it is intended that a new general medical service will be brought in, offering choice of doctor to those entitled to use the service. The proposals for this service have been under negotiation with the Irish Medical Association and the Medical Union for some time in anticipation of this Bill. Agreement has been reached on most points in the frame-work of the new arrangements. It has been agreed.

that most doctors under the new scheme would provide their services on the basis of an agreement with the health board; that an eligible person would, subject to certain restrictions — mainly as to distance — be allowed to register with any participating doctor willing to accept him and would be allowed to transfer to another doctor after giving proper notice;

that persons could be assigned to a participating doctor where this was necessary;

that special arrangements would operate for group practices and partnerships;

that there would be control on entry by doctors into the service;

that future vacancies in the service would be filled by public competition;

that patients would normally be seen in the doctor's private premises, but the health board would have power to make accommodation in clinics or health centres available to general practitioners where appropriate; and

that special arrangements would be incorporated to keep doctors in remote areas.

It has been agreed too that special guarantees in relation to entry into the new service will be given to those now holding posts as permanent district medical officers.

As regards the method of paying doctors under this scheme, I have told the profession that I am willing to operate a fee-for-service system of payment, provided that it can be shown not to be excessive in cost. At the present time, the organisations are considering a memorandum which I have sent to them indicating what I think the level of charges should be and the basis on which they should be calculated. I hope it will be possible to complete negotiations on this soon.

In the meantime, negotiations have been held with the representatives of the retail pharmaceutical chemists and with the manufacturers, importers and wholesalers. Here again, I am confident that the final details of arrangements for the supply of drugs and medicines through the retail chemists can be completed fairly soon. In the meantime, practical preparations for the operation of this part of the services are in train. It is intended that pricing of prescriptions and calculation of payments will be done centrally through a computer — a system which should also give us invaluable detailed information on consumption of medicines and drugs.

The other changes made in relation to the services are, perhaps, in points of detail but many of them are highly important details. For the hospital services, changes are made in eligibility, so that free treatment for children of all income groups will be provided for specified diseases and disabilities of a permanent or long-term nature, such as mental handicap. Charges for out-patient services will be abolished and flexibility is introduced into the provisions for charges for in-patient services, so that these can be varied by regulations. Out-patient services, too, will be available for children of all income groups for specified long-term diseases and disabilities.

For the middle income group, a service will be introduced under section 58 whereby that group will be indemnified against meeting heavy expenditure on drugs prescribed by general practitioners. Under that section, a person who can show that he has spent a specified basic amount within a period will be entitled to claim a refund of the balance, or a part of the balance of his expenditure in that period from the health board. This will be in substitution for the present "hardship" arrangements for the supply of drugs to persons in that group, which operate unevenly throughout the country. A new provision is also introduced whereby drugs for long-term ailments will be provided free of charge for persons in all income groups. A scheme of this kind at present operates for diabetics and its extension to other long-term diseases is highly desirable.

A new provision is included in section 60 for a home help service. This provision will allow health boards to assist in the maintenance at home of persons who might otherwise have to receive hospital care. The way in which this assistance can be given is not specified in the section and it is sufficiently flexible to allow the health board either to pay for persons to act as home helps, to give grants to voluntary bodies doing this or to do whatever else might be necessary to assist persons covered by the section to stay at home. This is a highly important section. Basically it has a humanitarian purpose but it also has an economic objective of keeping sick and infirm people out of hospital in so far as that is appropriate and can be arranged.

Section 65, dealing with the child health services, provides for many of the changes recommended in the report of the study group on those services which was published in August, 1968. The section allows for child health services to be arranged, where this is thought desirable, in general practitioners' surgeries and it is intended that this will be done in rural areas. As far as the school health examination service is concerned, the section largely repeats that of the provision which it replaces. It is concerned only with elementary schools. The study group report referred to the possibility of extending this service to secondary and vocational schools at a later date. No provision has been made for this because such an extension on a comprehensive scale is a long-term project and cannot be envisaged until the service for elementary schools is brought up to an adequate standard. However, it has been pointed out to me that there would be an advantage in making some provision whereby pilot examination schemes could be operated in secondary or vocational schools and I may consider on Committee Stage an amendment which would allow such schemes to be operated.

Part V of the Bill contains a number of important provisions. I would draw particular attention to section 76. This was introduced on Committee Stage in the Dáil with the object of giving the Minister an interim power to control the possession of drugs with hallucinogenic or other undesirable effects, pending the enactment of a comprehensive Bill on drugs and medicines which, I hope, will come before the House in the present year. There is ample evidence that there is urgent need for a section of this kind.

Section 82 gave rise to considerable discussion in the Dáil. Under this section, responsibility for operating the home assistance service will be left with the local authorities. It was put to me that this was undesirable as that service is closely connected with the health services and that both should be operated by the health boards. Having discussed the issue with the Minister for Local Government and Social Welfare, I came to the conclusion that the best thing to do in relation to this service was to endeavour to arrange that the local authorities would, under section 24 of the Bill, delegate to the health boards the day-to-day operation of the home assistance service. In this way, the local authority would maintain budgetary control and responsibility, which is important seeing that the whole cost of the home assistance service is met from the rates. I am initiating with the Department of Social Welfare and the local authorities the steps necessary to make arrangements on these lines. I should mention, however, that the whole future of the home assistance service may be thrown into the melting pot in the future in a general review of assistance services to be undertaken by the Minister for Social Welfare.

I have not, in this introductory statement, endeavoured to deal with all the changes proposed by this Bill: I have but selected the most important. I think it will be quite clear from what I have said, however, that it proposes many important and desirable changes in the health services and their administration. I commend it to the House for a Second Reading.

Before concluding, I should perhaps give the House an outline of the programme which I have in mind for the implementation of this Bill, on the assumption of its being enacted in the near future. I would propose to initiate the necessary statutory discussions with the local authorities to finalise the details of the new boards immediately on the enactment of the Bill. Simultaneously, steps would be initiated under section 12 to recruit the chief executive officers. I should hope to put the detailed regulations on the new administration before the Dáil and Seanad for approval before the summer recess. This would permit of the establishment of the boards by October. However, I would not envisage giving the health boards operational functions in the health services until 1st April, 1971. This would permit them to settle down and to plan for the changes in the services. I would expect that most of the changes in the services would also come into effect on 1st April, 1971. The other steps required for the full implementation of the Bill would also be taken in accordance with a detailed programme on this basis which I have prepared.

Before we go into the discussion of the Second Stage of this immense Bill — immense in every way — I should like to welcome the Tánaiste, Deputy Childers, as our new Minister for Health, in the sense that I believe — I may be mistaken in this — that this is the first occasion on which he has come before Seanad Éireann as Minister for Health. I formally welcome him.

I should also like to advert to the Minister's handling of the Committee Stage of the Bill in the other House of the Oireachtas. It was, I believe, his predecessor who dealt with the Second Stage of the Bill in that House. From reports that I have heard, from listening occasionally to the Committee Stage debate in the other Chamber and from reading the report of the debates I have come to the conclusion that the Committee Stage debate of the Health Bill in the lower House of the Oireachtas was one of the finest debates ever undertaken in the Oireachtas. All sections of that House must have lent themselves fully to the production of such a result.

I am quite sure that the Minister, acting in a responsible way, contributed in no small measure to bringing about this result and in so doing showed himself a responsible Minister. I am very glad to see that there are times when we do have responsible Ministers By his actions the Minister exacted from the Opposition and from speakers on his own back benches wonderful contributions to the debate on the Committee Stage. The result of the deliberations on the Committee and Report Stages in the Dáil is now before us and we have to deal now with the Bill as passed by the Dáil.

There are many things that we could say about the Bill as introduced in the Dáil. Some of the ground has been taken from under our feet by certain concessions that the Minister gave and certain changes he made in sections and subsections after prodding by members of the Opposition.

This Bill is a huge instrument. It must have involved a great deal of work and extreme care to produce it. It is not, in my opinion, a fully satisfactory Bill; it is not what I would consider the ideal, but it goes some way to satisfy me as to what a Bill should be. I shall not condemn the Bill out of hand at this stage. I will reserve my criticisms for later on in the Second Stage discussion and, in particular, for the Committee Stage.

All health legislation has one purpose in mind, that is, to safeguard the health of the community and, in particular, to prevent illness from getting into that community. One of the faults that I may find with the Bill is the exaggeration of the administrative and hospital sections to the detriment of the prophylactic and preventive aspects of medicine. There are points in the Bill — some of them will be brought out later—which advert directly to preventive and prophylactic measures which are becoming more and more important that curative measures and hospitalisation.

I will not deal with the sections of the Bill seriatim. As the Minister's predecessor said, this is the way draftsmen produce Bills. The most important sections are not necessarily at the beginning of the Bill.

It is the ordinary people that we are aiming at here in any health legislation. It is necessary, of course, to produce the machinery and the instruments by which curative and preventive measures may be provided for the community. These instruments are dealt with roughly at the beginning of the Bill. It is also necessary in health legislation to provide the method of lubricating that machinery, namely, the financing of the measure. The method of lubricating the machinery provided for in this Bill will, of course, be a matter of contention between us. I fear this will be the greatest bone of contention between us in the Seanad. As a party, we do not intend to obstruct the Bill for the sake of obstruction but to be constructive. There are one or two points on which we cannot agree with the Minister and I am sure he will accept that in the manner in which it is said.

I shall now revert to what I think is the most important part of the Bill, the health services which are covered in Part IV. As the Minister said in his memorandum there is not a great change but there are changes in name. Eligibility is one term and limited eligibility is another for people who cannot, through their own endeavours, provide health services for themselves or people with incomes or valuations below a certain level. There is one change which I commend and that is the taking out of the atrocious provision in the health services which took into account not alone the earnings of the relevant person but also of the dependants. This is taken out of the section and it is also taken out of further sections which I will deal with later and it is a very welcome development. Such a development seems to be a result of thought and experience but one criticism is that it has taken so long to evolve. It has taken three and a half years to find out something which, in fact, most people understood long ago, the iniquity of taking into consideration the income of dependants as well as that of the person involved. I am very glad this change has been made in the Bill.

I should like to digress slightly here. The Minister in his statement referred to the matter of regulations that will come up under practically every section. He indicated that much of the legislation will be by regulation. There are different types of regulation. There are regulations in draft which the Minister went out of his way to explain. I think I am correct in thinking that draft regulations laid before the Houses of the Oireachtas may be amended. This is all very well and I shall go along with the Minister inasmuch as it is appropriate in a Health Bill to legislate by regulation, draft or otherwise, more than in any other type of Bill as I understand that when new phases of administration, new instruments are being introduced, regulations that are either regulations per se or in draft are necessary but I wonder if the Minister has not gone too far in relying on legislation by regulation to the extent he has relied on it in this Bill. There are indications in other Bills that this type of thing is creeping into our legislation and that Ministers are inclined to reserve to themselves the right of legislating by regulation and are less inclined to embody the details in the Bills themselves.

I can be told that Oireachtas Members will have an opportunity of dealing with regulations when they are laid before each House of the Oireachtas but this is in no sense the same thing. One must recognise that the impact of a Bill is far greater than legislation by regulation. I think it is a human trait that nobody examines regulations as thoroughly as they examine a Bill. I accept that to a great extent in this Bill regulations are necessary but there is one anomaly I wish to point out. The Minister has provided by regulation or draft regulation for various things. I presume the difference between regulations and draft regulations is that draft regulations may be amended because they are in draft and may be changed when brought before the House but that regulations laid before the House must be either accepted or not. I understand that is the difference and if that is not so I can be corrected. There is one case where the Minister might have legislated by regulation but he omitted to do so. I am referring to a section increasing the maternity grant from £4 to £8. He has tied himself to the £8 when in my view this could have been done by regulation which would allow the Minister to vary the grant in years to come as the value of money depreciates.

Part IV of the Bill excludes, as I have said, infants and dependants and this is welcome. I do not propose to go into details on section 45 which can be more appropriately dealt with in detail on the next Stage. Again, I think the Minister is being too rigid in the figures he produces here.

He adverts to means tests. Another question arises about means tests, and this is another general statement that pertains not only to the Minister for Health but to other Ministers administering other State Departments. I do not think it is to the question of a means test that one really objects, but the multiplicity of means tests. Where means tests are necessary—and I do not say they are necessary in all cases —it seems to me to be wrong that investigators should be going from Health and Social Welfare and other Departments to investigate the means in any household. My view is that there should be one means test only.

I do not think anyone can object to one means test, because all of us have to undergo means tests no matter what our income is. The objection is to the multiplicity of means tests. I cannot see why a system is not evolved even for the lower income groups, whereby one investigator would cover the whole ground in relation to health, housing and social welfare for any Department in which there is a means test in operation at present. All that information could be processed through that one section. Instead of interrupting people in their households this information should be got from a central office and should be available to every Department.

Section 46 has been discussed in the Dáil. I have read the debate in Committee in the Dáil. Section 46 (1) reads:

When, in the administration of section 44 or 45, an officer of a health board decides that a person does not come within a category specified by or under the relevant section, an appeal shall lie from the decision to a person (being either another officer of the health board or a person not such an officer) appointed or designated by the Minister.

In my opinion it is not correct that an appeal should lie to a person already involved in the running of the health service. While I am averse to giving Ministers greater powers, in my opinion the Minister would be far more impartial in deciding an appeal of this nature. It should not lie with another officer of the same board to decide it because, human nature being what it is, if it is a borderline case, he will probably lean towards what the officer of that board has already decided. Perhaps, we will bring in an amendment on Committee Stage to deal with that.

Section 52 deals with charges for inpatient services. The 10/- per week has been abolished and power is being given—is it to the Minister for Health or the Minister for Finance? The section provides:

The Minister may, with the consent of the Minister for Finance, make regulations...

Up to this the maximum charge was 10/-. Usually it was 2/-, 2/6, 3/- or 4/-, but the maximum was 10/-. I can see a danger here that, if this can be varied by the Minister with the consent of the Minister for Finance, the maximum charge can go up and not down.

