Dáil Éireann díospóireacht -
Wednesday, 26 Jun 1957

Vol. 163 No. 1

Committee on Finance. - Vote 63—Health (Resumed).

Dr. Browne

With regard to the voluntary hospitals, the definition I gave, which appeared to fit, was that a voluntary hospital is one which is run mainly by subscriptions. Those conditions in relation to the voluntary nature of the hospitals do not seem to me to exist any longer. I was inquiring from the Minister whether he is prepared to review the position of the voluntary hospitals. As far as I can see, there is no democratic system of election to those boards which seem to me to represent nobody very much— possibly the Knights of Columbanus or the Freemasons, but as far as the mass of the people are concerned, they have no popular foundation. They have no power, as far as I can see anyway, to be the final arbiters in the decision as to how public money is spent.

It is clear because of Exchequer subventions which have increased very considerably over the years and because of the expenditure of the Hospitals Sweep funds on hospital buildings, that more and more demands will be made on the Exchequer and more and more payments will come from the local authorities in the form of rates and from individual taxation for services rendered in these hospitals.

There is a reasonable explanation on the whole for the very considerable increase in expenditure in voluntary hospitals since pre-war years. I do not know whether it is the complete explanation. That would be impossible to say without a more detailed knowledge of the methods of expenditure and a detailed understanding of the manner in which these hospitals keep their accounts. I was suggesting that if there is some disquiet—and if one reads the papers and listens to people talking, there seems to be uncertainty about these hospitals—would it not be some help if there was public representation on these boards, in view of the increased public expenditure on such hospitals?

I do not see anything wrong in that suggestion. It is already in operation in the Meath hospital and seems to work well. Public representatives, taken by and large, are conscientious, are more conversant with public affairs as we know them and as we wish to see them operated, are more conversant with the needs of our people in relation to health services.

There is another question which I would recommend to the Minister, that is the possibility of trying to get for the Department of Health some right of inspection in relation to the voluntary hospitals. Again, where considerable sums of public money are being spent, I believe there should be some right of inspection by officers, either of the Department of Health or of the local authorities—some right of access in the ordinary way which these officers have in the case of local authority hospitals.

I think that suggestion, if adopted, could be of great benefit. As well as ensuring that the maximum possible efficiency would be achieved in the supervision of these institutions, it would also ensure that the public, who are paying the piper, would have watchdogs both in the Department of Health and in the local authority to assure them that the running methods of these institutions are as competent, as efficient and as administratively economical as they can possibly be.

It is not generally realised that the Minister for Health has, as far as I am aware, in the majority of these hospitals no right of access whatsoever. As more and more of our public authority patients continue to go to these hospitals in the future, and as the Minister has no right of inquiry, if the patient is dissatisfied with the standard of treatment he gets, I think some effort should be made to give the Minister the right of access to these hospitals. I am not saying that the standard of treatment in such institutions is bad. It is as good as it is possible to get in this country, but I think the principle should be established that a patient who feels he has any sort of complaint or any grievance against the hospital authorities should be able to air or voice that grievance where it will be considered and where he can have a reasonable assurance of getting some satisfaction.

At the moment, it seems to me that these hospitals are carried on in the old tradition, where a patient was treated as a sort of charity, charity in its worst possible meaning, and where, if he did not feel he had been treated as well as he should have been, he had no right of appeal whatsoever, the idea being that he was very lucky to get treated at all. That, in my opinion, is all wrong. I think there should be an alteration in our attitude in this respect; people being treated in such hospitals should be able to emphasise that it is they who are footing the bill for the maintenance and the running of these hospitals and for the services available to all other sick people.

An Ceann Comhairle

Could the Minister do that by an administrative act, or would new legislation be required?

Dr. Browne

I am asking the Minister if he would consider adopting my suggestion.

An Ceann Comhairle

I am asking the Deputy if the Minister could do it by administrative act or if he requires legislation. The Deputy will realise that I have allowed him to go a good distance. I do not know whether the Minister could do it by administrative act. If he could, the Deputy would be perfectly in order in recommending it.

Dr. Browne

I shall not dwell upon it. It must be possible for the municipal hospitals and the voluntary hospitals, side by side, to give the same standard of treatment to the sick.

The subvention of £20,000 for the Voluntary Health Insurance Scheme is an item of importance in this Estimate. I wonder if the Minister would reconsider this question of the Voluntary Health Insurance Board and the decision to go ahead with this scheme. I feel sure the Minister who proposed this idea was bona fide in his anxiety to try to provide a suitable health service for a particular group—the middle income group, I think he had in mind— and that this Voluntary Health Insurance Scheme was proposed to aid that group.

