There are matters being discussed on this Estimate which are undoubtedly of great importance to every member of the House, and particularly to the people outside. Much has been said about dispensaries in various places and about the question of regional hospitals. I cannot in the least agree with the approach of Deputy Dr. Browne to the problem of dispensaries. In so far as these dispensaries are so often found in a crumbling condition I agree that they, at least, must be replaced, because these buildings were so badly constructed originally and so badlykept perhaps by local authorities that it would be fantastic and hopeless for any local authority to consider the possibility of reconstruction.
I certainly disagree with Deputy Dr. Browne when he goes so far as to say that all patients under the dispensary system should be treated in the doctor's residence. That may be all right for patients who are living convenient to the local dispensary doctor's residence but Deputy Dr. Browne knows very well—he has reason to have reliable knowledge resulting from his term of office as Minister for Health— that in rural areas many of these patients would have to travel a very long distance if they were to go to the doctor's private residence.
When we speak of the improvement of health services we must realise that the foundation to a generally good medical service in rural Ireland commences with the dispensary. We cannot expect our people to go to buildings known as dispensaries where cattle would not be housed. Because these dispensaries are so bad at the present time and have been for so many years back, we have the glaring fact that there are patients in local authority hospitals who would never have to go there if the medical dispensaries were in a proper condition so that these people could attend there when their illness would not be of a serious nature.
I have known many instances of people dreading the thought of visiting a local dispensary in the winter time particularly. As they say, they are almost certain to contract pneumonia out of it while waiting for attendance by the doctor. There is no waiting accommodation and no facilities of any kind in these places. That is one of the reasons why people do not attend dispensaries in many areas until their illness is at such a serious stage that they must go to the doctor and their next move is into the local authority hospital.
Any money we spend in the improvement of existing dispensaries or in providing decent dispensaries in every locality in the Twenty-Six Counties will be money well spent. It may seem tosome people inside this House and to people outside that too much money is being allocated for such Government services and that we should not go on with the building of these dispensaries. In their narrow outlook they may have some case to put up but taking the long-term view and considering the result accruing from the existence of these decent dispensaries, I am convinced that this expenditure is very much worth while. We could then look forward to the time when patients would not have to be drafted continuously into local county hospitals and could be treated in their own immediate neighbourhood. That is why we should, at the very outset, consider the importance of carrying on the scheme of building dispensaries in every area where they are required.
It is true that for the last few years money is being provided for the erection of such buildings. That is a step in the right direction. We should strain to the limits of our resources to provide for the programme of building local dispensaries. People may complain of the services available in these dispensaries. As a member of a local authority I will say that indeed at times they are justified in these complaints. I have known instances where if a person comes under the heading of a poor law patient with the ordinary dispensary ticket, and goes to the doctor in the local dispensary, he next finds himself in the local authority hospital. On the other hand, giving credit where it is due, I also know of places where the local dispensary doctor goes out of his way to provide facilities for his patients. I have even known times when that local dispensary doctor provided out of his own pocket money to procure medicines which were not made available by local authorities.
In order to augment the service provided in the dispensaries it is vitally important and would be of assistance to the dispensary doctor and of benefit to the patient if a qualified general nurse were attached to every dispensary area. Mention has been made of midwives. I do not intend to go into that matter at the present timebut I consider that what is of great importance is a liaison between the dispensary doctor and the patient.
To-day we have reached the stage when the use of drugs is an everyday practice and day after day injections with drugs of various kinds are recommended for patients. We know that very often in rural Ireland no relation of a patient may be in a position to help that patient by administering drugs or giving injections and it is not always possible to expect the local dispensary doctor to carry out that work. But if a fully trained nurse is attached to a dispensary, I consider that in her daily rounds such a nurse could attend at the homes of patients and administer these drugs or give necessary injections. While we all know that hospitals are wonderful places, there is always a certain comfort and satisfaction in being able to remain at home during a period of illness and in the knowledge that relatives are within easy call. I go so far as to say, and I shall stand by the statement if challenged, that there are many patients who have been in local authority hospitals for years who would never enter these hospitals if the services I suggest were provided outside.