Section 55 deals with out-patient services. Subsection (1) reads:

...does not include—

(a) the giving of any drug, medicine or other preparation, except where it is administered to the patient direct by a person providing the service..., or

(b) dental, ophthalmic or aural services.

These are excluded. In the concessions given in section 55 these are exclusions. I wonder why the Minister has excluded them. I am just adverting to this briefly because it will come up properly on the next stage of the Bill.

Section 55 (2) takes away the charges already in existence. So far as I am aware this is the section that takes away the charge of 2s 6d and the 7s 6d charged for X-rays. Of course, this is to be commended and I commend the Minister on this subsection of section 55. Subsection (3) provides:

A health board shall make available out-patient services without charge for children not included among the persons referred to in subsection (2) in respect of diseases and disabilities of a permanent or long-term nature prescribed with the consent of the Minister for Finance.

That also is to be commended.

I want now to get on to the general medical services. Section 57 (1) provides:

A health board shall make available without charge a general practitioner medical and surgical service for persons with full eligibility.

This section needs a lot of thought. The Minister has dealt with it at length. This is the choice of doctor. I am not clear as to whether the statement made by the Minister here was the same as the statement made by his predecessor on the Second Stage of the Bill in the Dáil. The then Minister, Deputy Flanagan, made certain statements. The Minister will appreciate that I cannot now compare his statement exactly with the statement made by the previous Minister.

First of all, let me advert to the difficulties that were arising at that time between the Irish Medical Union and the Department of Health and the County Managers' Association. Some of those difficulties have been resolved, especially those dealing with time off. In discussions with the Irish Medical Union the Minister recently resolved a certain number of the difficulties that were arising at that time. On 26th November Fine Gael had a meeting with the Irish Medical Union and the Irish Medical Association about this. We are glad to see—and I commend the Minister on this—that an arrangement has been made between the Medical Union, that is the medical profession, and the Minister with regard to time off. The Minister also adverted to the method of payment. I shall deal with that in a moment.

Would the Senator give the reference?

It is Volume 239, column 1637 of the Official Report of Dáil Éireann:

Substantial agreement has been reached on most things in these discussions and the essential features of the arrangements for the new service which I propose following these discussions are...

In order to avoid repeating what the Minister said in his opening statement today, perhaps he would tell us if what he said is identical with this because that would save time.

They are generally and essentially the same.

They are essentially the same. The Minister has said that agreement has not yet been reached between himself and the profession as to the method of payment. The doctors are looking for a fee for service and the Minister and his Department want to base it on a capitation fee. That is something the profession does not want to accept.

We are now negotiating on a fee for service.

I hope the negotiations will be successful.

Is it accepted now that it will, in principle, be a fee for service?

The Minister has pointed out correctly—here, I have a certain sympathy with him—that, while everybody agrees with the principle of choice of doctor, there are difficulties. The matter is not as simple as it might appear. Suppose in a town already served by three or four doctors another doctor wants to come in, who will decide whether or not he will come into this particular service of choice of doctor? One can visualise a situation in which a newly-qualified graduate might want to join the service. Mark you, a newly-qualified graduate is not necessarily the best qualified person to treat patients. He must do certain other work after he becomes qualified. How will that problem be solved? Will a board be set up to decide what doctor will or will not come in?

There will be a board.

I see. I think it was stated somewhere that two years experience might be the criterion. Again, this could involve a certain lack of freedom, but I cannot see how the Minister can get over this: if he intends to have a panel of doctors from which a patient can make a choice, then he must have a panel of competent doctors. As far as I remember, there is a qualification in the matter of choice; there will be a choice of doctor where it is considered desirable. What does "considered" mean? Surely it would be better to provide that there will be a choice of doctor where that is practicable. I appreciate that a choice cannot be given everywhere in the country. The Minister's predecessor referred to the Aran Islands in this respect, but there are other places besides the Aran Islands in which a choice of doctor could not be given. I can see the Minister's difficulty here. He may want to give a choice of doctor but he will not find such a choice practicable, irrespective of any consideration. The word "considered" should be deleted from this subsection. It has no value.

Section 58 makes provision for the supply of drugs, medicines, medical and surgical appliances to persons with full eligibility or limited eligibility. This is most acceptable and I commend the Minister for his humanitarian approach. The Minister is a very humane man, but I believe that this would have been the natural evolution anyway as a result of thinking and experience. There is also provision for a specialist medical service. This is very necessary and it is a valuable innovation in our health services.

Section 59 deals with home nursing. This is a most valuable service. Up to the present home nursing has been done in what I describe as a perfunctory way. In the sense in which it will be done in the future I describe it as an innovation. This is one of the cornerstones of our health services. I do not know exactly what is intended but I take it the service will cater for the aged at home. I am speaking now about nursing. This service could lead to the situation in which the aged could be nursed in their own homes instead of being sent into hospitals and institutions. It could deal with postoperative patients. It would shorten their stay in hospital if they were sent to private homes. It could also deal with people who are now taken into infectious disease hospitals to be treated. I shall deal with the whole question of bringing people with infectious diseases into fever hospitals later on. There would be no necessity for dong so if we had a proper domiciliary nursing service. I think the Minister was asked in the Dáil about providing home help for widows with children who have to go out to work, because without this service they would have to stay at home to look after their children.

An amendment covering that possibility went through the Dáil.

I am pleased to hear that. There is no change in the chapter dealing with services for mothers and children. Subsection (3) of section 61 enables a woman with obstetrical difficulties to go to a home or hospital of her choice and I understand the health authority will subvent it to a certain extent. Another section deals with subventing people who are going to hospitals of their own choice and this should be watched carefully because it might be cheaper to help them to go there than to allow them to go to other types of hospitals where the costs might be higher.

I commend the introduction of the child health service. Subsection (4) of section 65 states, and I quote:

A school manager may be required, when notice has been given to him by a health board to provide reasonable facilities for an examination under this section.

Both the Minister and his predecessor, Deputy Flanagan, in answer to Deputy Kyne, said that there was no element of compulsion in this. I hope I am correct in that.

Dental, ophthalmic and aural services cover a wide range of services. I am not certain that the services offered under the present Act are being worked correctly. Firstly, there are not sufficient dentists in certain places; and, secondly, when teeth are taken out dentures are not fitted in time. I think the whole question of dental, ophthalmic and aural services should be examined in great detail because there is a definite failure in the current system.

Section 67 deals with rehabilitation services and these services will have to be expanded. Subsection (1) states:

A health board shall make available a service for the training of disabled persons for employment suitable to their condition of health, and for the making of arrangements with employers for placing disabled persons in suitable employment.

Subsection (2) states:

For the purposes of subsection (1) a health board may provide and maintain premises, workshops, farms, gardens, materials, equipment and similar facilities.

Subsection (3) states:

A health board may provide equipment, materials or similar articles for a disabled adult person where neither the person nor the person's spouse (if any) is able to provide for his maintenance.

I should like the Minister to consider giving grants to voluntary institutions to enable them to provide the services he is asking the local health boards to provide.

It can be done under the Bill.

I am quite satisfied with that. Section 68 gives grants for disabled persons and this is a very good section. Up to this point I have agreed with the Minister but I am now turning to Chapter III on finance and this is where I am at issue with the Minister. Section 29 deals with the internal method of accounting and it states:

A health board shall submit estimates of receipts and expenditure to the Minister in such form, in respect of such periods, and at such times as he may direct, and shall furnish to the Minister any information which he requires in relation to such estimates.

Subsection (1) of section 30 states:

A health board shall not, save with the Minister's consent, incur expenditure for any service or purpose within any period in excess of such sum as may be specified by the Minister in respect of that period.

I understand what the Minister is getting at but there may be some difficulty here if an emergency arises because one will then have to get the consent of the Minister for this new expenditure. I cannot visualise how this could be done in an emergency.

It can be done by telephone.

I accept everything that the present Minister for Health has said but we have been reminded on more than one occasion that the present Minister for Health always will not be the Minister for Health. Section 31 is a controversial section which we do not agree with because the Minister is retaining the old system of financing the health services on a 50/50 basis. He has already said that it is 56 per cent in the Dublin Health Authority area.

Someone said somewhere that the total expenditure for the year 1970-1971 for the new region, that is, Dublin, Wicklow and Kildare, would be £15 million. The estimates which have been passed by Dublin Health Authority alone are £16,360,000. Of course, we get a proportion of that from Central Funds, but if that is the total expenditure by the Dublin Health Authority, when Kildare and Wicklow are brought in the total will be £20 million. I cannot envisage the expenditure being less than that under this Bill.

It may be invidious for me to advert again to what the Minister has said here before—the promises that have been made in respect of relief of rates. A Minister made statements in the Dáil that health expenditure by rating authorities would be held at the 1955-1956 level. The Minister's predecessor, when he was appointed and came to meet the Dublin Health Authority, reiterated that statement. I was present when he made the statement. That undertaking has not been fulfilled by the Government.

I wish to advert to another point that was mentioned by Deputy L'Estrange in the Dáil. The agitation about the impact of health expenditure on the rates had been so great over the previous year that the Minister's predecessor issued a circular to the various health authorities. Nearly everybody here is a member of a health authority. I believe there are approximately 27 health authorities, that is the various county councils and the four specialised health authorities. I am quoting the Minister's circular to which Deputy L'Estrange referred at column 443, Volume 240, of the Official Report of 1st May, 1969:

The Minister feels that in the health services substantial economies can be found without detriment to the efficiency or availability of the present services. He accordingly asks that each health authority should examine critically their forecast of expenditure for the coming year and that they should endeavour to achieve substantial reductions in their projected expenditure.

That is no fairy tale. All of the Senators here who are members of health authorities know that that circular went around. What does that circular mean? It means any one of five things: it means, first, that the people administering the health authorities are crooked; or it means they are inefficient; or it means they were careless in compiling their estimates; or it means those watchful guardians of the expenditure of money, the members of the health authority, were not doing their job; or it means that the health authorities should reduce the services they are providing for the public.

If those estimates could be reduced in any way, it means one of those five things. If the Minister does not believe it is one of those five things, then that circular must be window dressing on the part of the Minister to transfer the onus of the rate increase from the Department of Health to local authorities. That circular was sent to every communication media, the newspapers, radio and television. It is one of the most awful documents ever circulated.

Another aspect of this which I should like the Minister to examine, and which impinges on the Dublin Health Authority to a great extent, is that loan charges are not subvented through State funds. The State gives grants to the Dublin Health Authority three months in arrears, and we have to get a loan and pay charges on the money that is borrowed, money that should have come to us three months earlier. Those loan charges go on the rates, and I should like the Minister to arrange that the health authorities would get the grants that are due to them on the date on which they are due.

We do not agree, of course, that health charges should be defrayed by the rates. We ourselves have submitted an insurance scheme for health. The present system is an iniquitous one. Recently we had before the Seanad a rates Bill in two sections. One was to provide complete relief from rates to certain sections of the community and the other was to provide for paying rates by instalments. Nobody objected to the relief given to these lower income groups and people with certain valuations, but what happened? The Government did not pay for this. The Government put the extra money to be collected by rates on the other rate-payers so that, in effect, the remaining ratepayers, when the health charges go up, will have that extra inflation in their payments. That is another aspect that I should like the Minister to note.

Section 31 (7) reads:

"Regulations under this Section shall be laid before each House of the Oireachtas".

Would the Minister like to change that to "draft regulations" so that we could discuss it again? I shall leave that over to the next stage of the Bill.

I commend the Minister's idea to allow health authorities to accept gifts of money, property or land which I think are included in this. In the current Health Bill I think health authorities are precluded from accepting such gifts. This is a new innovation by the Minister and I feel he is absolutely right in introducing it.

I want to turn back to what is the instrument and the machinery for providing the health services in the first parts of this Bill—the administration of the health boards and the setting up of the health boards. The Minister has decided to set up what I term "area health boards". I am using that nomenclature myself, I do not know what the official term is, to distinguish them from what is coming later in section 40—regional hospital boards and regional hospital areas. I am referring now to the commencement of section 4. There was a document circulated to us which is headed: "Health Bill, 1967: Tentative Details of Proposals for Health Administration." I think Deputy Childers was Minister when this was circulated. It gives certain reasons why it should be regionalised. I shall not go into the details but I should like the Minister to note that the Eastern Regional Health Board consist of Dublin city and county, Dún Laoghaire—which is not mentioned there, I presume it is included in the county and we are still trying to stay out of it—and counties Kildare and Wicklow. That area has a population of 921,000. For that area, as I have already said, the estimated budget is £15 million a year whereas the current budget for the Dublin Health Authority without Kildare and Wicklow is almost £16½ million. I have the estimates here if anybody wants to verify this. In this regard, too, the Dublin county rate is going up 3/-, Dún Laoghaire 3s 10d, Dublin city 2/- or 3/-.

There is an excellent map towards the end of this document showing the regions. In fairness to the Minister, before he determines that these are the final areas, he has promised that he will consult the various counties and organisations involved. He mentioned that in his introductory statement to the House. However, there are great anomalies in the constitution of these boards. I want to bring this to the notice of the Minister and to the notice of the House. It has been brought to the Minister's notice already in consultation with various authorities but it might be no harm to refresh his memory on these points. I want to refer to what will be termed the Eastern Regional Health Board.

The population of this proposed area is 921,000, the best part of one million. The population of the Dublin Corporation area is approximately 600,000, of the Dublin County Council area 130,000 or 140,000. I have not got the exact figures. The population of Dún Laoghaire is 60,000, the Wicklow County Council area 60,000 and the Kildare County Council area 66,000. These are approximate figures. Look at the representation. Dublin Corporation have six members, six members to deal with 600,000 of a population. Is that equitable? Dublin County Council have three members to deal with 130,000 or 140,000. Is that equitable? Dún Laoghaire Corporation have one member to deal with 60,000 while Wicklow County Council have three members to deal with 60,000 and Kildare County Council have three members to deal with 66,000. There is something very inequitable about that. I know this has been brought to the Minister's notice but I feel the Seanad should also notice it.

