I am glad to have the Minister's assurance on that. We all realised that, whatever areas had been suggested for these health boards, there would have been criticism from various local members who felt their area was being downgraded. I think a long, hard look should have been taken at the county boundary system in an effort to produce eight, ten or any number of regions which it was felt to be administratively possible and which could work to the best advantage of the service without taking into account county boundaries. I think it would have been better to decide the areas on a geographical basis as well as on the basis of existing road networks and hospitals instead of simply containing ourselves within existing county boundaries. I imagine my suggestions are rather late at this stage.
Perhaps the Minister can tell us what is going to happen to the existing dispensaries and health centre buildings once the choice of doctor system comes into operation. The Minister is no doubt aware that Fine Gael have for some years been advocating major reforms in the health services. One of these reforms involves the choice of doctor system. The suggestion was then made that when the dispensaries were no longer necessary these buildings should be changed into community welfare centres which would contain the district nurse's office, the family social worker's office, the welfare clinic for mothers and babies, out-patient clinics and the home help centre. This seems to me to be a useful way of using existing buildings. I would be interested to hear if any thought has been given to what is going to happen to these buildings. I understand it has been suggested where a general hospital is to be closed down that the administrative centre for the health board should be sited in the county where the hospital is being closed.
Perhaps, the Minister would let us know whether it is the intention to have the administrative headquarters for each health board sited in the same town or city in which the main hospital for that board will be sited. It seems to be the obvious thing to do, both from an administrative and an economic point of view, but, perhaps, there are reasons for suggesting that it should be placed in one of the other counties. I am inclined to think that the only reason at the moment is to have it act as a sop to disgruntled members of the county in which the hospital is not sited.
I hope I will not be considered parochial if I refer to the Dublin region and, indeed, it could not be termed parochial as we have in the region, certainly if we want to refer to the eastern health board, almost one-third of the population. Indeed, if present trends continue we shall have more than one-third within a short number of years. I want to suggest to the Minister, as I did when local authority members from the proposed eastern health board area met him, that the area at present administered by the Dublin Health Authority is as large, if it is not too large, as can be administered properly bearing in mind the vast population already in Dublin city and county and Dún Laoghaire borough.
It has been stated by officials of the Dublin city and county planning department that the rate of expansion taking place in County Dublin is one of the most rapid either here or in Britain. They forecast that within 15 or 20 years the population of Dublin city will remain static, in the region of 600,000, but that the population of Dublin county will rise to equal that figure. I am not quite sure what figure they give for Dún Laoghaire but it does not represent a sizeable increase because of the fact that the major part of the borough area has already been built upon. One can see that Dublin county is fast becoming a largely dormitory area in which new suburbs are being created and new towns being planned so that within a relatively short number of years—and I presume this Bill is intended to cover the functioning of health services for a considerable time to come—the Dublin county area will be an area of one rather large city surrounded by satellite towns between which there will be large suburban dormitories.
It does not seem to me in the long term to be a good thing, bearing in mind these forecasts, and, indeed, just taking the evidence of one's own eyes as one sees these developments taking place, to join with this urban and surburban area, which is essentially becoming more urban, the essentially rural areas of Kildare and Wicklow. Whatever expansion may take place in Kildare, and to whatever extent the towns in Kildare will expand, as they obviously will, the terrain in County Wicklow—as the Fine Gael Leader in the House could so well explain—is so mountainous that it will largely remain a rural area for some time to come if not for ever. To join the mountains and hills of Wicklow to the urban complex of Dublin does not seem to be the best proposal administratively. Even at present in Dublin County Council we resent our link-up with Dublin Corporation because we feel that the larger body gets the better deal. We may or we may not be right but I am afraid that once Wicklow and Kildare become joined with the main area there will be serious complaints from those counties, especially Wicklow, that they are not getting a fair deal from the health board and that all the services are geared towards Dublin city and county at the expense of the ratepayers in the other counties.