I have known of instances in which dispensary doctors shifted patients into local authority hospitals and while it may not have been the fault of the dispensary doctor always, the main desire was to get these patients cleared away. Yet we complain of a shortage of beds in many hospitals at present. In the course of the debate, mention has been made of the fact that we have trained nurses in this country as capable and efficient as any nurses in the world. Many of them are forced to seek employment in other countries and I think a greater effort should be made to retain their services for our sick here at home. I believe that we should try to utilise their services by having one or more nurses attached to each dispensary district at, of course, a decent salary to enable the nurse to enjoy a reasonable standard of living.
Another matter which has often been mentioned at meetings of local authoritiesis the manner in which medical inspection of dispensaries is carried out. We have consistently objected to the system at present prevailing. I object very strongly to the principle under which these medical inspections are carried out. How often are inspections carried out in dispensary districts? Roughly from the information I have got as a member of a local authority, I am aware that they are carried out once a year or once every year and a half. We cannot be blind to the fact—and every member of a local authority will bear me out in this statement—that the careless dispensary doctor, and we have some of them, knows when the year is out that he may expect an inspector any day from the Department. It is quite easy to have everything in order for a short period and then, after the inspection is over, to lapse into the old indifferent method again. I strongly object to a system which has been in operation, not for the last 12 months but for years back, under which members of a local authority cannot get any information or report on the inspection carried out in certain instances by the local government inspector. We have had difficulties in this respect and I have mentioned them openly at meetings of the local authority when I considered it my duty to do so.
As many people know, we have some dispensary doctors who are a credit to themselves, their dispensaries and their profession but if we have such individuals and if we can see the report of the inspector on their dispensaries and their work, why cannot we see the reports in respect to others who are frequently incompetent or indifferent in many ways in regard to their work? Why should members of local authorities not be given a chance of questioning an individual who may be failing in his duties in a particular district?
We sometimes get complaints from individuals regarding the treatment meted out to them in dispensaries but we are handicapped because of the fact that, for various reasons, these people while willing enough to make their complaint to a member of a local authority, will not put that complaint in writing. Very often they are afraidthat it may involve some difficulty for them in the future either with the local officials concerned or in some other way. Therefore, while the county manager may be quite prepared to have the matter investigated, without the necessary information and the necessary witnesses we cannot go on with it. I believe that if the inspection were carried out more regularly and frequently and if the members of the local authority were supplied through the county managers with a copy of the reports, we would be taking another step forward towards improving medical services in the various dispensaries.
It is true that in the last few years a great improvement has been noticeable in the treatment of tubercular patients. I have said previously, and I shall repeat it publicly because I believe no one in this country will want to deny it, that great credit is due to Deputy Dr. Browne for the work which he did as Minister during his term of office for tubercular patients. While we are making great strides in providing curative treatment for tuberculosis, we are inclined, I think, to be somewhat short-sighted in regard to the treatment of other diseases. It is correct, of course, to say that there are facilities in Dublin to deal with the dread disease of cancer, but what about the rest of the country? I am not complaining that facilities are available in Dublin which are not to be found in other parts of the country. After all, we must commence with the capital of the country, but I think we should not be content to concentrate all our efforts on the capital. I think the system whereby local authorities must send patients from various part of the country to Dublin to have diseases such as cancer dealt with, is a bad one. I know that we cannot overnight or within a short period provide all the facilities locally to deal with this particular disease.
There are a few other diseases that I should mention in this connection. One which is so often attended by fatal consequences and comes on its victims so quickly is infantile paralysis. I wonder are we making the stridestowards a discovery of a remedy for this disease which we should be making. It has undoubtedly left terrible marks in many parts of the country, and what is more serious for everyone is that the fatal results are increasing each year instead of decreasing. It is true that other countries cannot say that they have a remedy for it but I wonder are we concentrating sufficiently on trying to find a remedy. Are we, while doing our utmost with regard to preventive treatment, and so on, for tuberculosis, forgetting the possible dangers which are becoming so noticeable daily in relation to these other diseases? In the case of heart disease we can see its results daily when friends of our own are suddenly taken away, and I feel that these are all problems on which we should concentrate to a greater extent.
