I hope to set a good example by being rather brief. A great deal of detail can be gone into during Committee Stage. At the outset I wish to congratulate the Minister on the work he has put into the Department of Health since taking over and on the very patient and cooperative approach he has adopted to this very important reorganisation of our health services. My only hope and wish is that he will be left in the Department to see this through—that there will not be any other calls on his services from another Department.
We have been impressed by the way the Minister has quieted down the turmoil that has surrounded health in this country for many years. He has cleared up many of the misunderstandings and misapprehensions that were prevalent in former years. The general tone in this debate so far, and the general feeling abroad, is that the Minister can be assured of the cooperation of all in his efforts to make a success of this reorganisation.
Health is something that touches all of us very intimately. We all share the concern to make available the best facilities possible to all, but we must equally be realistic and appreciate that this costs a great deal of money. We have got to face up to financing: we must all the time be conscious of the fact that we cannot provide as much as we should like to because of considerations of finance and shortage of skilled personnel. We can always go on improving and having our goal continually set for the future.
Regionalisation is certainly overdue because no longer can administration on a county basis serve our needs. Therefore, the division of the country into eight regions would seem to be a fair arrangement and there should not be any real geographical difficulties. However, it is a very big undertaking and the amount of money involved at present, between contributions by the Central Fund, by rates, by voluntary bodies and so on, must be somewhere in the region of £100 million a year. Consequently, the administration of this is a major undertaking and I welcome the initiative of the Minister in this Bill in selecting the chief executive officers for those regions even before the setting up of the regions concerned and, if necessary, sending these CEOs away for training.
That, of course, is as it should be because hospital administration has become very specialised. Especially in the United States, there are many excellent courses available that profitably could be taken by future administrators here. On this matter, however, I suggest that the Minister does not go far enough. I do not think it is sufficient to pick merely the No. 1 man in each area. The second line are even more important still because they in their way carry much greater specialisation than the CEOs in the different areas, whether it be responsibility for engineering or the other main subdivisions of the health boards. I would suggest, then, that the Minister should adopt a very flexible approach to this.
It may not be possible or even desirable to pre-empt these posts below CEO level but certainly training grants should be made available on a very substantial scale to suitably selected persons who are anxious to train themselves for consideration for these posts. Young graduates of two to five years standing might be interested in taking up a career in hospital administration. Provision should be made now to give them the necessary scholarships to enable them to go to, say, the United States of America, to England or elsewhere in order to get the necessary training. Then they would be suitable for consideration for these posts.
On a lower level still, the Minister would do well to approach the university authorities about the provision of graduate diploma courses in hospital administration. In future, hospital administration will be quite different from what it has been in the past. Hospital administration will draw much more heavily on the skills of management, operations research, and all the rest. It will become increasingly involved with the computer. It is desirable, therefore, that there should be the necessary training background. It is a type of training for which a diploma could be provided. It probably would take two years for graduates from various streams, the commerce stream, the engineering stream, to gain the diploma. Some qualified medicals might wish to take the diploma. The need for the diploma exists. The Minister might consult the Higher Education Authority in regard to the provision of the diploma or, alternatively, he might make direct approach to some of the university centres with a view to establishing the diploma.
Unfortunately, in the past, a great deal of hospital administration has been bedevilled by a clash between the professionals and the non-professional administrators. Only three days ago I was speaking to a resident medical superintendent of a large hospital. I was shocked by the picture he painted of the idea of administration possessed by some of those in high positions in the health authority. Apparently they had no hesitation in going right through his line of authority and contacting people in his hospital in any way they wished without his knowledge or without going through him. In modern administration that should not happen. He had often heard secondhand about happenings in the hospital in connection with appointments. He had heard about them from others before he was officially communicated with. Therefore, I would ask the Minister to clear the channels of communication in his investigations into proper administration.
We must look to the future. With increased opportunity for university education these administrative posts will be filled by persons who have a basic university degree. Otherwise, why are we encouraging university education on the scale on which it is being encouraged? The graduate has a very distinct contribution to make, especially in dealing with professional people and, above all, in dealing with the medical profession. Very often there is a great deal of misunderstanding in communications. If the Minister could persuade persons with medical education and with a talent for administration to go to the States and to take a two year course in hospital administration he would have the ideal type of CEO for these health districts.
On the question of specialisation, the Minister has mentioned the scarcities involved and the necessity to conserve specialists. I fully agree with conservation and with the proposal made by the Minister. I would, however, suggest that in the recruitment of specialists we have been a little too orthodox in our approach in that we define a specialist, largely, as a man who has a particular training or speciality at the time at which we want him, whereas in an economy like ours, in a situation where there is change, we should be eager to get persons to specialise, to go away to study and acquire a qualification.