The Minister has promised that on these boards local authorities will have more than half the representation. It is not embodied in this but the Minister has in fact accepted that the representation from local authorities will be greater than 50 per cent. If we come back to the Eastern Regional Health Board, how is the Minister doing this? Is he doing it simply by reducing either the number of doctors or the Ministerial nominees and keeping the same numbers for Dublin County Council, Dublin Corporation, Dún Laoghaire, Wicklow and Kildare; or, if he intends to increase the membership of local authorities on these boards, where is this going to fall? Is it going to fall on Dún Laoghaire Corporation, which have only one member? In this document it is the only corporation in the whole country with one member on the health board, whatever the Minister may do by regulation. Is the Minister to give an increase to Dublin County Council, Dublin Corporation or the county councils of Wicklow or Kildare?

A further point arises here which it might be as well to mention. At the moment Dublin Corporation are dissolved and are at present represented by Mr. Commissioner Garvan. How is the Minister going to get six members from Dublin Corporation? When the corporation were dissolved Mr. Garvan represented the corporation on the Dublin Health Authority. He took the place of 15 members, but had only one vote. No matter what is given to Dublin Corporation at the moment, will Mr. Garvan be representing them? Will he still have one vote? If this is so, the representation of Dublin County Council, Dún Laoghaire Corporation and the county councils of Wicklow and Kildare will have to be increased by three to four members apiece in order to have more than 50 per cent local authority representation.

Equally, if each of these four bodies left after Dublin Corporation have been dealt with is given an increase of one member each there will be an anomaly because, while there will be four members from Wicklow and Kildare County Councils, there will be two from Dún Laoghaire Corporation, four from Dublin County Council and still one from Dublin Corporation, making a total of seven in all. Wicklow and Kildare will have greater representation than Dublin County Council, Dublin Corporation and Dún Laoghaire Corporation together. Perhaps the Minister might deal with this point.

The Minister concedes a point when it is worthwhile. I am glad he has decided to change what was originally in the Bill, as introduced in Dáil Éireann, with regard to the appointment of a chairman and vice-chairman. The Minister has given to the local board the right to appoint their chairman and vice-chairman. This change is a very excellent and welcome one. The Minister has brought in most of section 4 (2) (c):

...the first appointments to a health board under paragraph (a) (iii) shall include appointments made on nominations of bodies which, in the opinion of the Minister, are representative of the medical and ancillary professions...

That is another change from the Bill as introduced in the Dáil. It is also welcome and I commend the Minister for it.

Other provisions about local committees are brought in. Local committees and local representatives are given greater membership. The Minister brought in another welcome amendment at section 7 (5) (a).

Let us turn now to section 11. There is provision here for a public local inquiry into the removal of a board from office. This is an excellent idea. I presume that subsection (2) of section 11 was brought in to avoid a recurrence of what has occurred in Dublin Corporation. If this subsection is read closely I think this is what it was intended for. It means that any Minister or Department may withhold money from any local authority who do not provide a proper health grant. I will not give my opinions on dissolution. Subsection (3) of section 11 was discussed in the Dáil with particular reference to the two-year period. I will not dwell on this. There was a long debate on the Committee Stage. Section 11 (3) reads:

Within two years of the removal from office of the members of a health board under this section, the Minister shall by order provide for a new appointment of members to that board.

Certain people think that period is too long. I was in the Gallery in the Dáil when the Minister was making his case and, while I am not sure that the Minister's case was "the greatest" it was nearly as good as the case made against him. The Minister adverted to the chief executive officers of the health boards in his preliminary statement. The functions proposed to be given to them are not the functions that lie with the manager and the local authorities at the moment. In fact, they are more confined and deal with questions of employees and eligibility. These are the main items with which they deal and all other things are left to the members. There have been deputations to the Minister about this. We, in the eastern region, feel it would be better for us who will be dealing with one million people to leave the position as it is operated at present in the Dublin Health Authority. The Minister has adverted to this in his opening remarks.

This can be done under section 16 (4) (e), by delegation.

Section 16 (4) (e).

I told the members of the Dublin Health Authority about that.

Is it intended to prescribe the functions?

Health authorities very much want it so. If you look into the workload of the managers there is a question whether any board could really do the whole thing themselves and whether they would have to delegate a few more functions.

I will now come to Part III which deals with hospitals, et cetera. In general this is implementing what is proposed in the outline for the future hospital system which is generally known as the FitzGerald Report. Subsection (3) of section 37 gives power to the Minister to direct the closure or user of existing institutions. That is a rough paraphrasing of what the subsection means. I know that political boundaries will be crossed here by this particular subsection and that members of each party will have divergent views on the matter but I agree that it is correct that the matter should be left in the hands of the Minister after, as the subsection states, “a local inquiry” has been held. It is right that it should be left in the Minister's hands rather than that we should enter into the realm of parish pump politics here. Section 40 deals with the three regional hospital areas and the Minister has given his reasons for this. I subscribe to a great deal of this as I think anyone who has read the Todd Report would. I agree with a lot of what the Minister is trying to get at here, whether or not this is the correct method of doing so.

In this section the Minister brought in a new subsection, subsection (4), on the Report Stage in the Dáil. It deals with the appointment of the chairman and vice-chairman of each of the regional hospital boards. This probably arose when the Minister conceded that the health authority boards should themselves appoint their chairmen and vice-chairmen. He then had to eliminate from the Second Schedule those elements which covered the appointment of the chairmen and vice-chairmen and it was then seen that at the same time this eliminated his authority to appoint the chairman and vice-chairman of each regional hospital board. I presume this is why this was inserted. I will not go into more detail on this now as the matter might be left to Committee Stage.

Section 43 refers to the Central Mental Hospital which was formerly called the Dundrum Criminal Lunatic Asylum and which was under the charge of the Board of Works. It is proposed that it shall be still under the Board of Works and I do not think that the Bill will change the ownership of the building. Why do the Board of Works want to hold on to it if we are going to staff it and run it? It will not be the whole country that will be bearing the cost of this but the eastern region. The imposition for running this hospital will fall on the eastern region health board because it states here that:

The Minister may, by order made with the consent of the Minister for Finance, arrange for the transfer of the administration of the Central Mental Hospital to the health board (in this section referred to as the relevant health board) the functional area of which includes the county of Dublin.

So that the charge for running the hospital will now fall on a circumscribed area.

It will be apportioned as before.

I am grateful to the Minister but he will not blame me for taking——

Not at all.

——that meaning from it, as I am entitled to. Now I come to a point which worries me, just as it worried Deputy Clinton in the Dáil on Second Reading. It is in regard to the particular functions of regional health boards and area health authorities, their responsibilities and their overlapping. Is there a danger here of a clash? In the Dáil Deputy Clinton said that he was not clear about these functions and wanted them spelt out in detail and the Minister, and I admire him for this, said that he himself wanted them clarified and that he would issue a document on the matter. He made that statement again today. He used the words "White Paper" but qualified them by saying that it would not be the usual type of White Paper. He said that this document would be provided and there would be clarification of the functions of the regional health boards and the area health authorities.

In conclusion, may I say that I may have been harsh in regard to one or two points, especially in regard to section 31, but at other times I gave the Minister credit, which he deserves as do those who debated this Bill in the Dáil, for producing this Bill. I hope that in his deliberations and discussions with us in the Seanad the Minister will show to us the same tolerance, understanding and patience during the Second Reading of the Bill and the Committee Stage, which may be more difficult, that he showed in the Dáil.

I do not propose to engage in the same searching analysis of the Bill as Senator Belton because I believe this is primarily a Committee Stage Bill and I look forward to a very stimulating and searching analysis on the Committee Stage. Therefore, what I have to say on the Bill now will be general and brief. I was surprised that in his introductory speech the Minister did not make any reference to the regional hospitals. All the emphasis appeared to be on the regional boards. I am sure the Minister has not dispensed with or discarded or jettisoned the idea of the regional hospitals.

To say I am disappointed with the Bill would be an understatement and I am sure many other Senators also are disappointed with it. When the White Paper was issued in 1966, we were led to believe that we were about to get a Health Bill and health services worthy of the name, but unfortunately many things have happened since that document was issued. Three years have elapsed and now we are getting what I regard as a watered-down version of the Health Bill that was envisaged by the then Minister for Health, the late Deputy O'Malley.

In saying that, I do not wish to be taken as casting any aspersions on the late Deputy O'Malley's successors, Deputy Seán Flanagan or the present Minister for Health. We all know that the late Deputy O'Malley had a way of getting things done that very few of the people who have been in public life in this country had. Therefore, it would be very difficult to expect anyone to bring in any measure as revolutionary or as good as the late Deputy O'Malley would have done.

In voicing my criticism of the Bill I do not wish to be taken as knocking it for petty party political purposes. I should like to assure the Minister and the House that the Labour Party representatives in the Seanad are prepared willingly to support any improvement that there is in the Bill. Unfortunately, improvements are hard to find and therefore I do not expect we shall be overworked in that respect.

I find this to be a rather complex and difficult measure to understand. Perhaps the Bill is meant to be complex, and I have a certain amount of sympathy with the Minister now before us because he was not the architect of the Bill. I am sure that when he took over from Deputy Seán Flanagan he had to do a certain amount of research and study on the Bill before he familiarised himself with it and I should like to congratulate him on the job he has done in making himself familiar with the various facets of this complex measure.

As the Minister mentioned in his introductory speech, the Bill has had a chequered history. It was introduced and had its Second Dáil Reading late in the life of the Eighteenth Dáil when Deputy Seán Flanagan was Minister for Health. It was then put into cold storage until after the general election and it was resurrected and reintroduced in the Nineteenth Dáil by the present Minister. Nine months later, we get it in the Seanad. In those nine months, although there have been improvements—I give the Minister credit for the improvements that have been effected since the Bill was read a Second Time in the Dáil—they have not been what one would describe as spectacular.

As I said earlier, I was amazed not to find anywhere in the Bill any reference to the regional hospitals. As a member of a local authority, this has a big bearing on my attitude to what seems to be the prime purpose of the measure being introduced here today, that is, the setting up of the regional hospital boards, and I have no doubt that on those two items the sparks will fly.

First of all, there will be a power struggle to get on the regional hospital boards and there will be debated in those boards the question of the siting of the new hospitals—where they are to be. We must remember that in the north-east region, which comprises four counties, this will be a difficult decision, but a decision will have to be taken.

When the Minister took over this Bill, last September, as I mentioned earlier, he notified local authorities that he would like to consult with them and have their views on the setting up of the regional boards. I think we should be grateful to him for that. Senator Belton mentioned, and it is also mentioned in the Minister's introductory speech, that the Minister had further consultations with the various local authorities.

I happened to be present, as a delegate from my local authority, at a conference with the Minister. Now, as we all know, at that conference the Minister was very courteous: he is a very courteous Minister and I was not surprised at the way he received the representatives of the four local authorities concerned. He listened with attention to all the points made, and there were many points made and different opinions expressed. However, I came away from that conference asking myself if my journey or that of any of the other representatives had been necessary. The attitude seemed to be: "This is the Bill and you have got to take it, to like it and to operate it."

It was therefore rather amazing that from there on there was this power struggle as to where the new hospitals would be sited and where the new office blocks would be sited, and I am sure we shall hear a lot more about it before the location of the new hospitals and of the office blocks for the new regional areas is decided on. I agree that we should have specialised hospitals but is it necessary that we should have those huge buildings that will in effect involve the elimination or closing down of many hospitals in the regional board areas with consequential upheaval and upsetting of both the hospital medical staffs and the local health authority staffs?

Then one must take into consideration the patients and the friends of patients who would like to visit them and who may have to travel very long distances to hospitals. Is it necessary that a patient would be sent 50 or 60 miles, past an existing very good surgical hospital, for, say, a simple appendix operation or, in an accident case, with a broken arm or leg? These are but a few of the problems that will arise in the future. I can only speak for the hospitals in County Meath but I have no doubt that the standards in the hospitals in most local authority areas are as high as those in the hospitals in County Meath. I can vouch for the efficiency, skill and dedication of the staffs of those hospitals. If you will bear with me, I shall read a paragraph or two of a submission that was made by the Meath County Council when we had that conference with the Minister in the Custom House in October/November. I quote:

The Meath County Council are in the happy position that the range and standard of health services available within the county are reasonably adequate. Patients who in exercising their right of choice of hospital wish to go to extern hospitals are within easy reach of Dublin and Drogheda but the range of standards and services in Meath are such that only for a limited range of specialities is referral to external hospitals necessary.

The regional orthopaedic unit at Our Lady's Hospital, An Uaimh, with 82 beds staffed by orthopaedic surgeons already caters for a wide area besides Meath and the surgical wing of Our Lady's Hospital is efficient and active.

In these circumstances the Meath County Council feel that the people of Meath will benefit in no way from the inclusion of the county in any health region which would include a proposal to lower the status of the Meath County Hospital. Meath County Council would therefore request the Minister to reconsider his proposal to include Meath in a region for health purposes.

Perhaps it will shorten the debate, or shall we say, make unnecessary a great deal of comment of this kind, if it is made quite clear that the power to close a local authority hospital is not being changed in this Bill and the fact that regional health boards are being set up does not alter or diminish in any way the power of the Minister to close a hospital or to change its functions. An inquiry will still be held. There will be consultation. The passing of this Bill does not in itself result in any of the recommendations of the FitzGerald Report being implemented. There is absolutely no change as a result of the passing of this Bill and when this Bill goes through the Oireachtas and is signed by the President no particular part of the implementation of the Bill can go ahead unless the decisions are made. So that no one in this House is committing himself or herself to the knowledge that a hospital will either change in its function or be closed. Indeed, of course, there is no question of closing hospitals all over the country. There has been a proposal in the FitzGerald Report that the functions of certain hospitals should be altered and changed. I want to make that point. Otherwise we could have a debate that would last for three weeks in which every single person who wanted to comment on their particular hospital could do so, thinking for some reason or other that the passage of the Bill makes these changes inevitable. It does nothing of the kind.