Because these vicious problems have to be surmounted I believe that Deputy Esmonde is correct when he advised the setting up of a consultative council or some such body. I do not agree with Deputy Browne, whose view is that we have very few, if any, experts amongst our medical practitioners, but the Minister should do his utmost to secure such experts. It is strange that the many young Irish doctors who have had to leave their own country because there were no vacancies which they could avail of make such a name for themselves in other countries. Outside critics may tell us that we are spending a lot of money on various Government Departments but I consider that, no matter what Minister is in office or what Party forms the Government, every effort should be made—and the question of expense should not enter into it—to secure the services of experts, whether Irish or foreign, if through their services we can help to prolong the lives of people who have not the benefit of these services at present.
The Minister also mentioned the mentally deficient. That is another problem and, from my own experience, I can say that it is a horrifying and lonely experience to go through some of the hospital wardscontrolled by our religious orders who are doing such wonderful work in the treatment of these patients. It is deplorable to realise that even at present we have not sufficient accommodation for such patients. It is sad to think that the mother of a family with such a child who knows that she can do nothing for the child and who longs to get the child into a home where it will be under the special care, medical and otherwise, of the members of these religious communities, must be told, as she very often has to be told, that there is no accommodation for such a child.
We should take advantage of the building programme to provide additional accommodation for these cases and, what is more important, we should facilitate to a greater extent than we are doing the provision of such accommodation. In that connection, I give Deputy Dr. Browne credit for helping during his term of office by providing as much as possible in the way of financial aid in relation to the provision of accommodation for such cases. The work done by these religious communities is of such a valuable nature to the country that we should be prepared to strain our resources to the utmost to secure for them as much as possible in the way of financial assistance to help them to get on with their very valuable work and to take in more of these patients who are on a waiting list for such a long time.
Deputy Dr. Browne's reference to the voluntary hospitals struck me as being very surprising. He may be correct—I do not know, because my experience of voluntary hospitals is limited—but, although it is limited, I cannot let this occasion go without telling Deputy Dr. Browne and the House that, from my experience of one voluntary hospital, as a member of the board, it is not correct to say that, in that hospital in Cork City, there are pauper beds, nor is it correct to say that there is special treatment for "Mr. Murphy" as against "Murphy"—the phrase used by Deputy Dr. Browne.
Cases go into that hospital and the staff are never aware—they never askor care—whether the patient is a paying patient or a free patient. The staff are not concerned with the financial end of it. That is dealt with in the secretary's office, but I can say that the same treatment has consistently been given in the South Infirmary in Cork City to the patient who is never able to pay a penny as to the patient in the private ward paying five guineas and six guineas a week. It is only fair to let the people outside know that, whatever about the other voluntary hospitals mentioned by Deputy Dr. Browne, there is at least one in Cork City which does not come within the category mentioned by him.
The Minister, in his introduction, drew attention to the increased deficits of these voluntary hospitals. He is quite correct in that, but there is one problem facing the dispensary hospital which the Minister must not forget. The boards of voluntary hospitals have been faced with one very big problem, not for the past year or two, but consistently over the past ten or 11 years. The medical staff at all times, where they considered it necessary, have ordered the provision of most expensive drugs for their patients. It is true to say that patients got these very expensive drugs whether they were paying patients or not. The difficulty so far as the hospitals are concerned is the expense of these drugs. It very often happens that to treat just a few patients the amount of money involved in connection with these drugs is fantastic. Yet the hospital authorities never question these matters. Their view at all times is that if they can save a life it is their duty to do so.
If hospital deficits have increased undoubtedly that is due to the increased price of medicines and particularly up-to-date drugs. That is responsible for the increased deficits in some of these voluntary hospitals. I am glad that the Minister some while ago considered the necessity of increasing the amount to be paid to the voluntary hospitals for national health patients. The situation was rather difficult for a period. The Ministerpaid through the national health four guineas and expected the national health patient to pay the other guinea. I am glad that position has been remedied at any rate.