I would urge the Minister to examine the situation which exists in Dublin in view of the population forecast and also the fact that Wicklow will remain an essentially rural area and to see whether or not Wicklow might not be served better, and, indeed, whether Dublin area might not be served better, by leaving the Dublin area much as it is at present and joining Wicklow with, perhaps, the south eastern region. The Minister stated that 56 per cent of the health costs had been met by the State in recent years. In the case of the Dublin Health Authority the official percentage in recent years has been 54.7 per cent but there is a feeling that the State contribution has not even been 54.7 per cent. The main reason for this is that many of the good provisions in later sections of the Bill were already being provided by the Dublin Health Authority because we —and as Deputy Ryan pointed out in the Dáil the Fine Gael Party are in the majority in this authority—and our officials were conscious of the need for a home help service, meals-on-wheels and a domiciliary service and we were providing these services and providing them in a number of cases by financing them completely from the rates. Someone has done the mathematical calculation which I was always too frightened to embark on and has arrived at the conclusion that instead of 54.7 per cent —the figure thrown up by the Dublin Health Authority accountant—we were only getting 46 per cent of our health costs from the State because some of the services were services for which we could not seek a State contribution.
An interesting point about the Dublin region is that while there is a national average of 30 per cent of our people holding general medical cards— and in some counties the figure rises far beyond that—on the last occasion I inquired about the percentage of the total population covered in the area the figure was 14.5 per cent and that percentage, of course, was taking the actual number of card holders as a percentage of the whole country as shown by the 1966 census. It is obvious that the 1966 census is quite out of date: the population has increased substantially so that the percentage, if it were accurate, would be even less for that area.
Bearing all these things in mind, the Dublin area deserves closer attention. A special scrutiny and study should have been made of the present Dublin Health Authority. The eastern health board, as the provision stands, will administer for a population of one-third of the country, and of the figures given in the Minister's memorandum, therefore, 30.9 per cent of the total estimated budget, estimated presumably by the Minister's officials, for the entire country, will apply to this region. I am taking the figure given by the Minister's officials. I am not being in any way critical: I am merely pointing out how rapidly things change in regard to health services and how difficult it is accurately to estimate financial need to run a service.
The budget the Minister's officials gave was £15 million for the eastern region, comprising Dublin City, Dublin County, Dún Laoghaire and Counties Kildare and Wicklow. Yet we, as members of the Dublin Health Authority, have in the past three weeks tentatively accepted a budget for the coming year of £16½ million, not taking into account the amount of money needed for the present health services in Kildare and Wicklow. If the estimate for Kildare and Wicklow could be added to the Dublin Health Authority estimate, and if the population of Dublin is to continue to increase, it must become obvious to the Minister that the eastern health board will be administering approximately 40 per cent of the total budget for health services throughout the country, due largely to the suburban area with the rural tag on it.
I should like to refer briefly to the representation of local authority members on health boards. County Dublin has a population of 174,000 and they have three representatives. The whole of the midland region has a population of 178,000—approximately 4,000 more—and they will have 12 local authority representatives. It seems to me that when considering local authority representation account should be taken of population increases and of immediate future increases and decreases.
I do not know whether it was through my inattentiveness or because of the dreadful acoustics in the House —something should be done about this —but I understood Senator Belton to speak about the transfer of the Dundrum Central Mental Hospital to the health board or to the Board of Works. The question the Senator was asking was whether the ratepayers of the eastern region would have to bear half of the cost of running that hospital. I was not able to hear the Minister's answer and, perhaps, he would be able to repeat it when he is replying.
It is a good thing that the administration of that hospital will be undertaken by a civic board, whether it be the eastern board or the board as suggested my myself and other Senators. It is long overdue that the administration of that hospital should be taken from the hands of the Department and handed over to proper administrative people.
Following the debate in the other House, I noticed that the Minister— I can congratulate him—decided to allow the health boards to appoint chairmen and vice-chairmen. That decision interfered with one of the schedules. The Bill at that time used the schedule to explain the set-up in regard to the hospital boards and as a result of the Dáil discussion the Minister is allowing the boards to appoint their own chairmen and vice-chairmen, and consequently he abolished part of the schedule which allowed him the right to appoint the chairmen and vice-chairmen of the regional hospital boards. The suggestion was made to me—I felt, rather unkindly—that the Minister was retaining the right to make these appointments because the three regional hospital boards would be what I might call the crunch boards which would set up the procedure in relation to the closing down of any hospital or institution, a process which would be most unacceptable except from a political viewpoint.
The suggestion was that consequently the Minister was taking on himself the responsibility to make the appointments of strong personalities in order to ensure that this line would be carried through. I do not imagine that is what the Minister had in mind. It may be that he wished to retain these appointments to himself because these were the boards that would be engaged in the long-term planning of the hospital services of the country and that he felt there should be some close connection between these boards and the country. It would be useful if the Minister opened his mind to us in this respect when he is replying.