I think the Minister has got me wrong. I am quite well aware of what the Minister has said but the object of the Bill, let it be in five, ten, or 15 years, is to bring about what I have just stated. I know that, on the passing of the Bill and its being signed by the President, the Minister will not write to this or that county secretary telling him to close down a hospital, because there is no alternative accommodation at the moment. But what will happen when these new colossi are built? That is what I am worried about, not the immediate future. I know that the regional hospitals have yet to be built when the sites have been selected and I expect that it will be ten or 15 years before that can happen, so that there would be no immediate danger of the closure of any of the existing hospitals. What I should like to know is this: while we are waiting for the new hospitals, what will the new regional health boards be doing that it would appear will be in operation about April, 1971, and while we wait for the new hospitals we must maintain the standards of our existing hospitals and in many cases they would have to be considerably improved. So, we spend money on the existing hospitals and, perhaps, on the setting up of these new regional boards, and will we be expected to contribute to the building and equipping of the new regional hospitals that will serve the area now served by the existing hospitals?

When the regional hospital boards are set up they will meet. What they will be meeting about and what they will be talking about, at this stage, it is difficult to understand. Will they take over the existing health services in the four local authority areas which they will represent? This is a matter that I am worried about. Perhaps I will be accused of a certain amount of parochialism in this matter. It is rather strange that as a member of the Labour Party I might be considered conservative or old-fashioned, not wishing to see change even though that change may be for the better. I have been for 27 years a member of a local authority.

Everybody knows what the local authority hospitals were like 30 years ago, due to no fault either of the State or the local authorities concerned. We all know of the wonderful improvements that have been carried out and of the wonderfully high standards that we have at the present time. I am very proud of the fact that I was a member of the local authority during all those years of change. The Meath County Council are very proud of what they have achieved in our county as a result of the efforts of the various county councils. While there were members of those county councils who were elected on various political tickets, they all worked together as a team and nobody tried to claim that this party or the other party played any greater part than any other party in bringing about those wonderful changes.

There are in the House two members of that local authority—Senator Fitzsimons and Senator Farrelly. Senator Crinion is a newcomer to the Meath County Council. He will excuse me for leaving him out. I speak of Senator Fitzsimons because he has been for 35 years on the Meath County Council and has seen the wonderful changes that have been brought about and, no doubt, like myself, Senator Fitzsimons does not view the proposed changes with any enthusiasm. I am sure the same applies to Senator Farrelly.

Perhaps, the Minister is neither amused nor pleased by what I said. I may seem to have been very critical but he will forgive me for that. A tremendous amount of money has been spent and it is proposed to spend much more on the new service. If it will bring about a better service the money will be well spent but it will be a long time before that question can be answered.

I can mention two of the improvements in the present Health Bill. We have a choice of doctor. This will work very well in populated areas but I wonder how it will work in areas not so densely populated and not developed —areas that cannot keep a doctor at present. The choice in such cases will be very limited. I am sorry that the medical card remains although it is good that the income of parents only will be taken into consideration in future and not the income of all members of the household as at present. Can we not dispense with the medical card altogether? To me it is a relic of the old poor law system. I am sorry I cannot be more enthusiastic about the Bill but I assure the Minister who I know is working towards a better health service—perhaps in a way different from that which I should like—of my co-operation and that of my party in improving the present services.

This Bill is a big step forward. It was needed when one considers the growing trend of specialisation in the world. Gone are the days when the surgeon in the local hospital was prepared to do every conceivable operation from removing toe nails to, perhaps, vital operations on heart or lungs. During the past 20 years doctors have been specialising and if this Bill were not introduced together with regional boards and centralised hospitals, local hospitals would find it difficult to get the services of specialists particularly in the surgical field because such people would naturally gravitate to where they would be fully occupied in their chosen sphere. We need only look at Dublin hospitals at present to see how many people are there from all over Ireland. In the case of my own county when people are sent from Meath to Dublin it is not so bad as the journey is not so great, but I pity people from Donegal, Mayo or Kerry or other counties who are sent to specialist hospitals in Dublin. If we hear that somebody has been taken to the Richmond Hospital after an accident it is more than an even money bet that it is a case of head injuries. If someone is transferred by helicopter to Dún Laoghaire there is a shrewd suspicion that it is a case of spinal trouble, that he may have a broken back.

Local authority hospitals have realised the change that has taken place and have been sending particular cases to Dublin hospitals where they will get specialist treatment but I think the people deserve a better service than that. I may be speaking a little against my own county in this because of our proximity to Dublin but on the whole —and in dealing with health services one must take the country as a whole —if we are to encourage specialists and people of that calibre to remain in Ireland we must be able to provide hospitals throughout the country in which they will be able to work and with an area that will be sufficient to keep them supplied with patients in their particular fields. That is the only way in which such services can be assured and I think the Department agree with that. The only hope is to have fairly large regional areas of some four counties, catering for about 200,000 people, an area large enough to keep a regional hospital going as well as the existing hospitals.

People say that hospitals will be redundant but I do not see that happening and it is not envisaged in the Bill. For the first time local general practitioners can work in a nearby hospital and this will be of great benefit to them. They will be able to deal with minor cases without the necessity of people having to go further afield. We shall have regional consultants coming to the general hospitals in the different areas.

In the early 50s many hospitals were built in an attempt to eradicate TB. They were very successful and, to a large extent, TB has been cleared from the country. I think there is only one hospital catering for TB patients now and there may be another which is partly catering for them. We have come a long way in those 20 years. What has happened to all the hospitals which were built to cater for TB patients? None of them has been closed. They are all working to full capacity in some other field. There is no fear that any hospital will be left empty or will be completely redundant. TB is just one specific disease. I do not know exactly how many hospitals were built for TB patients but there were quite a few. There was one at Blanchardstown, St. Mary's, Peamount, the Cedars and Newcastle Sanatorium. There were many others and they are all now working at full capacity. They were all absorbed into the general service. I am sure we will find that when the new regional hospitals are built the existing hospitals will still be working at full capacity as time goes on.

We have to admit whether we like it or not—and I do not think the medical people may like to admit it— that there are a number of diseases the cure for which has not been discovered. There is the common cold which Dr. Barnard in South Africa or my own local doctor at home cannot cure. The flu had to run its own course. Those are two common complaints and I know there are plenty of others about which the medical profession do not know very much as yet. With modern drugs and modern techniques we hope that in the not too distant future the cure for the two greatest killers, heart disease and cancer, will be discovered. We will have patients suffering from those two diseases but we hope that there will be a breakthrough and a cure discovered for them. Money is going into trying to get a breakthrough in the case of cancer. Let us hope we will get that breakthrough in the not too distant future.

We are living in an age of specialisation and we have to bring our health services up to the standard the people deserve and expect. The world is getting much smaller and people are reading about operations and treatments all over the world. It is a pity that within the past year one child had to be brought to South Africa and another to London for different operations. I should like to see the day when our own medical people will have the specialised training and, possibly, more important the facilities to carry out such operations.

We in Meath have seen the benefits of regionalisation. We have an orthopaedic unit which covered six counties, and now it will cover only four. It has worked extremely well. We have a specialist there and the work he is doing is exceptionally good. Even though people have to travel from as far afield as Westmeath, Longford, Cavan, Monaghan and Louth, very rarely do we hear objections from these people at having to travel those distances. The reason for that probably is that when a person is sick his main worry is where will he be cured. If he realises there is a good service and a good specialist in that hospital he does not mind having to travel some distance to get the job done successfully. That is the kernel of the matter. When I represented part of Westmeath I often visited people in hospital and never once did I hear any objection to having to travel that distance because they were happy in the knowledge that they were in a good hospital and getting the proper treatment.

I should like to come now to the question of cost. The Minister has said that at present 75 per cent of the cost of hospital charges comes out of the Central Fund.

All health services, including hospitals.

We must also take into account the relief of rates given to farmers. Portion of that relief is in relation to the health services. From 1966 to the present the health service grant has gone up from 50 per cent to 56 per cent. When we add on the percentage for relief of rates given to farmers, that brings our overall contribution to 75 per cent. Each year when the rates estimate comes in people talk about making health a national charge. All jolly fine, but the money has to come from somewhere; one way or the other, the taxpayer will have to pay.

People should realise that by keeping some part of the contribution at local level it will be possible for them to have some say in the administration of the services. If the contribution comes completely from central funds one cannot very well expect local representatives to have any say in the expenditure of the money or in the administration of the services. We all know what a help it is to have local knowledge, particularly in cases of hardship. Sometimes illnesses are of a confidential nature and people do not like disclosing confidential matters to strangers. In such a case the person with local knowledge will have the information and be able to help the individual concerned. It would be very difficult to give that local knowledge to the faceless ones here in Dublin. If there is insistence on central funds paying for the services the result will be that administration will be removed further and further from the ordinary people; people should think again when they ask that the cost should be met completely out of central funds.

There will be local representatives on the various boards. Decentralisation is always good policy. Local representatives should, as far as possible, be given some say in administration. Senator Belton said we were adding an extra burden on the rates in helping out widows and old age pensioners living alone. It is an extra burden but, if the Senator examines the figures for County Dublin, he will find that the extent of the burden is only one penny in the £. I do not think anybody would begrudge an extra penny in the £ for the benefit of the less well-off sections of our community.

A good deal has been said about voting on the boards. There will be more local representatives than specialist people. I am glad the Minister has come round to this point of view. He is even allowing the boards to vote for their own chairman in the first instance. I doubt if a great deal of voting will occur at these meetings. I should imagine they will try to avoid the necessity for voting. There will be more local representatives on the boards. Can anyone see all local representatives agreeing to vote in a particular way against the specialists? There are different parties here and it is very rarely all the parties vote together. Apparently the idea is that the local representatives could be outvoted by the specialists. For the life of me, I cannot see the local representatives all voting the same way. I do not say there would be a party issue involved, or anything like that, but I can see differences of opinion. That is the normal experience on any board. As a rule, one does not try to push people into a vote. One tries to iron out the differences. It is only in the case of a very fundamental issue that a vote might be taken. I imagine these boards will work harmoniously. I doubt if very many votes will be taken. They will work for the betterment of those needing these services. I doubt if debating this unlikely eventuality will help us. It is time-wasting.

The Minister is to be commended for the manner in which he has gone out of his way to consult on this Bill. He has given way on quite a few matters. It is quite obvious that he wants the service which will benefit the people most. He is not trying to be a dictator, shoving the Bill through irrespective of argument. He is prepared to discuss the Bill in order that he can evolve the best possible scheme. That was clearly demonstrated by the number of amendments he accepted in the Dáil. Naturally, a Health Bill tends to be controversial because all of us are imbued with the idea of self-preservation. It is something about which people are very concerned.

Business suspended at 6 p.m., and resumed at 7.15 p.m.

One big change brought about by the Health Bill is the choice of doctor. Under the old Act expectant mothers had a choice of doctor. As far as I remember in an area where there were two doctors 60 per cent of the people with medical cards changed over to the other doctor; where there were three doctors in an area 70 per cent changed over; where there were four doctors in an area over 70 per cent changed over, and where there were five doctors in the area between 84 and 85 per cent changed over. This changing about was an indication to the Department and to the Minister that a choice of doctor was both required and desired. I am glad that a choice of doctor has been brought in because the people need and like to be able to make a choice.

It has been asked how it will operate in the rural areas. I live in a very rural area with no town near me and where people are not satisfied with the local doctor they will inconvenience themselves to go farther afield if they think they can get a better service there. As a result of the introduction of a choice of doctor I can see doctors setting up practices at the extreme ends of dispensary areas. In time, I can see a doctor setting up practice in Ballivor, which is at the end of the Athboy area. Of course, eventually, group practices may be set up. We have only to look at the veterinary profession to see how this has worked out. Anyone requiring a veterinary surgeon in Kinnegad used to have to send to Mullingar in order to get one but now there are two veterinary practices in that area.

One defect is that you often have three or four veterinary surgeons but no doctor in a district.

We have a doctor as well. If you look over the district you will find that we have more doctors than vets. A chemist also came into the district. It is healthy to have competition. The Bill provides that in assessing eligibility for a medical card the means of an individual and his wife only will be taken into consideration. We will no longer take the income of the whole household into consideration. This has been a very thorny problem particularly in recent years. In some cases the total income of the family would be quite high, particularly where several members of a family were earning. Small earnings from girls in knitwear factories, combined with the earnings of their parents, could bring the total income of the family to quite a high level. In such cases reports have come back from the local authority that the combined income of the house is quite high when, in actual fact, in most cases the girls of the family were well able to spend the money they earned. Often these girls paid only a small contribution towards family expenses. It is an improvement to have the incomes of the husband and wife only taken into consideration.

The Minister is taking power to lay down standards for the whole country. I hope the Minister uses his power because at the present time people do not really know who is entitled to a medical card. Before the last general election I dealt with three county councils and I found there were great variations between the incomes of medical card holders in the various counties. In Westmeath an applicant for a medical card had to have means 30/- below those of a recipient in County Kildare, while a man in County Kildare had to have means 10/- per week below those of a man in County Meath in order to be eligible for a medical card. These variations in entitlement to cards as between one county and another created disturbances and annoyances amongst people living on the borders of counties. I often discussed this with Meath County Council who said that they were still giving the same percentage of people medical cards as were the county councils of Meath and Kildare. That is not a logical answer. If possible, the Minister should lay down a standard for the whole country and let such standard be known to all. The Minister mentioned "flexibility" on quite a few occasions. Even with a set standard there is need for flexibility, particularly in cases of hardship. There must be flexibility.