If radiologists are not available in sufficient numbers I would suggest to the Minister that it is a case, again, for going along and saying that we want to give six, eight or ten attractive fellowships that will appeal to existing people who are already in pretty good positions to change their line of work and become qualified as radiologists. The same approach should apply to any other specialisation. The graduates are there, they are people with a fundamental training and they are available in most positions. What is missing in many cases is anticipation of demand in various specialist areas. I suggest that we can solve that simply by selecting and sending abroad.
Again, a speciality which the Minister will require very much in this matter in the future is aid to medicine by the computer, whether for storage of case histories or statistics, data, etc. This is a very rapidly developing side of medicine, in fact in America you are almost completely handed over to the computer in many instances. I suggest that this is something we should act on quickly because we are going to have to move with this as well. Again the question is one of having people trained on the medical side of computer usage and it is a very important one. Indeed in connection with the three regional hospital boards in each of those areas Dublin, Galway and Cork we have computer facilities based on the universities. It would be a very profitable and long-sighted act by the Minister to make available in each of those centres sufficient to appoint to the computer centre in those places one research officer to develop and investigate and get established locally the use of the computer in the medical problems of the area. The cost at most would be a few thousand pounds in each area, yet if this is done, and done pretty soon, the computer capacity is there at least for the experimental stage and it can be experimentally used, with certain of the hospitals in the area and the necessary knowledge for more widespread usage can be built up.
Speaking for Cork, I know that the computer centre at the university there would be very happy to co-operate in that work, but the plain fact at the moment is that their very meagre resources in the computer centre are already strained beyond breaking point with our immediate problems of servicing the university departments concerned, and therefore I would say that nothing short of having one well qualified man completely designated as research officer in the application of the computer in medicine would really achieve quick results. I would therefore commend this to the Minister for what it is worth.
I am glad that in the Minister's introduction and also in his provision for Comhairle na nOspidéal and the health boards recognition is given of the work done by the voluntary hospitals and of the great contribution they have made. We can never be too grateful to the voluntary hospitals and the voluntary educational bodies for what they have contributed to our country at a time when finance was scarce and the idea of the State getting more actively involved in those areas was not operative. Now in the development for the future we should see these in as active members. I think that nobody need worry about the fact that the voluntary hospitals are going to take over the country or anything like that. The statistics show at the moment that they cater for 44 per cent, and this is a declining percentage, due largely to the expensive equipment and the fact that the recruitment of members for orders and so on is posing further difficulties. All this means that there is going to be a gradual decline in the amount that will be done by voluntary hospitals in the future, but the amount that they are going to do is really very important, both because of what it provides and also the type of somewhat different service or approach compared with the public run hospital. There will be a difference of approach, and that is all to the good. Each will learn from the other. By and large the voluntary hospitals tend to be more personal in their approach, and again that is very good. I would suggest that just as in every other field we have recognised that we have here a mixed economy, neither socialist nor capitalist, in so far as education, industry and so on are concerned, and that we should encourage and promote partnership so that the voluntary or private sector does what it can and the State complements or supplements it where necessary, the same thing, I hope, will characterise and mark the Seventies in the evolution of this Health Act.
Above all in the representation on the various boards I think that the Minister should see that those voluntary groups are adequately represented. I share Senator Keery's questioning of the percentage on the health boards, that more than half should be elected directly by the local authorities. I think that the other half would provide for election of medical groups, by nominations by the Minister and so on. I have a feeling that a half is going too far and I think that one-third would probably be more reasonable, especially as the main claim in the past by the local authorities to be represented was the fact that the financing was so dependent on the rates. Now there is a shift away from financing by the rates and that shift will become much more marked in the decade coming; in fact I would suggest to the Minister to do the bold thing right now and cut the financing from the rates. I would be realistic about it in so far as rather than cutting completely we should freeze it at its present level of contribution or else freeze at the present level of contribution as a basis with a sliding scale that would be applied nationally. The sliding scale need be no more than taking account of the depreciation in money values. Thereby you would ensure that all the wrangling that is bound to arise as to whether the rates should be increased by this extra amount to provide those extra services would no longer be needed. That is a type of arid controversy which we should seek to avoid. After all, whether you provide the money from the rates or from central taxation, it is coming from the taxpayers in any case. This would lead to much cleaner administration and the removal of needless controversies, if some formula could be worked out that would rule out in the future any discretion at county level as to the amount that the rates have to pay for the health services.