The suggestion has also been made —it is hard to decide whether there is validity in it because of the vagueness of the relevant section—that when the regional boards are set up there is a danger a clash may occur between these boards and the employees of the boards, between the CEOs and the senior officers of the health boards. It would appear from certain indications in the section allowing for the setting up of the regional hospital boards and Comhairle na nOspidéal that a consultant employed by the boards to provide services in general hospitals might be in conflict with the CEO or the administrator of the local general hospital and that the consultant might adopt the attitude that he was not an employee of the board and that he would not accept the dictates of the administrator—that he owed his allegiance to Comhairle na nOspidéal. This might lead to discussion on lines of demarcation. It is something that should be clarified by the Minister so that there will be a clear-cut distinction between whom allegiance is owed to.
In relation to the three hospital regions as specified in the Bill as being based in Dublin, Cork and Galway, these boards will provide the new regional hospitals. It was suggested that the board based in Cork would administer the area of the south and mid-west, that the Galway board would administer the west and north-west and that the Dublin board would administer the eastern and midland regions.
The Minister's predecessor said in the course of the debate in the other House—Volume 239, column 2087 of the Official Report—that approximately 80 to 90 per cent of the surgical problems in any local authority area at present were within the competence of the county surgeon and that presumably it would be—I think Senator Ryan referred to this early today—only the remaining 10 to 15, perhaps as much as 20 per cent, who would have to go to the regional hospitals for surgical treatment. If this is the case, presumably contained within that percentage would be a fairly large number of persons who were urgently in need of an operation and whose condition was so acute or so dangerous or so rare that it could not be dealt with in the local general hospital. Why, then, are we to have a situation where the county of Waterford, in the south-eastern health board region, will have its regional hospital in Dublin and where a patient in west Waterford who would be approximately 40 miles from the regional hospital in Cork would have Dublin as his regional hospital board area? A similar situation would obtain in parts of north Clare where the people would be very convenient to the regional hospital in Galway but presumably would be expected to attend the regional hospital in Cork because they were living in the mid-western health board area. Such anomalies will arise in any policy, programme or suggestion for rationalisation or regionalisation and we ought to get a clear-cut, categorical assurance from the Minister at this stage as to whether people will be allowed to cross regional hospital board boundaries if a regional hospital in another area is more convenient or adjacent to them.
It seems ridiculous to suggest to somebody who is in urgent need of surgical attention and who is living in west Waterford that he lives in the Dublin regional hospital board area where there are the finest hospitals, the finest medical and surgical staff, the finest equipment and the finest nursing-home waiting for him if only he can survive the rather dreadful 120 or 130 miles trip by road by ambulance. Unless this problem is tackled at this stage we will get a situation where the press of rural Ireland will be reporting that the verdict at various inquests was that the patient could have been saved had it been possible to get him to the regional hospital in time where the finest equipment awaited him and everybody will regret that fact.
Can the Minister give us some clarification on this point at this stage? Obviously the new regional hospitals will be ambitious. Presumably they will have the very best and most modern equipment available and will be staffed by the most competent persons. All of this will involve very high costings. I do not think we have got any indication from any source as to who, in fact, will be responsible for the financing of regional hospitals.
It is interesting to note the proposed constitution of the regional hospital boards. One-half of the membership of these boards will be ministerial appointees and one-half will come from the health boards. It is interesting to bear in mind that the health boards are creatures which already have almost one-half of their members appointed so that by the time the regional board comes to be set up we will be lucky if even one-fourth of the members of the regional board are local authority members, public representatives, the people who are responsible to the general public. Indeed, as one goes through the proposals for administration one sees that the power, influence and scope of local authority members, public representatives, is diluted to such an extent that it is almost washed out.
I rather facetiously referred to the creation of all the additional committees which will be necessary to administer the policy of regionalisation and rationalisation. I can assure the Minister I realise that many of them are very necessary but I want to say something which perhaps will not be very acceptable politically either to members of my own party or to other parties. As far as I can see, the proposed local committees, who will have solely an advisory function, are being set up as no more than a sop to members of local authorities who realise only too well that their powers are being taken from them and that the health services will be controlled very definitely from the Custom House in future and the only reason for setting up these local advisory committees is to endeavour to convince county council members that they still have some power and some say in deciding on health policies. They have not and they know it and they resent it. If these local committees are still meeting six months after the initial meeting, that will be a matter for surprise. There was provision made in the 1960 Act for local committees to meet within the Dublin Health Authority. These local committees ceased to meet after a few months because the members realised only too clearly that there was no point in meeting to discuss something on which they could not take any decision.