In regard to the choice of doctor, I am very glad to see that a medical card patient will now be received in the doctor's private house. At present there is discrimination and the medical card patient is received in the clinic or the dispensary and a patient who is paying is brought into the doctor's house. I know of cases where paying patients happened to go to the dispensary to obtain something to which they were entitled free of charge, such as the polio injection or some of the other injections, and when the doctor saw them he said: "Oh, I would prefer if you would just go around to the house and I will see you there." People will not readily accept that sort of discrimination any longer.

Under the proposed system no one will know whether another person has a medical card or not. The same will apply to the matter of obtaining drugs and medicines; everybody will now be going to the local chemist. I am glad that this discrimination is being removed. The move will be welcomed throughout the country particularly by people who are unfortunate enough to have, say, mentally handicapped children, and who will now be eligible for free services under this Bill when it becomes an Act. In passing, I should like to say that I am very glad to see more money being devoted to providing services for handicapped people both in regard to education and health. For far too long these people have been left in the background or have been put away in mental asylums, which I regard as being a terrible thing to do. Quite a lot can be done now to give these people a certain amount of independence. Today with modern science their life expectation has been increased considerably and in a number of cases they can expect a full life span, whereas before 20 years was the normal life expectation.

The provision of a free service for diabetics is also welcome. A friend of mine suffers from this disability and I know how important it is for these people to have regular injections and so on. Sometimes when people found they had to pay for this service or had to go to a doctor every time they wanted it they became neglectful and we know the awful results that can follow such neglect. Now we are not only providing this service but we are providing it to the extent of supplying automatic syringes so that people may inject themselves. This type of service is being expanded in other directions also.

The provision of the home help service is also very welcome. I have visited many old people and I know that in all cases they want to stay in their own homes. They do not want to go to institutions because even though such institutions may have nice names a stigma is still attached to them. They are much happier in their own environment among their neighbours. This type of service has been provided to a degree in some counties but now the service is being put on a proper basis and voluntary bodies can be paid to do the work. If these people are in their own homes there is always somebody, perhaps, children or neighbours, who will call in to see them and this obtains even in the quietest areas.

Even from the economic point of view it is good for the State to do this because if these people have to go into institutions it will cost the State much more. However, I would prefer to look at it more from the point of view of the comfort that such a service will provide for these people living in their own homes. In the last few years the Government have been moving in this general direction because they realise that people prefer to stay at home, in the place where they spent the greater part of their lives.

I am glad to see that the school services can be expanded to take in secondary and vocational schools because occasionally there has been a breakdown and sometimes children moving from national schools lost out. Therefore, I am glad that there is a possibility that the service will be extended as time goes on. Finally, I should like to compliment the planners of this Bill for providing us with a very useful measure.

I do not wish to go into such detail as Senator Belton. I wish to speak as a member of a local authority for more than 20 years and to give my views on how this Bill reflects the attitude of mind first of all of the administrators and, of course, of the people as a whole. Nobody should forget that this Bill, although the Minister has described it as a short and a rather vague measure, is breaking new ground never broken before.

Everybody knows that local authorities as they exist today were established 50 years ago and that they existed in other forms for many years previously. Local authority members have served a useful purpose, experienced as they are in the traditions of their people: they have served such a useful function that many people will want to see that that principle of local administration should not be lightly cast aside. All local authorities are jealous of their powers and functions and all of them would fight tooth and nail to hold the powers they have.

At the same time, all of them realise that in face of the mounting cost of health services and the increased burden they impose on the ratepayers, they had to open their minds to a new idea if such new idea meant better services at lower cost, which we all hope will happen, though we are rather chary about ever achieving such a situation.

The Minister must be complimented for seeking the views of local authorities. He met them and he listened very carefully to what they had to say. He also made it his business to go to Scotland and to study there the effects of the health services in a country comparable with our own from the point of view of local administration. He was able to convince a number of sceptical people that what he was about to do was something that needed to be done and that in the long run it would be in the best interests of all concerned.

There are prejudices among members of local authorities based on sound traditions. Local authorities have had powers given to them by the votes of the people. Members of local authorities know the areas they represent better than anybody else and they wish to hold on to the powers that have been given to them. On the other hand, I think most local authority members are convinced there is a necessity for regionalisation. It is an ugly word but it seems to have become necessary in this day and age. It is the general population of the country who I find are not as willing to accept regionalisation as are members of local authorities, and for many and varied reasons. Many of them fear that if you have the local hospitals degraded and have to transfer patients 50, 60 or 100 miles from home, the difficulties of visiting them will become enormous. Everybody knows that from the point of view of therapy visits from relatives and friends are a great factor in recovery. As I say, many people fear that it might not be possible to get transport to the places where their relatives were being taken care of. They also fear that the transport might be very expensive and that they might not be able to make the trip in one day. These fears exist.

If the proposals in this Bill are found to be workable, it will not be necessary in the future for people who have passed the acute stage to stay in the hospitals where they got specialised treatment. During the acute stage patients might not be expecting or indeed allowed visitors because visitors might be more of a hindrance than a help in the process of their recovery. If such patients, after the acute stage of their illness, can be sent back to convalesce in their local hospitals, that will be the proper way to deal with this problem.

I wish to speak for a moment on the setting up of health boards. As has been said earlier, we know that local authority members will make decisions not so much by vote. People will be selected from the various parties in local authorities. I would hope that such selection would be based on the interest certain members of local authorities have taken in the medical, surgical and general hospital set-up in their areas.

Although some people think it is not very important, when he met the people from the west of Ireland in Athlone the Minister had the idea in his mind that there would be equal representation as between local authority members and professionals and others on the health board. I am glad to see the Minister has changed his mind on that idea. Other representatives and I, including members from the Fianna Fáil Party, put the case that the local authority members, being the people who have to go back to their areas and carry out the necessary movements to finance the health services, should be the people to be given superior representation on the health board. After all, the budget would have to be carried by the local authorities.

For that reason, the Minister was right to ensure that the change was made to give local authority members superior representation on the board, not indeed that local authority members might be at daggers drawn with the professionals or anything of that nature, because I would hope that the professionals will be advisers to the local authority members as to what they should do in an administrative capacity. I hope there will not be any tug-of-war between the elected members of these boards and the representatives of specialist services and others elected to the boards.

Of course there may be conflicts between members of one local authority and another with regard to the membership of the boards. Coming from the western area which comprises Mayo—putting my own county first— Galway and Roscommon, I might say that there is unequal representation on the board. The Galwegians, who claimed to be a bigger county with a bigger population and a city, asked the Minister to give them bigger representation; and the Roscommon people, whose county is the smallest, wanted to ensure that they would have equal representation with Mayo. It is not easy to satisfy everyone but in the main, after discussion with the Minister, most of them were satisfied that the representation as set out would be near enough to sufficient.

There was also experience from the past. Heretofore, there had been joint representation by Galway and Roscommon. There was a regional hospital in Galway which catered for Mayo as well as Galway, and the local authority members from both areas had experience of meeting and thrashing out the problems together. That experience will be a great help in the future when members of these local authorities come together to discuss details of hospitalisation in their areas.

This Bill must ensure a better service for the general public. It must also ensure that the professional employees, nurses in particular, will be satisfied with their jobs and, even though there is a free choice of doctor, that doctors would also be satisfied. It is recognised today, possibly as never before, that unless people are satisfied and happy in their work they will not give the best service.

We remember the old general practitioners who were dedicated men, who were martyrs to the cause of medicine. They had not the means of transport that are available today. They had to go out in inclement conditions, on bad roads. They never murmured. They were at the beck and call of the people 24 hours a day. If, due to the stress and strain imposed upon them, it happened that one of them arrived at a country house smelling of a good drop of liquor, the old woman would say: "Ah, the creature. The devil a mistake he would make only he might take the tablet out of the wrong waistcoat pocket." These men did a magnificent job. I only hope that the men who will step into the much easier conditions that obtain today will carry on the traditions that those great men laid.

When I was a young fellow I was in a hospital where the surgeon, after operating, had to take the patient in his strong arms and carry him from the operating theatre and lay him down on the bed and then had to take care of him. There was no such thing as an intern or a registrar or any other help. If there was an emergency during the night the surgeon had to be called to attend to it. These were dedicated people. When I recall that man carrying the patient from the theatre to the bed. I pray that God may rest him.

We have witnessed changes for the better in the 20 years that I have been a member of a local authority. The people in Dublin do not realise how happy they are to have a hospital within a stone's throw, to have specialist services within easy distance. In places like Mayo people have to travel up to 90 miles to the county hospital and up to 15 miles in some cases to get a dispensary doctor. The people in Dublin should realise how fortunate they are in having medical services within easy reach, in having lighted streets and footpaths to walk on and in having specialist services available at no inconvenience to themselves. In the country, that kind of service can never be available but we would like to have the best possible service that can be devised for the conditions under which we live. That service can be provided only by dedicated people. First, there must be a plan that is as near perfect as possible. I hope that this Bill when it is enacted will be as perfect as it is humanly possible to make it. However, it is on the human element that we must depend to make its implementation successful. The human element must be considered and catered for. One way of doing that is to provide for nurses and doctors the best working and living conditions and to make available the ancillary services they require.

There are tremendous advances being made in regard to medicine. We do not want to be left in the backwash. So far as is humanly and economically possible we should advance at the same rate and to the same degree as more affluent States are advancing in the field of medicine.

Many of the matters that I would wish to mention have been covered by other speakers. There are a few points that I would make at this stage. It is difficult to get nurses in County Mayo. The reason is that their living conditions leave a great deal to be desired. The nurses have to go outside the hospital to get "digs". Their emoluments are not sufficient in this day and age. I realise that the Minister is concerned about this matter. He must ensure that nurses are paid for the job and are given suitable living conditions. No longer can it be considered suitable to have nurses jammed into poky rooms with two or three beds in them. Nurses are entitled to have proper sitting rooms, to have television and all the other amenities that would contribute to a restful period after their strenuous working day. I hope that the boards set up under this Bill will be directed to provide these amenities for their nurses and for the doctors, interns and others, in local authority hospitals who, also, are entitled to proper living conditions, suitable bedrooms, rest rooms and sitting rooms.

County Mayo is a region rather than a county and can never hope to have the services that smaller counties can have. The size of the county and geographical and other features make travelling difficult. We have problems there. I might mention that a hospital extension that was completed over two years ago has not yet been taken over. I do not know if the Minister can say anything about that. Probably, the matter is sub judice at the moment and may not be mentioned. It is a scandal that a rather large building that cost £137,000, designed for the purpose of an admission and treatment unit for psychiatric patients, should be left unused. It was supposed to be opened in 1967. There is no hope of its being opened. I do not know what can be done about it. I can only hope that such a state of affairs will never occur again.

The world has been contributing to our hospitals for a great number of years. But for the Irish Hospitals Sweepstake we would not be in the happy position that we are in today. Due credit must be given to the men who had the foresight to establish the sweepstake. We have taken the money but, as a nation, have we done anything significant in regard to medicine? Have we done anything to repay the world for what the world has been doing for us? Rheumatism is a scourge in this country and is responsible for the loss of more man hours per year than any other disease. It is responsible for a great deal of psychiatric problems caused by the fact that people are half crippled while trying to do their daily work. It is responsible for travail in many households where people who are semi-crippled have to sit by the fire while the work that they should be doing remains undone.

In order to repay other countries for what they have done for us we should establish a research unit for rheumatism here and should get the best possible brains to man it. There is an ample field for rheumatism study in the west of Ireland and I think such a unit should be established in Galway. Other and richer countries are doing research on heart disease, cancer and so on and are able to do so because they have the necessary resources but it would not strain our resources if we set up a research unit for rheumatism and in this way we would be making a great contribution to the welfare of our economy and possibly to our own image abroad. It would only be a fair return for the millions we have collected in other countries.

Everybody is aware of the high cost of hospital treatment and while people in the lower income bracket will be taken care of there are people in the £1,200 bracket and people with valuations over £60 who are in many cases unable to pay the high charges for hospital treatment. The cost of a private ward is something beyond people's capacity to pay. There is something in the Bill to the effect that if they pay a certain basic amount they are entitled to recoupment but I am thinking of people unable to pay this basic amount. There should be some flexibility written into the Bill so that those unable to pay, even though they are nominally within the bracket which could pay, would get some relief in regard to hospital bills. This is absolutely necessary.

I am worried also, not about the fact that chemists will be taking over, but about the cost of drugs and medicines. For many years we have been advocating in our local authority that the methods of purchasing drugs and medicine and their distribution leave something to be desired because there is always a feeling that requisitioned medicine would be lying on dispensary shelves until outdated and until it had to be destroyed or otherwise disposed of. As costs mounted year by year there was always the fear that medicines were not being properly looked after or availed of and that there was financial loss involved. Anybody who had to visit the chemist during the flu epidemic realised that you needed an extremely high income to avoid feeling the impact if you had to buy medicine for a number of children over a period. Something should be done to control the price of drugs and medicines. I do not know how it can be done: there are probably closed shops involved but an investigation should be made into the cost of drugs and medicines throughout the country and import controls should be examined. Possibly the Minister could not deal with all these matters which might involve other Departments but it is time that the matter was examined because the sky seems to be the limit in the cost of medicine at present.

I do not know the position in regard to dental services elsewhere but in Mayo while we have advanced considerably in recent years we are still only scratching the surface as regards providing a dental service even for school children. The initial steps have been taken but there is no follow up. If children's teeth are to be preserved and properly looked after, now is the time for action. If it is not done in the early stages mounting costs will be incurred and will be a burden on health boards and parents and the children will be less happy all their lives than if they had received proper care in the initial stages.

I hope the Minister will try to ensure that dentists trained in this country will stay at home. Individual liberty cannot be restricted and it is not easy to say to somebody: "You stay in Ireland." The spirit that should animate a small country like ours that has only regained freedom seems to have departed. Young people who, at the expense of the community, were enabled to acquire education and knowledge to fit them for these jobs should feel it incumbent on them to give some return and spend at least some time in their own country so as to help the people who helped them. It is long past time when this idea should be emphasised. Youth are ready to take up any kind of lost cause—fair play to them provided they do it properly —but I think the sense of dedication and goodwill for our own people and the idea of giving some return for sacrifices made is something that is too seldom mentioned. This should be dinned into the ears of young people at present.