Membership of those boards, especially health boards covering an area, is a very specialised task and therefore it should be something much more than the undoubted good service that local representatives have given in the past. It is now removed that much further from the local scene and consequently, as the Minister indicated in his opening speech, the board should be prepared to allow the running of affairs to the officials. They are becoming more policy-minded; they are moving up a stage and there is a logical case for more specialised representation so that each member of the board will be seen to be capable of contributing not merely to the health problems of his own district but to the development of a health system for a region of three or four counties which requires a totally different approach and much bigger thinking.
The other necessity for the local knowledge and the intimate link with the people would surely be better met in the subsidiary local committees that the Minister envisages the health boards having in the various areas. I share Senator Keery's fear that the Minister has gone too far both in taking over past ideas of representation and in yielding too much to pressure for a democracy that does not altogether fit in with the best functioning of health boards.
I welcome the efforts by the Minister in the Bill to ensure that local authority representations will be proportionate. Where each member is elected by a quota of the council it means that each section in the council will have its representation on the health board and there will be no case in which because one party or another controls the council an undue proportion of places on the health board are taken by such a party. This is a worthwhile provision and I hope it will be followed in regard to representation on other boards.
I think the provision whereby GPs can be admitted to local hospitals on the lines suggested in the FitzGerald Report is good and long overdue. I have often felt there was too much of the closed shop element in the medical approach to the question of who in the profession had the right to enter hospitals. Admittedly, this is at the lower level of hospitals but it is still a step in the right direction. I can see the Minister's concern about the provision for a proper coverage of GPs throughout the country especially in remote areas. Undoubtedly, inducements will have to be given but the main thing necessary is to try to organise the provision of these services in a twentieth century manner. We no longer can have a situation in which one man is on call 24 hours a day. A panel system is overdue whereby you have three, four or five members with regular hours and, consequently, a doctor available at all times. This is beginning to operate in the cities and is doing quite well. The Minister should encourage this as much as possible. It is the only way to make life tolerable for GPs and at the same time ensure that for any really serious cases medical advice is available 24 hours a day. That is a real step forward.
The provision of home nursing and home help is very well worthwhile but, as envisaged, I think it is largely intended for those qualifying for free services. The need in all the other income groups is just as great but they are quite prepared to pay for the service provided they get it. The paradox of the modern affluent society is that things that really make life pleasant such as provision of home help in case of sickness or when otherwise required such as at the time of having children and so on are far less available than they were 30 or 40 years ago. This service is something that, perhaps, will require to be organised on some kind of co-operative basis. Paying for it is never a problem; it is a matter of getting suitably trained people for the service.
I suggest to the Minister that services made available for the homes of those qualifying for free treatment should also be made available to all who need such services but on the basis of paying an appropriate fee. Not alone will that give an excellent service to those in the paying category but it will demonstrate that the same service is available to rich and poor alike. It is the quality of the service and not who pays for it that really matters.
Help through local community efforts should be stimulated. We find local voluntary groups making great efforts to help old people, for instance, by means of meals on wheels, holidays and so on. Very often these efforts are hampered by lack of funds. Could funds be made more easily available to such voluntary groups while at the same time calling for the maximum voluntary help from the community?
We are dealing with the most expensive side of living in the health services and consequently we have a right to look for economy and efficiency. The key is provided by the medical schools turning out well-trained graduates equipped to deal with the community, providing refresher courses and everything else required. Under the present system of financing of our schools a great deal is left to be desired and I ask the Minister to take some interim steps to try to increase facilities. Above all, I appeal to the Minister to look at the whole question of medical education and our involvement in it in the context of the world and examine how far we in this country can get into the medical training business for the world as a whole, whether in the training of medical personnel for the ordinary medical functions or training for the hospital administrators I have mentioned or for any one of the myriad skills that are required in the administration of a health service.
How far can we go to get into that industry? I use the word "industry" deliberately because this is something that is required and will always be required by the world at large, and they are prepared to pay for it. I believe that when we have sufficient people trained for ourselves, there is unlimited scope for training people for other nations, on a strictly commercial basis. We have the example of the College of Surgeons doing that here in Dublin and doing it very successfully. The other facets of a modern health service can probably be approached in the same way. Let us see how far we can go.
I have great respect for the Minister's imagination. I know he is capable of envisaging the day when we are really in the export business in this field.
Most of the other points can be left to Committee Stage. It is more satisfactory when we can have question and answer and when we can really tease out the problems. The success of this service will be ensured if the Minister can avoid local "wrangling about increases in rates due to this amalgamation. He can do that only by working out some formula or scale that will make the local contributions completely mandatory, and decided on a national basis. If this can be worked out, we will get away from looking at it on a county basis. We will get away from feeling in one county that we are paying through the nose for a huge establishment in another county. We will get away from that parochialism. The Minister has his remedy if he puts the rates contribution on a mandatory basis.