No man becomes elected to a local authority unless he has some degree of commonsense and some intelligence. He will not be a member of any body for very long before he realises what its power or usefulness is. Normally, he is a busy man and he will resent being expected to appear on committees like this where he cannot come to any decision or make any clearcut recommendation. It would have been better if the Minister had been more honest and had said: "We are taking the power away from local authority members. We are allowing some of the members of each county council collectively to form just over one-half of the membership of the health board. We are restricting the way in which the health boards can spend money. We are ensuring that no local authority can refuse to provide the money. We are doing all this because we do not like the way in which you have been administering the service, because we do not like the way in which Dublin Corporation protested, and in order to make sure that our system of financing almost one-half of the health services out of the rates will continue. We are going to make darn well sure that nobody is going to protest about it in the future. We are not going to have any local committee because it would serve no function. It would be a waste of time—of your time and our time—and incidentally it would waste a considerable amount of the ratepayers' time because of the necessary attendance of officials there and the rooms that must be available, and the expense of subsistence allowances and all that, which will be of no avail."
Perhaps, it is not too late yet for the Minister to consider either doing away with those committees or deciding to give them some real power, recognising the contribution which the members of those committees have to make and deciding to give more teeth to those committees and allow them to do more work. I assure the Minister— and I am sure that from his visits around the country he knows it only too well—that these people are only too ready and anxious to help in furthering the administration of our health services.
There is an interesting departure in this setting up of those local committees in that for the first time ever as far as I can see or find out the county manager, a man who derives his whole position from the Management Acts and who had a very definite position in relation to members of his local authority, has been taken out of that official position, which is clearly laid down by the Management Acts, and is being told "You serve on a committee with elected members and you serve as a member of that committee." Now I am not the greatest advocate of the management system. I believe that there are many changes that could be made to the Management Acts, but to just decide to make one small change like this which changes the position of the county manager in relation to public representatives does not seem to me to be a very worthwhile thing to do, especially when it is in relation to a committee which will have no useful function anyway.
Many of us hoped that when a new Health Bill would be introduced the old Victorian poor law system, the concept of someone being eligible for services if they could not provide from their own income or other lawful means, would be recognised as what it was, and that a fresh approach and a new look would be taken at this whole business and that there would be a clear-cut definite line laid down. While the Bill does abolish this dreadful phrase of "lawfully from his own income or other lawful means" it gives us instead the equally trite and meaningless phrase "undue hardship". My definition of undue hardship, the Minister's definition and the definition of any of the other 58 or 59 Senators in this Chamber could differ, and differ radically, from each other. What might be undue hardship to the Minister might not be undue hardship to one of the Members here, but it might very well be great and grave undue hardship to somebody sitting in the public gallery. We are asked to accept this as the modern 1969 replacement for this Victorian set of words. I think, again, that this is a section which should be examined to see whether there cannot be some definite and clear-cut things laid down here to give a fair indication to the general public as to what undue hardship or whatever it is was in the mind of the Minister or of his officials or the draftsmen when they wrote that section.
I want to welcome with all my heart —and that is an awful lot to give—the provision that from now on only the husband and his wife will have their incomes taken into account in deciding upon eligibility. How often have so many seen the situation where a large family were refused a general medical services card because of the income of one of the eldest children where we as public representatives knew, and knew only too well, that that eldest child either through selfishness or for personal reasons was, in fact, making no financial contribution whatsoever towards the home? Yet the health authority were obliged to take a certain amount of the income of each child into account. They were not allowed to investigate whether or not that child was making a contribution to the home. I can assure the Minister that the numbers who will immediately become eligible for general medical service as a result of this move will be considerable and I hope that the increase in numbers has been budgeted for. I know that it will be welcomed in many parts of County Dublin. Indeed, if the Minister ever has to seek a new constituency he might well think of coming down there after this. However, what I do want to say is that it is rather a dreadful thing in this year of our Lord 1970 that we feel it necessary to consider continuing this blue card system, this general medical services card system with its means test to any extent. As far as I understand it virtually every country in Europe with the exception, I think, of one particular part of Finland has managed to provide some sort of medical service for all its people, and apart from Finland the Republic of Ireland is the only place where a general service for all the people is not provided and this continuing means test with all the annoyance and embarrassment which it invariably must cost is to be continued. I am sure that the Minister would like just as much as I that this should be abolished, and I recognise that presumably it is just not economically possible at this time, but I would hope that it is the thinking of the Minister and his officials that as soon as ever we may we will get rid of this means test and of the questioning and probing which almost invariably fails to elicit the true picture, fails to bring out that, perhaps, the husband has gone on spending more money on drink than actually reaches his wife, which is a very small sum indeed. It often amazes me that with all the questions asked by these inquiry officers about the family's situation hardship of that degree is invariably overlooked, and they seem to be more concerned that the people may have cabbage planted in the back garden from which they might derive an income of 10s than to find whether, in fact, the husband brought his wage packet home at all last week or the week before.