I do not want to go into the sick question of drugs but I am delighted that the Minister is taking immediate action and that there will be a more comprehensive Bill dealing with this matter later. In passing I wish to say that there is need for education of all our people, adults and children, in regard to the dangers of drugs, the different types of drugs and their effects. This kind of education does not seem to be forthcoming except in the wrong way. Either the Department of Health or Education should organise lectures all over the country. Many people are competent to give such lectures, perhaps, at vocational school level, and so ensure that everybody is cognisant of the essential facts in relation to drugs and the steps to be taken to avoid them and what can be done if somebody is unfortunate enough to fall victim to them. It is high time that was done. Education in health matters will become more and more important as time goes on. I am thinking also of education in regard to the dangers of such things as electrical appliances and the tragic consequences that may result if they are not properly handled. There is a great lack of knowledge in this respect among the young people. These matters should be brought to the notice of the man in the street and radio and television could be used effectively in this field.

I do not want to delay the House much longer. Most of what I said needed saying and other things I intended to say have been covered by other speakers but one thing that was not mentioned so far is the voluntary service given by different organisations that are performing very useful work. The Minister should ensure that people who give voluntary service such as meals-on-wheels and domiciliary treatment for old people should be encouraged by subventions in money and otherwise. The things they need should be put at their disposal. The more voluntary service is encouraged the better it is for the country. Self-help is still the greatest help. Christian charity, or even non-Christian charity —the House will know what I mean —is seldom mentioned nowadays but if the time ever comes when charity dies and there is the feeling that there is no scope for a man to help somebody less fortunate than himself, it will be an unhappy day for the people who need the help and also for those who should be able to give it.

I will conclude by wishing you, Sir, and your staff a very happy New Year, also the Clerk and his staff, the Minister and his advisers, the Official Reporters, the Press and my colleagues in the Seanad.

As someone said earlier today, this is really a Committee Stage Bill. Like a number of people who spoke before me I am a member of a local authority and a member of a hospital committee and, like them, I have some experience of the health services. I do not suppose that a demand for improved health services was imposed on the Government, or that the improvements were demanded by the people, who require the best possible health services the State can afford to give them. I was a bit perturbed about the application of the Bill to the area from which I come but, having listened to the Minister at the conference we had in Nenagh, and heard some of the explanations he gave there, I was not quite so perturbed. Having listened to his speech today my mind is a bit easier.

Legislation by regulation has been criticised in this House on a number of occasions. In this particular Bill this is possibly the most practical approach, because this Bill is launching the country into a new service and a new type of service. I do not believe that the experts, who would prefer the FitzGerald Report or the other reports on our health requirements, have such expert knowledge that they could produce a Bill that would be perfect in the first instance. I am convinced that this Bill will have to be operated by the Minister through special regulations to deal with the difficulties as they arise from time to time. If I were to talk about the special circumstances that apply to my county, like Senator Lyons I would think that I would be considered a bit parochial but, in the course of putting this scheme into effect, all kinds of difficulties will be thrown up. I would hate to see a rigid Bill that laid down strict regulations by which everything was to be done and requiring amending legislation to set them aside when they were found to be unworkable.

The Minister is to be commended for telling us that these important regulations will be made by him in draft form and brought before the two Houses of the Oireachtas. Those of us who have experience and who feel that we have some contribution to make to the regulations can do so. We can pressurise the Minister to bring them into conformity to meet the conditions which we think are required. This is one Bill in which I think legislation by regulation is to be commended.

We could talk here for a month and I do not think any of us could bring in a suggestion that would be acceptable to the whole country at large in relation to the question of paying for the health services. There is a general outcry against paying for them from the rates. At the worst the State is paying 50 per cent of the charges. I could not think of any way in which you could distribute that part of the charges more equitably other than that the people who can afford it would pay their share and the people who cannot afford it would not be required to pay. If everybody in this country had reached an equal level of wealth, if you like to call it that, or of affluence, I could see a levelling off in an insurance scheme; but if you went into the various categories you would have to consider you would find that you would have to exempt so many people, because of their inability to pay in an insurance scheme, that you would have about 50 per cent of the population who would have to opt out of an insurance scheme and you would be back to square one again where the other 50 per cent would be required to pick up the chips and pay from there on. I have not heard any suggestion of a better system. I have heard criticism of the rates system.

What about a system based on the insurance principle? That has been put forward very forcibly.

I have said that I am quite certain that about 50 per cent of the population would have to opt out because they would not be able to pay for an insurance scheme.

If 50 per cent is being paid from the Central Fund now are we not in that position?

You would be swopping horses but you would not be any better off.

You would be taking it off the rates and remember that rates are in no way related to a person's ability to pay. That is the whole fault of the rates system. Sorry, but it is interesting.

I would not go along with that side of the story that rates are not related to ability to pay because, while the rating system may have some inequalities, it is mainly well founded. However, I do not want to push it beyond that. We in Clare will have the difficulty that our patients will probably be going, some to Limerick, some to Cork and some to Dublin and, if the hospitals which are to be built in Limerick, Cork and Galway are to give the kind of service everybody hopes they will give, the probability is the people will opt to go there because people who require medical attention will always go to the place where they think they will get the best attention.

While their relatives may have some difficulty in going to see them, the patients themselves will ordinarily feel that because of the better service they will get it is more important for them to be in the right place than that facilities should be made available for their relatives to visit them. I agree with Senator Lyons that visits from relatives can have curative effects on patients but nevertheless the patients will want to go to wherever the best services are available. At the moment we find there are people who opt to go to hospital in Cork or Dublin because they feel they can get treatment there which they cannot get in our own hospital at home.

A lot of the talk about the changing of the surgical work in hospitals like the Clare hospital is caused because it is being widely said at the moment that within eight or ten years the medical schools will not be producing any general surgeons and that the graduates from the medical schools will be directed entirely to specialisation. That seems to be the nub of the problem. If we do not have general surgeons then we cannot have general hospitals. I do not know whether the medical schools are to be praised or criticised for this development. It means, I believe, that the products of these schools will not be as good, generally speaking, as their predecessors. We are very happy in my county at the moment in that we have an excellent surgeon, an excellent physician and an excellent nursing staff. We have, however, been slowly convinced that we are not likely to continue in that happy position in the future. That evolution is to be regretted.

There is one aspect of this that perturbs me. We do not hear a great deal of talk about the training of nurses. Every hospital in the country has had to bring back married nurses, women who have their own families to look after, because the hospitals are in such dire straits from the point of view of nursing staff. I do not know what provision will be made for an extension of training facilities for nurses but all these schemes that we are planning will never come to fruition unless we have sufficient nurses. Were it not for all the young girls who have trained in Britain and who have come back here to staff our own hospitals the position would be truly chaotic. I do not know how we would have managed to carry on. Something will have to be done to solve this problem.

Everyone hopes that this Bill will provide the best medical attention and the best hospital services the country can afford. I am not satisfied that these will be provided under the Bill as it stands. A great deal of water will flow under a great many bridges before we get anywhere near perfection. I am glad the Minister has decided that the regulations will be laid before both Houses of the Oireachtas and that we will all have the right to comment on them. This is very important. It is a step in the right direction, too, that the Minister has agreed to consult with local authorities before closing any hospitals. There is a general impression that the moment the Bill becomes law the closing of hospitals will start. I am glad of the Minister's statement today that this will not be the case. There is no provision in the Bill for the closing of hospitals and the Minister has undertaken to have local consultation before any hospitals are closed.

As I said, this is really a Committee Stage Bill and the really informative debate will take place on the Committee Stage. I shall postpone my other comments until we reach that stage.

I agree with the last speaker that the most important stage will be the Committee Stage. I should like to compliment the Minister on his very fine opening statement. It clarified much of the Bill for me. It was very informative. We must all welcome this Bill in that it represents an extension of our health services and introduces a new dimension into these important services. The Bill has been welcomed by all sections and it augurs well for the decade that the first piece of legislation to be considered in the 'Seventies is the Health Bill, 1969.

The Minister, while clarifying much that is in the Bill, also rather cleverly anticipated much of the criticism that might be directed against the Bill but I do not think we will be deterred from criticising where criticism is justified. As a lay person, the first thing that struck me on reading the Bill was the fact that so much would be done by regulation. We are considering today really the outline or framework of what the future health services may be. I should imagine the professional people in the Seanad will have more to say about this idea of legislation by regulation. There is a great deal to be said for and against and in the case of this Bill there may be more to be said for rather than against.

In his opening statement the Minister pointed out that there is a new concept in regard to regulations in that the draft regulations will come before both Houses of the Oireachtas and in that way we will be given more power than we would have under legislation. On a quick look through the Bill, it appears to me that there are only two instances in which this will happen. In all the other instances the normal procedure with regard to regulations will apply. As Senator Belton pointed out, it is the nature of regulations that they do not get the same attention as legislation. First of all, no White Paper is issued. There is no First, Second, Committee and Report Stage. It is understandable that regulations could get by without too much controversy. I suppose we have to accept that the price of democracy is constant vigilance. I shall be very vigilant in regard to the regulations made under this Bill.

There is a new concept of administration in the introduction of regionalisation. I know the Minister is very anxious, and rightly so, to have the Bill fully operative by April, 1971, but I appeal to him before he finalises the regional areas and administrative centres to look at what is happening in local government. I mentioned this before. I cannot stress how important I think it is. We are heading for administrative chaos. By introducing regionalisation piecemeal without any overall plan we will end up with what may be considered a bureaucrats' nirvana but certainly one that could not be considered efficient. We will have, apart from the existing county councils and urban district councils, regional health boards with local committees, hospital boards within the ambit of the health services, tourist development regions, industrial development regions, planning regions, such as that which exists in Limerick and that which is to be introduced in Galway and Mayo. I do not consider this an efficient way of administering any service and I doubt if those on the receiving end and the paying end would consider it efficient. I refer to the taxpayer and the ratepayer.

The Minister referred to the fact that there is a significant departure from the management system. There is a genuine attempt in the Bill to bring the health boards and local committees more into things. It is a pity—I may be taking too specific an interpretation of what he said—that having made this genuine effort we find, on examination, that the power is still very much with the Minister. The word "direct" appears throughout the Bill, not the word "sanction" to which we are accustomed in the local government code. Basically the Minister will still be the initiator. He and the central authority will still have the responsibility rather than the local health boards and the local committees.

In his final reply in the Dáil the Minister indicated that he would keep his mind open on the question of staff representation on the boards. It was, therefore, with absolute disappointment I heard the Minister say in his opening statement today that he had finally come to the decision that the clerical, administrative and manual staff are not to have representation although he felt the medical and ancillary professions had a contribution to make. I do not, for one minute, imagine that the Minister meant to be discriminatory, but the only way one could take it was that he felt the clerical, administrative and general staff of the future health boards did not have a contribution to make. I know the Minister has been pressed very hard on this point in the Dáil and by union representation. I hope he will maintain a somewhat open mind about it. I would inform him, as that is the policy of the Irish Congress of Trade Unions, I shall be putting down an amendment on that point. We feel this is an opportunity for the Government, perhaps the first in recent times, to experiment in worker participation and I cannot express enough my disappointment at his decision.

I welcome the Minister's remarks on the progress being made for the inclusion of home assistance within the health board. I know the staffs concerned are very anxious that this service should be included within the ambit of the Health Bill. Unlike most Senators present I am not a member of a local authority, but I think I am the only Senator who is an officer of a local authority and I represent the staff side through their trade union. Grave concern has been expressed to me at all levels that there is nothing in this Bill which specifies what the qualifications for offices under the board shall be, except in section 17 where it says the Minister may direct or approve.

The Local Government Act, 1941, is considered by the officials and the staff as their charter. It was amended in 1946 and again in 1955. All the staffs are very anxious that the local government code, as expressed in the 1941 Act, should be transferred to these staffs. I know the Minister has given an assurance, and I accept it—as indeed the staff do—in good faith. But, alas, we may not always have the present Minister as Minister for Health and assurances do not replace legislation. Perhaps many of the problems that we anticipate will be ironed out at the ad hoc council the Minister has agreed to set up, which we welcome. We are anxious that a degree of uniformity between individual health boards and existing local authorities be maintained. The reason we seek this uniformity is to avoid leapfrogging.

When the Minister is replying I should like him to correct my assumption that when this Bill comes into operation in April, 1971, which is the date the Minister has set, if there is no elected body representing the citizens of Dublin and Bray at that time, their places on the Eastern Regional Health Board will be filled by appropriate commissioners.

In conclusion, I should like to welcome the Bill. I consider it a significant step forward in social legislation.

As has been remarked already, this is very much a Committee Stage Bill and for that reason I shall be brief at this stage. There are, however, several aspects to which I should like to draw the Minister's attention, because they are rather wider than could be raised on a particular section.

I was pleased to hear the first spokesman for the Opposition congratulating the Minister on his handling of the Bill in the Dáil. I should like to congratulate the Minister on his opening speech here. It clarified much for me and it told me a great deal that I had never managed to find out from the Bill itself. I got to the point of wishing that the Minister had drafted the Bill as well as he had drafted his speech because it would have been easier to understand.

Several Senators have remarked on this Bill as being legislation by regulation and this is very true. There can be no objection to this as long as there are certain safeguards. I want to quote from page 1 of the Minister's opening speech because there he more or less outlines the points of view and the angle which I propose to examine at this stage:

Much more is contained in the Health Bill than one would infer from its moderate length: it is a highly-compressed instrument for the development of future policy on the health services. The Bill has, indeed, been criticised because of the inevitable appearance of vagueness which is a consequence of this, and for the extent to which details are left to be filled in by Ministerial regulations, orders and directions. I think, however, that when one looks to the nature of possible future developments in the health services, the kind of flexibility which the Bill will permit is highly desirable.