There is another matter which is of great importance, particularly to the people in the rural areas. I refer to the schools medical inspection. This will undoubtedly show excellent results in the future. I know that many parents, whether through shortsightedness or plain ignorance, consider it humiliating for their children to submit to an inspection in school. They may prefer to avail of the services of their own private doctor. As long as the child feels well the parent will never think of bringing a child to the doctor. One of the great factors towards improving the health of the children of the present day—the men and women of the future—is a schools medical inspection. I consider that should be done regularly so that the health of the children can be constantly reported on and the parents made aware in any particular case of the slightest flaw in the health of the children. If that were done the difficulties could be attended to and a remedy provided in the shortest possible period.
Side by side with a schools medical inspection, there is another matter which affects the people, particularly in rural areas. I refer to the system of dental treatment for school children. Cases were reported to me where parents were advised that the children should have their teeth attended to. Because of that, the children were directed to be sent to Cork City or some other large centre. The parents were then faced with this difficulty. On account of the number of children who attended on the same day, the dentist, despite his utmost endeavour, was unable to deal with them all. The Minister may say that is a function of the local authority, but I believe that the Minister in his wisdom should draw attention to the matter and ensure that these programmes are so planned by local authorities that they could be carried out in the spirit in which it was intended to have them carried outwhen legislation was introduced in the past and facilities provided.
I now come to a matter in which every member of this House is interested. That was not always so, because a few years ago there were some who did not agree on the matter. I refer to the improvement of county homes. When Deputy Dr. Browne was Minister for Health, he sent out a circular to every local authority. As a member of a local authority, I read with the greatest interest the copy I received of that circular. Some members considered that the document should not have been sent out. At the time, some members, perhaps in good faith, believed that it was a fantastic document and that the suggestions in regard to improvement contained in it were fantastic. Time is proving how right the then Minister for Health was in sending out that document. We cannot be satisfied with saying that things are all right. We take pride in the fact that our county homes are vastly different from what they were in the past when they were known as workhouses. We cannot afford to stop when certain improvements have taken place. The present Minister is quite correct to ensure that more improvements are carried out in these county homes. He will have to keep constantly trying to bring them to a state of perfection if that is possible.
Local authorities with the greatest desire in the world of trying to carry out these improvements are faced with the problem of finance. While the Minister has given 50 per cent. recoupment on loan charges, I wonder will we get the local authorities in every county to face up to their obligations to have these improvements carried out. Members of all Parties in this House and members of many parties on various local bodies are anxious and eager to throw in their weight behind any suggestion to carry out these important improvements but with the best intentions in the world to do so they are always faced with the problem of finance. This is not the time although it is the place, perhaps, to go into that problem but, perhaps, I could not go into it very easily either. However, I say openly for the record that whateverwe may say in regard to other Departments we should be prepared, no matter on what side of the House we may sit, to definitely throw in our weight behind any suggestion to provide money for these important improvements.
The Minister's suggestion in regard to these improvements is a good and worthy one but from the reaction of members of various local authorities, I am afraid I cannot hope to see these improvements carried out in the time we would wish nor can I hope to see them brought up to the standard we would wish. I should like to draw attention to one matter in respect of which I would ask the Minister to give me information either when he is replying or at a later date.
On the 19th May, 1948, I asked a certain question in the House. The question which I addressed to the then Minister for Health on the 19th May, 1948, dealt with the problem of non-paying patients in local authority institutions. The question was based on the fact that a decision in our courts went against an applicant who, while being treated in a local authority hospital, suffered some injury which his counsel maintained was caused through the neglect or fault of the staff or servants in the hospital. The finding of the judge was in favour of the plaintiff, but because he was a non-paying patient he could not get any compensation. If he had been a paying patient, and if negligence were proved, he could succeed in getting damages.
The irony of it was that, because he was a non-paying patient in the local authority hospital, he could not recover damages for the injury he had received. The then Minister, Deputy Dr. Browne, promised to look into the matter. Owing to the fact that I was not able to attend for a period myself due to illness, I really do not know what has since happened. I want to ask now whether any alteration has been made which would have the effect of protecting such non-paying patients.
My colleague, Deputy Corry, referred to the question of new hospital plans. We have as many plans for hospitalsin Cork, and we have sent up as many to the Custom House, as would provide plans for the building of hospitals in every capital in Europe. The whole thing seems to be a joke were it not for the fact that it is such an expensive joke. The building of hospitals is now going to cost the State and local authorities millions of money. I suggest that these hospitals could have been built at a time when the cost of doing so would not be a fraction of what it is to-day. These plans are being sent up and down the country year after year. Big fees are being paid to architects, engineers and consultants for every alteration that has to be made in them—even if it is only a new pencil line on the drawing.