I understand that in the future rather than each local health authority deciding on what should be acceptable standards for the issue of the general medical services card the Minister or his Department will issue clear-cut standards which cannot be deviated from by any health authority. This is a good thing which is to be welcomed, and I hope that it is something which will be brought into operation at the earliest possible date.
I want to refer to the provisions of section 45 whereby there is a ceiling of £1,200 for limited eligibility. This is a ceiling fixed late in 1965. If I may I would point out, as other speakers have done, that there has been a very definite and marked fall in the value of money since then, as Members know, and as Members of the other House know even better, because shortly before the Christmas Recess, in answer to a parliamentary question, the Minister for Finance explained that the 1969 pound was worth 16s 8d in 1966 or 16s 4d in 1965 terms. Taking it in terms of 1966 and working out what £1,200 is worth in terms of 1969 we arrive at a figure of £1,440. Yet, here in this Bill we have the same ceiling of £1,200 continued even though it must be quite obvious to the Minister's advisers and draftsmen and to himself that the people who were entitled to services with £1,200 in 1966 would be no better off today if they were earning £1,440. There is a clear case for asking the Minister to amend this figure and at least bring it into line with the fall in the value of money, if not to increase it substantially.
In regard to section 52, I very much regret that the Minister has felt it necessary to continue the provision whereby charges may be made per day for hospital service. I think the Minister and his officials know that the amount of revenue derived from this charge in the past few years has been a very small fraction of the revenue required to meet costs, something like one-sixtieth, without taking account of the administrative costs of collecting that 10/- per day. A Bill that sets out to be a modern Bill dealing with health services should not continue this provision.
The Minister is to be congratulated in regard to his decision to allow free choice of doctor where possible. This is something for which the people have been agitating for a very long time, something which has formed one of the cornerstones of Fine Gael policy on health in the past few years. We have been agitating for it at every available opportunity. As a party we feel proud that this part at least of our suggestions is to be implemented in this Bill.
When we refer to free choice of doctor—this is a choice of general practitioner—it is only right to acknowledge the debt which Irish society owes to general practitioners down through the years. Very often, especially in remote rural areas, they have acted as friends and advisers as well as medical practitioners. They have given very considerable service and because of this I am specially concerned that, wherever it is not found possible to provide a choice of doctor, every effort should be made to ensure that some doctor is available. Obviously, in more remote areas doctors will be reluctant to stay and we should see to it that very definite incentives are made available so that they will consider it worthwhile to live in these remote areas.
Remote areas are not always, as Senator Dr. Belton suggested, in places like the Aran Islands. In this respect I want to quote from the Irish Independent of 8th January of this year an article on the front page dealing at some length with the fact that the tiny village of Tinahely perched high in the County Wicklow mountains has been endeavouring to combat a raging flu epidemic without the aid of a resident doctor. “Already,” it says, “one villager has died from flu complications, according to a local resident. Almost every house in the village (population 417) has been struck by the virus and the only medical assistance available is from the doctor in the district dispensary who travels the six miles from Shillelagh twice a week.”
Interestingly enough, a member of the other House who is also a medical practitioner, Dr. Hugh Byrne, who travelled to the stricken village at the request of the Irish Independent said: “There is near-panic here at the moment. When there is a fantastic incidence of flu as at present, it is these isolated places which are worst hit.” Dr. Byrne blamed the new Health Act, to become law in April, 1971, for the difficulty in attracting resident dispensary doctors to places like Tinahely. “These temporary part-time non-pensionable positions are not attracting any applicants because they offer no security. The shortage of doctors in such areas should have been anticipated when the legislation was being introduced,” he said.
With all due respect to my colleague, Deputy Dr. Byrne, perhaps he is a little bit harsh but this does emphasise the problem which exists even in areas——