This very clear statement is almost painfully true. Those of us who can look back a number of years are only too aware of the increasing tendency to legislate by having so much detail left to regulations. Most people admit, with the complications of modern life, that it is impossible in ordinary legislation to go into great detail. I see nothing wrong with this tendency as long as certain safeguards are incorporated. I want to know what the safeguards are in this Bill. On Report Stage in the Dáil the Minister brought in an amendment to subsection (3) of section 2 which leaves it reading:

A reference in this Act to any enactment shall be construed as a reference to that enactment as amended or extended by any subsequent enactment.

When I read the draft of this amendment I wondered what was meant by the subsection. It seemed to me to be unnecessary if it merely meant an amendment or extension subsequent to the Act. It seemed to be rather in the line of the statement which used to be heard on the radio news that the deceased had met with a fatal accident and had since died. If on the other hand it meant that any enactment referred to in the Bill might, subsequently to the passing of this Bill, be amended and, by some odd reference back to this Bill, be included in it it struck me as a curious way of dealing with it.

I should explain to the Senator that it is simpler than it looks. It looks rather like a draftsman's puzzle. If, for example, some other enactment is involved to which the Health Act relates, such as a Social Welfare Act, and if that Act is amended, then in relation to the Health Act you can quote the new Act as well as the old one. It is a drafting amendment to enable the Health Act to proceed without constant amendments because other Acts may have relevance to it.

This is precisely what I feared. I did not think the Minister would be guilty of a merely tautological amendment. It is unusual. When I saw this provision I decided I would listen to the debate on it in the Dáil and hear what was said. The provision went through the Dáil quickly and I missed it, but I looked it up in the Official Report and noticed that the Minister said it was a drafting amendment. Everybody was satisfied. From the Minister's explanation my own fears were correct. The Minister is legislating very much for the future. I can appreciate that in certain aspects there is nothing objectionable in this but it is a very sweeping statement. The law officers may give a reason which nobody but themselves would have ever thought of—and they are quite capable of that—but I am worried that anything should be put in stating that any enactment which is referred to could be amended in 1980 and one would have to discover that it not only amends that particular enactment but amends also the Health Act of 1970. Legislation by amendment reference backward is bad enough but if we are going to have amendment forwards as well it is even worse. I have great sympathy for those to whose care the Health Acts are consigned but I have much more sympathy for the officials of the Department of Local Government and of the Minister's Department who will have to operate this Bill. The Minister was right when he referred to vagueness.

Another point which worries me is how far the provisions of the 1947 Act in regard to regulations apply to this Bill. The 1953 Act was fairly specific. The third section of that Act linked it with the 1947 Act. No such tight link appears this time. There is just the usual thing that the 1947 Act and the 1953 Act should be construed together. This is in section 1. I am willing to accept that. The 1953 Act went further in linking the 1947 and the 1953 Acts particularly in regard to regulations. The Minister has told us that in some respects the powers of the Seanad have been improved. This is quite true. So far as I know it occurs twice that regulations must be laid before both Houses of the Oireachtas and passed by them. There are a great many regulations besides the two mentioned and I cannot discover whether all or none of those regulations must be laid before both Houses. In endeavouring to discover what would happen I must confess I got more and more confused. If I am confused now it is not really my fault but the fault of the Bill and possibly of my limited intelligence.

Important Acts should be reasonably understood by the people whom they affect as well as by the administrators and the lawyers who are trained in interpretation. The 1947 Act is quite specific. All regulations under the 1947 Act are laid before both Houses subject to the 21 days rule. The 1953 Act continues this. I am not sure whether this is true in this particular case now. From the two cases I mentioned where the system is changed and the regulations must be actively passed by both Houses of the Oireachtas there is a subsection in each case which says that subsection (5) of section 5 of the Health Act 1947, shall not apply. In these two cases stricter rules are implied. By implication one would assume that all other regulations in the Bill would be laid before both Houses. Another section which produces regulations specifically states that they shall be subject to the 21 days rule. From that we imply only where it is specifically mentioned that the regulations had to be laid before both Houses would they, in fact, be laid. In some sections it is mentioned that section 5 (5) of the 1947 Act applies. On reading other sections one would think by implication that section does not apply.

Somebody mentioned that regulations are not the same as enactments in that they appear and that is all that happens. There are no Second Stage, Committee Stage or Report Stage debates, nor any passing actively through both Houses. The fact that they are laid before the Houses means they are examined. The Minister is aware that there is a Committee of this House which examines Statutory Instruments with great care. It is important from the public point of view that this facility should be opened to this House. I hope the Minister will be able to assure me on the point that the regulations under this Bill will be treated in the same way as the regulations under the 1947 Act.

Perhaps the Senator would like me to relieve his mind about this for the benefit of the House. It is difficult for people to understand the complexities of the Bill. The following regulations will pass before the Dáil and the Seanad as the subject of special resolutions: the constitution of the regional health boards, the constitution of the regional hospital boards, the constitution of Comhairle na nOspidéal, the regulations in regard to the means test for the lower income groups and any changes in the means test for the middle income groups, the regulations for any hospital charges to be levied and any changes above the normal hospital charges, the selection procedures if and when Comhairle na nOspidéal can make up their minds how they were going to appoint consultants instead of the appointments being made by the Local Appointments Commissioners on a special basis in collaboration with the teaching hospitals. All these things come before the Dáil and Seanad as a special resolution. All the other regulations in the Bill are laid on the Table of the Houses of the Oireachtas and wait for 21 days for annulment or for "no comment".

Perhaps the Minister would put all that in an amendment on Committee Stage and it will clarify the position.

I am thankful to the Minister for this information. It was not easy to read this in the Bill itself. Some of the provisions appear contradictory. The Minister has saved me a great deal of time on the Committee Stage.

There were one or two other points which I intended to raise but they are minor points which seek information on specific matters and I do not think I should delay the House now as they will arise more easily on Committee Stage. I would say, however, that I am rather fascinated by the number of ways in which the Minister may deal with matters in this Bill. He may make orders and he may make regulations and he may also determine certain things but it does not say by what instrument. He may also give directions and here also there is no mention of the instrument by which he will give the directions. There are also some references to "prescribing". I will refer to this on Committee Stage and whether prescription by the Minister arises by regulation or in some unnamed way. I do not think it is appropriate to weary the House with that sort of detail now.

I am glad that the Minister deals with this matter of dangerous drugs. I do not intend to try to pronounce the word the Minister used for specific drugs. I am glad that the matter has been taken from section 66 of the 1947 Act. As I read the 1947 Act, medical and toilet requisites are covered under section 65 and this is done by regulations laid before the Houses. Certain surgical appliances and other substances are referred to rather vaguely in section 66 by order and the order is not laid before the Houses. As far as I can gather, the substances referred to in section 66 of the 1947 Act could be taken to include dangerous drugs. At the time it was apparently decided that it was inadvisable to do this by regulation. I am glad that the Minister will now be dealing with these matters by regulation which will be laid before the Houses. Finally, I want to compliment the Minister again on his opening statement. I hope he will issue a White Paper because it would save me an awful lot of research.

This is one of the most important pieces of legislation that have come before the House for quite some time although, frankly, I am disappointed with the improvements in the services in the Bill. Having listened to all the praise which the Minister has been getting I expect that on Committee Stage he will be in a most agreeable mood and, perhaps, some, if not all, of our amendments will be accepted and we will finish with an even better Bill than the one we have before us. I should like to compliment the Minister on one small point because it is something that we do not always get here and that is that each Member received a copy of the Minister's Second Reading speech, which was most helpful. Some Departments only circulate one or two copies of a Minister's speech.

The point that is receiving most attention here is the establishment of the administrative machinery in the new health regions. However, what will concern future patients will not be the actual administration of the services but the quality and intensity of the service provided. I suppose it can be argued that if you have a good administrative set-up improved services are bound to follow. Quite a lot has been said about the composition of the proposed regional boards. The Minister proposes to announce the composition of the boards in some of the regulations and he has given an assurance in the Bill that the local authorities will have more than half the representation, but I should like to know if he proposes to increase the number of council representatives, in the counties where he has suggested there should be three, to four. People may not realise the reason why politicians in general have made the case that local authorities should be strongly represented on these boards. As I see it, the new boards will be able to ask for definite amounts or levy certain amounts on the various local authorities and the local authorities must be strongly represented because they will have to provide that money. This is something which is presenting each and every county council at present with a considerable headache.

Section 7 deals with the local committees. This is an admirable provision but one would hope that these committees would be an improvement on what has gone before. I should like to see them bearing no relation whatever to the consultative health committees which are at present "non-functioning" in practically every county council. These committees were established some years ago but never served any useful purpose. Perhaps, I should not refer generally to them but certainly in my own county I do not think the committee have ever met. Certainly, at the initial few meetings the thing was quite disastrous and if the proposed local committees to be set up under section 7 bear any resemblance to the local committees under the last Act, it will be a failure before it starts.

The important thing I see from reading section 10 is that the Minister, in the foreseeable future, gradually will finish up three regional health authorities. Section 10, to my mind, will enable him reasonably easily to do that. This, I assume, would be regionalisation on a grand scale. Of course, the Minister may not have any such thing in mind at all. I shall pass on to section 12 and ask the Minister if the new chief executive officers will be subject to the new regional health boards.

Section 31 is, perhaps, foremost in the minds of local authorities at the moment, in the months of January and February when they examine the estimates for the coming financial year through which local authorities endeavour to strike rates. When subsection (6) (a) comes into operation, there will be no future embarrassment for the Minister for Local Government because he will not be obliged to dispense with the services of any local authority. Apart from that, this section provides for the making of regulations. This is something one never feels happy about. For instance, during the passage of the Marts Bill there seemed to be provision for an alarming number of regulations but we find that the Minister responsible has not seen fit to implement the more disturbing features of that Act.

Nevertheless, in reference to subsection (3), I should like to appeal to the Minister to bear in mind or, perhaps, endeavour to avoid a situation whereby a local health board might have an amount of money on hands, earning 1½ per cent or two per cent interest as a result of the local authority which supplied them with that money having borrowed at a rate of 9 per cent. The point I wish to make is that the Minister, the CEOs and the councils should be able to get together to ensure that these health boards would have sufficient money to function at all times so that they would not have to go to the councils at times when their coffers are at their lowest, between May and July before the rate collectors get in the first moiety, and again at the end of the financial year when local authority overdrafts are at their peak. It would be regrettable if ratepayers were stuck with additional taxation just because a little consultation on foot of these regulations was not available.

My reason for putting this to the Minister is that I know that at present, under the managerial system, when you have councils contributing to joint hospital boards, this consultation exists and in that way it is possible for one body to borrow in order to keep the other going.

Section 30 also worries me because during past years local authorities never have been able to live within their estimates. This is mainly due to the fact that the voluntary general hospitals have invariably increased capitation rates shortly after local councils struck the rates for the coming year. If that should happen after section 30 comes into operation, where does it leave the new regional health boards and how does the Minister propose to circumvent it? The section as it stands would be all right if we could be sure local authorities could live within their estimates or if we had a guarantee that the costs of running our institutions and ancillary services would not be increased suddenly from the time the rate is struck until the end of the year.

Section 40 deals with the composition of boards and the election of the chairmen. I am in agreement with the Minister when he seeks power to appoint the chairmen initially because it is desirable that the personnel of these boards, especially the all-important chairmen, should be the best possible people to do the job. I have read section 41 and it is not clear to me which of the proposed new organisations or bodies will undertake the present work of the Hospitals Commission.

Having read the Bill carefully, I am not clear on the Minister's intentions regarding mentally handicapped children, particularly in regard to persons suffering from long-term defects. Under the 1947 Health Act, this would involve no more than £35,000 annually and it would not amount to more than £70,000 to cater for children so affected under the 1966 Act. These costs are insignificant by comparison with the amount of administration necessary. Therefore, there is a good case for a free service for all.

I am not sure whether this comes under section 44 or section 54, but it seems to me that the proposed health boards will not be obliged to provide sheltered employment for those not able to compete for open employment. Section 66 obliges health boards to provide services for the training of disabled persons and permits health boards to provide workshops, et cetera, for this purpose. The Bill makes no reference to what we consider should be an obligation on health boards, that is, the provision of facilities, including premises, for the employment of disabled persons in a sheltered environment.

One of the most difficult problems facing us at the present time is the inadequacy of the services catering for the mentally retarded. For too long this matter has been left to the good offices of voluntary organisations. For many years it was left entirely to religious and charitable organisations. Of late, services for the mentally retarded have been organised on a wider scale and there is trojan work being done. I am worried because my county would appear to be a black spot in regard to this matter. We have there just one part-time school.

There is ever-increasing difficulty in getting mentally handicapped children placed in suitable schools. I have read recently that the country needs at least 500 more beds for these children. A crash programme is required to alleviate the suffering and hardship caused in this regard. The Minister should avail of this Bill to get to grips with the problem.

Some time ago Senator Crinion paid tribute to Deputy Dr. Browne and the inter-Party Government for the determined manner in which they tackled the TB problem some 20 years ago. The problem of dealing with mentally retarded children is not of a scale comparable to what the TB problem was. The State has not played a significant role in this sphere. I hope the Minister will tackle the problem in a serious and determined manner. The introduction of better grants for the five-day residential schools could alleviate the problem.

I should like to see mental hospitals preserved as mental hospitals. When a RMS is obliged to take severely retarded persons or mental defectives into a mental hospital it takes from its status as a hospital. There should be special homes for the severely retarded or mental defectives. It is deplorable that in practically every mental hospital one can find three, four or five children aged from six years to teenage. Tribute must be paid to the staffs of mental hospitals for their wonderful dedication to duty and their care of these children. Nevertheless, the children in such institutions have not got the same opportunities as moderately handicapped children have in properly run homes for these categories. In the mental hospitals the older patients are inclined to spoil the children there. In every district mental hospital one finds these children because the RMS has been forced to take them in on humanitarian grounds, perhaps, because a parent is ill and there is no one to mind them. It is a disgrace that such children should be in mental hospitals.