My opinion is that there should be a special staff in the Department of Health to deal with plans for hospitals. We have consultants in the country doing a good practice. They have their fixed charges and I hold are entitled to receive them. My point is that we are not entitled to be putting money in the way of various professional men if money could be saved by having a simplified system of planning for hospital buildings through the Department itself. If we had, hundreds of thousands of pounds could be saved to the ratepayers and to the nation as a whole. I think we should shake up our ideas in this House as regards the planning and building of hospitals and make a more energetic effort to have all these grand drawings on paper reduced to a practical form for the accommodation of our sick people.
I would like to draw the Minister's attention to some of the problems that local authorities are faced with. To some people these may seem small matters but they are by no means small to the people affected. I mentioned earlier that it is a common thing now to hear of sudden deaths. I have had some sad cases concerning widows brought to my notice. I know of one who was in very bad circumstances when her husband died. She had the usual funeral expenses to meet. It was only when all her trouble was over that she got the bill from the undertaker. She found then that she was not in a position to meet it. Thatis an example of cases which come before local authorities. We are asked to provide some financial assistance, but, under the regulations, we cannot do so. The local authority could help in a case of that sort if the local home assistance officer were approached before the burial had taken place. I would be glad if the Minister would do something to have that matter investigated. I think some change in the regulations should be made so that in cases where home assistance officers and county managers are satisfied that widows and others are genuinely in need of some help, they should be in a position to give it.
I should like to make appeal on somewhat the same lines in the case of people in bad health. It must be admitted that our health services have been improved year after year, and that the special allowance which is now paid to dependents of people suffering from tuberculosis has been of great advantage in these cases. You have, however, the cases of other people suffering from different kinds of disease who are in very straitened circumstances and are not entitled to any financial help. I have in mind the case of a man who served this nation well. The wife and himself are complete cripples, not from tuberculosis but from rheumatoid arthritis. The wife is not able to do anything at all for herself. They have a young family. The husband tries to do the best he can about the house but that is very little. All that they are entitled to is home assistance. Perhaps some arrangement could be made to give some financial assistance to such people after a thorough investigation has been made as to their circumstances. If that could be done, it would be a godsend to people suffering as this family is suffering.
There is another matter that I should like to deal with. It has been mentioned by other Deputies and particularly, I think, by Deputy Dr. Browne. Up to a certain point it shows the amount of agreement that there is between us. I am hoping that perhaps something further may be done. I refer to doctors in the country carrying on a private practice.They are noted for the help they give, very often free, to patients suffering from different ailments. They are not dispensary doctors. In some of the areas that I have in mind the people have no faith in the local dispensary doctor. When they are ill, they go to the doctor who is carrying on a private practice. These doctors do all they can up to the point where the patient requires hospital treatment. Then a difficulty arises. The private doctor cannot send a patient into a local authority hospital and it is not so easy for him to get patients into voluntary hospitals, especially in the South, owing to the limited extent of our hospital accommodation.
In drawing the Minister's attention to this, I am not asking that the doors of the local authority hospitals should be left open to everyone. Is it not strange that a patient will go to a private doctor when there is a dispensary doctor available? When that happens should we not ask whether the local dispensary doctor is giving the service we would wish for?
That is a matter that is very difficult to prove. The best proof of the incompetency of a dispensary doctor is the fact that patients avoid him and go to a private doctor. I have not in mind patients who can afford to pay. That is completely different. I am referring to patients in rural Ireland who have no hope of paying but who have to go to a private doctor. It is a pity that some system could not be adopted whereby returns of cases dealt with by the local dispensary doctor could be investigated. In any case where the return showed a remarkably small number of poor law patients being attended we would be entitled to have an investigation as to how the medical service had been carried out in the particular area.
I am not asking the Minister to reply to this matter when he is concluding the debate but I would ask him to bear this problem in mind so that a better medical service may be given to the people in rural areas.