I would impress on the Minister the grave need that exists for the provision of at least 500 new beds for mentally retarded children and I would ask him to let us know if he has in his Department any proposals for the provision of a number of new beds or new wings in children's hospitals for such patients.

Section 43 deals with the transfer of the Central Criminal Mental Hospital to the eastern board. That does not directly concern me. I should, however, like to ask the Minister what the position will be in the ordinary district mental hospital in respect of payment for the upkeep of what are now termed custody patients. Most mental hospitals have at least six of these patients and they are paid for by the Department of Justice. Will this arrangement continue?

Sections 44 and 45 raise some very sore problems as to those who qualify for the services under the Bill. The Minister proposes to introduce regulations. It is a pity that the Minister did not give us some idea of what he had in mind. The 1954 Bill had many shortcomings. Section 44 will create a tremendous number of borderline cases. Many people who should qualify will be denied the services. In section 45, which refers to persons with limited eligibility, the position is even worse. Subsection (1) (b) refers to persons whose yearly means are less than £1,200. I hope the Minister will find it possible to introduce a sliding scale in this respect which will provide for persons with family commitments and that the figure may be increased in the case of persons with children or dependants. Similarly, the figure mentioned in subsection (1) (c) is totally unrealistic and inadequate and represents no improvement on the Act of 1954.

A farm with a £60 p.l.v. is not even a viable holding at present in many cases. The buildings on such a holding, one can say, will have a valuation of up to £20 leaving the valuation of the land at £40 representing an average acreage of 40 or 50. That may or may not be a viable holding. We are assessing a person's eligibility for service not on his income but on a figure that does not take facts into account. The sooner we get away from the present rating system, which is well over 100 years old, the better. This same rating system has, I think, beggared the country and many people in it because it does not take account of the ability of ratepayers to contribute.

The Minister is preserving the very same clause in this Bill. I want to remind him that it is not uncommon to find a widow with a young family living on a farm of £70 or £80 valuation that is in debt or mortgaged. Yet, when that person seeks services it is the valuation that counts and she either pays or does without the service on that score. The Minister cannot be proud of this and I would ask him to substitute some type of income measurement instead of valuation.

You may say farmers do not always furnish accounts but nowadays it is difficult not to furnish accounts if you are asked to do so because the numbers of livestock are registered under the blue card system and it is very easy to declare and guarantee your income to anyone who wants to know it. It would be much preferable—and most farmers would welcome it—to have a provision whereby they would be assessed on their income rather than stuck with a valuation limit that may be, and in many cases is, meaningless. Therefore, I would ask the Minister to amend subsection (1) (c) to read:

Adult persons whose yearly means are, in the opinion of the chief executive officer of the appropriate health board, derived wholly or mainly from farming, if the rateable valuation of the farm or farms concerned is not more than £60.

This excludes the phrase "including the buildings thereon" because the amount of income derived from the buildings on the majority of farms is negligible.

The provision in section 48 (2) is welcome. When one asks for the percentage of persons registered for general medical service or having medical cards one is invariably told that it is 30, 33, or 36 per cent and in some counties I think it is as high as 40 per cent. I am inclined to question these high figures. I suspect that in the annual review—I should not like to make a firm allegation—some of the officials of local authorities forget to remove some of the deceased persons from these lists. Also, there are people on the list in some cases who should not be there. Therefore, I think subsection (2) is a good provision and should certainly prevent real abuses. It is something new in this type of legislation and I compliment the Minister on putting it in. It should be a reasonable safeguard to ensure that the service will be more equitable in future.

In the course of his discussions with local authorities I was one of those to whom the Minister spoke and I recall him saying that it was preferable for the victim of a road crash to travel, I think, up to 200 miles by ambulance to one of the regional hospitals rather than be treated in the present county hospitals. I imagine I should disagree with the Minister on that point. I must admit that I am a layman but in regard to our own proposed region in the midlands and living in the southern county of the region, if the new regional hospitals are built other than in the southern county all the patients in my county will have to go across country to a hospital over roads that are certainly secondary, naturally twisty and quite bumpy. I would not envy any prospective patient travelling 50 or 70 miles to a proposed regional hospital in the midlands

While ambulance services are improved—and great credit must go to the Minister's predecessor for the generous scale of grants given towards radio equipment in ambulances—I think the general public would prefer not to have to travel long journeys outside their own counties. The cost of the ambulance service increases substantially each year in every county. Everybody knows there are many abuses of that service which I think is a good service in most places but what most infuriates me is seeing people availing of clinics being transported at pretty high cost in a local authority ambulance while at the same time, perhaps, there can be outside the house of that medical card-holder one, or perhaps, two motor cars.

I wonder would it be possible for the Minister to make regulations offering some incentive to people to use their own mode of conveyance when they want to attend clinics in order to alleviate the high cost of the present service. At present people are collected in country districts and brought to a central clinic where they have to wait for one, two, three, four or, perhaps, six hours before they can go home again. This is a disgrace. Insufficient thought has been given to it. Surely it should be possible for some type of appointments list to be drawn up to minimise the waiting period at these clinics. Perhaps, people who came in their own mode of conveyance could be given a definite appointment. That might be of help.

I was slightly disappointed with section 61. The mothers of this country are given scant recognition in many of the maternity hospitals. Very little energy is put into making their stay as comfortable as possible or to alleviating their suffering. I am sorry the Minister has not seen fit to make specific provision for ante-natal physiotherapy classes or clinics. I imagine this service would be of tremendous value and assistance and solace to mothers. It would cost very little. Very little equipment would be needed for this service, inexpensive equipment, and yet it is very hard to find this service throughout the country. Apart from in the cities and a few major towns it is nonexistent, yet we have the personnel. I should like someone to assure me that the personnel we have, the physiotherapists, are all overworked. I doubt very much that they are. They could be given extra duties, even on overtime. If a special ante-natal physiotherapy class or clinic were established in every area in the country, it would be a tremendous help to our mothers-to-be.

I also feel that in our maternity hospitals the stay of the mothers, especially those in the lower income group, should be made happier. There should be additional staff and they should be given almost a guarantee of a good rest. That is something many of them do not get, especially mothers of big families. The after-care service should be greatly stepped up. As I said, I am disappointed that the Minister has not been able to effect any improvement in the present system.

In all the legislation and in all our institutions great care is taken to have an annual audit to ensure that our finances are 100 per cent correct. Yet, to my knowledge, there is no specific inspection to review the services rendered in these institutions and hospitals. We should have a meaningful inspectorate from the Department of Health to ensure that our patients get the very best possible service and treatment during their stay in hospital. The time has also come to introduce male nurses or at least orderlies into our hospitals. One often sees very slim and frail-looking girls, young nurses, having to lift very hefty and heavy patients. I regret to say that we have nurses, who are professional people, doing work which could be done equally as well by medical orderlies at a cheaper rate. I do not advocate that on financial grounds alone.

In our hospitals we have been slow to keep abreast with modern trends. Our nurses were one of the last sections to get a reasonable reduction in their working hours. These are things which should have engaged the attention of our active personnel in the Department of Health over the years. The attention of the public seems to have been directed mainly to the surgeons and county physicians in our county hospitals. I should like to pay a very special tribute to these dedicated professional people who have given a wonderful service over the years and will for many years to come, in my opinion, be called upon to give the very same service. At the moment it is almost impossible to get even a £25 sewerage grant out of the Department of Local Government, and has been for some months back. I think there is quite a scarcity of money.

I cannot see any of the proposed new regional hospitals springing up like mushrooms within the next five years. Certainly, I think the plans as envisaged and laid out by the Minister will not appear in bricks and mortar for at least a decade. So, these people will still be called upon to continue to provide the very high standard they have been giving up to now.

Had our country surgeons and physicians and the rest of the medical staff been given a six-day week, not to talk of a five-day week, all the emphasis now on the fact that they are overworked, working 24 hours a day seven days a week, would never have arisen. Perhaps these people were too quiet for too long.

I should like to take issue with the Minister and his Department for their failure to sanction the appointment of dieticians and ancillary professional people to some of our county hospitals. They have been very slow and very cautious. In some cases they have allowed services to become very slim indeed. In my own county almost 50 per cent of the medical staff are temporary. It is wrong to expect people to come in and work on the bottom of the scale; they can command far greater remuneration overseas. The Department's refusal to sanction the permanent appointment of doctors is a disgrace. Because of the increased incidence of sickness over the past few weeks the physical strain on our doctors has been intolerable. Individual doctors have been doing the work of two and three men. This is causing grave dissatisfaction. I lay the blame for the present unsatisfactory situation fairly and squarely on the Department of Health because of its dilatoriness over the years in making appointments. It is just not good enough to ask people to wait for another ten years until sufficient money is found for the building of new surgical hospitals. Every county hospital should have an intensive care unit, a casualty ward and a children's ward until such time as proper hospitals are provided.

In this connection I should like to see a proper children's ward. Tribute must be paid to those responsible in the Children's Hospital in Harcourt Street. Over the festive season the hospital was beautifully decorated. There was a santa claus on practically every window. Children in hospital should be made as happy as possible. Small things like this mean a great deal to sick children. They are an important therapy.

I have, as I said, no bouquets to offer the Minister's Department with regard to the replacement of worn out equipment in St. Fintan's Hospital, Portlaoise. They have been waiting now for close on three years for the replacement of kitchen equipment. If the Minister's officials had to work under the conditions some of the staff in Portlaoise have to endure I am sure something would be done very quickly to bring about the desired improvement. I would ask the Minister to take this matter up with his officials urgently and ensure the present situation is not allowed to continue for another two or three years.

I cannot understand the Department. There are professional staffs available. Indeed, every time one makes representations a new face appears on the scene. There are some things an institution can do without, but proper kitchen equipment is a basic requirement. No kitchen equipment has a life of more than 30 years. After that it must be replaced.

The Minister referred to the percentage of cost contributed by his Department to our health services and he included in that the rate abatement on agricultural land. This is always cropping up. Urban dwellers regard this rate abatement as a gift to the farmers, a gift the taxpayer makes to his well-off brethren in the farming community. May I point out once more that if the farmers were able to pay rates they would be made pay them. The Government and the Minister know full well that a very high percentage of the farming community would not be able to meet the full rates if they were levied on them and so the Government, in their wisdom, devised this scheme of rate abatement until such time as the whole rating system is revised. The sooner the commission reports and the sooner the appropriate Minister introduces legislation providing a new rating system for the whole country the sooner we will finish with this tedious red herring of rate abatement whenever rates or taxes, or anything else, are under discussion.

Ba mhaith liom fáilte geinearálta a chur roimh an mBille seo agus cúpla pointe a lua gan dul siar ar na rudaí a dubhradh cheana féin.

I welcome this Bill. The most significant provision in the Bill is that of choice of doctor. All down the years this lack of choice must have been a constant irritant to those availing of the health services. To me this choice of doctor spells victory for the freedom of the individual. It will go a long way towards restoring the normal doctor patient relationship. That is an excellent thing.

With regard to standardisation of the means test, perhaps, the Minister may be able, when he is replying, to give us some idea of the sort of standard he proposes to set. One welcomes this aspect of the Bill because we shall now have a standard laid down by the Minister. From time to time one comes across cases where one feels that there is hardly justice, but stress and hardship instead for the people who are subject to a means test. I presume we are now able to afford to take into account dependants and this is a very welcome thing.

I commend the suggestion made by Senator Belton for having one authority to handle the question of means tests. This would, of course, involve other Departments but it would reduce the people's frustration because many of them do not understand regulations of this sort, and at first sight it would appear to cut down administration costs.

I welcome regionalisation because it seems to me to involve a decentralisation of power to some extent. Senator Miss Owens said that this was a similar type of regionalisation to that carried out in the tourist industry. Certainly, regionalisation seems to be working there and one would hope it would work here. There is a fairly clear decentralisation of power and authority to the regions in the regional tourist system. Responsibility is being placed to considerable degree on the different councils from which the boards will be made up.

The Minister has cleared up the question of regulations. The introduction of a home help service is very welcome. This will make it possible to relieve hospital beds and it will also mean a saving in costs. In many areas there are not sufficient beds. The choice of doctor is also a very welcome innovation.

I would like to stress the urgency in bringing in control on drugs. Drugs have been described as a developing evil in our society. I hope the Minister, with his colleague the Minister for Education, will ensure that young people have an educational understanding about drugs and the law. I compliment the Minister on the amendment he has brought in to deal with this.

Like other Senators I welcome this Bill very heartily. I congratulate the Minister and the members of his Department for producing it. I should like also to mention the Minister's performance in the Dáil when this Bill went through the Committee Stage and Report Stage. I thought his performance, as far as my experience of this kind of legislation is concerned, showed a new approach on the part of a Minister with regard to suggestions for amendments made by every party whether they came from the Minister's side of the House or from the Opposition. The result of this is that it will be very much easier for this Bill to be put into operation and it will be worked in a much more whole-hearted way by people all over the country.

We all know the extent to which the Minister went to make clear to all local authorities exactly what the Bill meant and why it was necessary to have legislation of this kind. These were pills, which it was not easy to persuade local authorities to swallow, because it meant they had to give up functions which they had had since the foundation of the State. These functions are now going to be taken over by new bodies under this Bill.

I regard this Bill as just another stage in our health legislation. It is more than 20 years since the pattern of health legislation changed very drastically from the previous type of arrangement to the one which we are working towards now. It was then recognised for the first time that the State had an obligation to provide not only for the health of the medically indigent but also for others. It was recognised that in the evolution of health services certain aspects of the services had become so costly that they could not be met by people even with moderate, modest means, and that the State would have to make some arrangement for alleviating the burden on people who were reasonably well-off.

Debate adjourned.
The Seanad adjourned at 10.3 p.m. until 10.30 a.m. on Thursday, 15th January, 1970.
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