I do not know why Deputies avoided one problem which should not be avoided, that is, the cost of medicines.Deputies have referred to patients who may be classified as poor law patients and they have referred to the white collar workers and displayed sympathy towards those people. Every day I hear middle-class patients complaining of the exorbitant price of medicines. Has the Minister any control over that matter? Is there a ring operating that we cannot break? The doctor does his part but then the patient has to provide the medicine. Again, it is a matter of finance.
I want to avoid bringing into this debate any reference to future legislation in connection with this matter. I am dealing with the present position. Possibly the problems that exist now may not be remedied by future Bills. Medicines are required at a time when people are ill. They cannot be done without. The prices charged in many instances are prohibitive. Then we have discussions on restrictive trade practices and rings. I am not singling out any particular chemist. I have no particular chemist in mind. The matter is one that must be approached by the present Minister or future Ministers. No matter what Bill may be introduced, the problem of ill-health will remain if the people cannot afford to pay the high cost of medicines.
Reference has been made to the nursing profession. The nursing service in every hospital, local authority hospital, voluntary hospital, has proved to be excellent. As it is excellent we should treat the members of the profession properly. I should like to group with the nursing community a section that may at times be forgotten, namely, attendants in local authority hospitals. The worth of the attendant is not at times appreciated. In view of the reply the Minister gave to a parliamentary question last week about proposed increased salaries for attendants, I would ask him also to take into consideration the importance of the work these people do in the hospitals and to realise that they are entitled to what has been recommended for them. I hope he will say "yes" to a proposal that has been sent up to him in this matter.
The nursing council should be prepared to co-operate with every localauthority. They have co-operated with the authorities in Cork as regards a certain number of male nurses in the particular hospital there. There should be attached to every local authority hospital a number of male nurses, whether it is one, two, three or four. Any difficulties in the way of having fully qualified male nurses attached to these hospitals must be overcome. In many local authority hospitals, difficulties arise for patients which only a male nurse can solve. Our nursing service is an excellent service. When we refer to that service, we usually have in mind female nurses. There are many instances where the people who should appreciate their services most do not do so. I refer to the doctors who depend on nurses to carry out their instructions for the care of the patient. We must be prepared to give nurses what they could get in other countries, not just a meagre living, but a decent living. If we do that, we can have a contented nursing profession and plenty of recruits for the profession. If we do that, our hospitals, be they new hospitals or dispensaries, will not be short of nurses.
My final remark is based on one point—"No End to It." Members may say there is no end to me, and I do not blame them. The words may not mean so much to people here but to people outside they may seem of great importance. To the editor of a certain newspaper published in Dublin last night, these words "No End to It" were of great importance, as he was drawing attention to the amount of money being provided for health services and the amount we are in a position to provide. I am not picking out anyone to attack. People who use these words are entitled to use them, but our answer must be, as I said at the start: "Are we prepared to barter the health of our people because someone says there is an end to the money?" Are we prepared to say we cannot give proper dispensaries, proper hospitalisation and proper help to improve the health of young children?
Some of us in this House know from our own experience what it means in body and mind to deal with theproblem of ill-health. We can speak our own minds and we know that there are those who may never have been faced with such a problem and who, if they were in need of medical attention, were lucky enough not to have to worry about financial problems. Some of us know that it is the problem of finance to the person who is ill, to the father and mother of the child, that very often means serious illness or death because they cannot afford financially to get what would save that life. Are we prepared to give lip service to Christianity and yet say that some sections must go without medical attention? Can we allow people who can provide their own medical attention to tell us there must be an end to the provision of money for medical attention for those who cannot provide it for themselves?
I tell the Minister that where the Labour Party is concerned he will have their backing in any provision of security for the physical well-being of our people, because the members of the Labour Party are fully aware that this is a constant problem facing the people in every part of the country. Whatever we may say about other services, there is one thing that we will say, as Irishmen and as Christians, that we will never question any Minister for Health who brings in recommendations which in our hearts we know will be of benefit to the people who need them. Any Minister who is so sincere as to bring in proposals of that kind will get our support, as we know the good end which those proposals are designed to bring about. Not alone will he get our support but the blessings of the people in rural Ireland who in 1953 are so often not able to provide for themselves and their families the medical attention which at times is so urgently needed.