To me, it seems that if we go ahead, we are just introducing another complication into an already very complex and complicated situation in the country in relation to health services. A voluntary health insurance scheme seems to be damned from the start by the fact that it is impossible to operate satisfactorily, that it must envisage the setting up and the development of administrative machinery which is already there, either in the voluntary side of the health services or in the local authority health services.

There are a number of anomalies and disabilities which must arise and which will render the scheme devoid of any real value in meeting the needs of the middle income group. These will mean, too, that proper health services will not be readily available to the people in this group, when they fall ill. I have discussed this with experts on insurance and I cannot see how one can devise an overall comprehensive scheme, actuarially sound, on an insurance basis, without the assistance of a vast expenditure from central funds.

The only alternative to that is to provide for a very limited scheme. If the scheme is to run on insurance contributions exclusively, it must necessarily be a very limited one. On the other hand, if we decide that there must be a subsidy in order to provide the best possible scheme, giving full cover in respect of all forms of sickness, medical preparations, medical appliances, equipment and so forth, then we shall have to provide a vast subsidy in order to keep the contributions at a reasonable level. If we so decide, I have no great quarrel with that proposition, though I would prefer a scheme such as that laid down in the 1947 Act.

If, on the other hand, the decision is to provide a limited scheme with limited cover for a limited group, as is envisaged under the Voluntary Health Insurance Scheme, it seems unfair that any taxation should be asked from those who may not be permitted to benefit under the scheme. Chronic sick persons will not be covered by this scheme; the old will not be covered because they are regarded as a bad risk. I do not see why they should be asked to pay taxation in order to subsidise a service of which they cannot avail. Unless the scheme is available to all sections in the middle income group, irrespective of age, medical history or any of the other disabilities I have mentioned, it is unfair to ask these people to pay taxation to subsidise a scheme of which they will not be permitted to avail.

There is then a point in relation to contributions. If a person has to pay a certain number of contributions—16, 17 or 18 contributions— and he has not paid them and falls ill, what kind of service will you give him? Will you give him any kind of service? You obviously cannot let such people into the scheme because, if you do, they will not pay their contributions any more. If they can get the scheme without paying contributions, then they will not pay contributions. What scheme then will you give such people? What kind of service will you provide for them? Will you provide a less satisfactory service, because they have not paid their contributions? Will you provide a less efficient service? Assume you have an improvident man with a family who does not keep up his contributions and takes no interest in the scheme at all, will you victimise his children by subjecting them to a lower standard of health service when they fall ill because of their parent's disinterest? Surely that is in principle unsound ethically.

I have gone into this question of a comprehensive insurance scheme. I have here a commercial insurance scheme which is presumably run as efficiently as private enterprise can run such schemes. Presumably, it offers both the optimum and the maximum benefits it is possible to offer under this type of scheme. There is a note saying that this insurance scheme does not render assistance in respect of (a) maternity treatment; (b) congenital mental deficiency, senility or illnesses in respect of which claims have been paid; (c) dental diagnosis, treatment and dentures; (d) examination of the eyes by an ophthalmic surgeon; (e) any injury or illness caused by or arising out of an accident; (f) any illness, disability or injury self-inflicted or arising out of war, invasion, etc.; (g) cost of medicines and drugs separately charged in private wards, or ordered for private out-patients, or surgical appliances and spectacles; (h) medical cases normally treated by the patient's own doctor, including vaccination, inoculation, and other treatment undertaken as a preventive measure. It would have been easier if they had put in a list of the things they do cover.

It is quite clear that there is a vast sphere of medical treatment and care which cannot and will not be covered by any insurance this Voluntary Health Insurance Board can provide. There are all the other disadvantages to which I have referred—the bad risks, the person in the bad health category, the aged. They cannot cover those people and it would be unfair to ask them to provide cover if the scheme is to be run on an actuarial basis and not as a scheme catering for the overall needs of the individual. But has not the person with the bad medical record a perfect right to any treatment or care he or she may need when he or she falls ill? Who needs such a scheme more? Who needs protection more? The aged will be excluded. Surely the old person is in greatest need of medical care and attention.

I would ask the Minister, when considering the desirability of going ahead with this type of scheme, to bear in mind the fact that he must either ask us to provide such subsidy as to make it an overall scheme in return for contributions within the capacity of the individual to pay or, alternatively, let the board run the scheme without the help of any subvention from the central authority at all. I think that would be the fairest solution of the problem, but I cannot for the life of me see why it is necessary to confuse the already fairly confused health service situation by introducing this voluntary health insurance.

It is not as if we were pioneers in health legislation; we have plenty of examples of how to do this properly at home and abroad, to justify our carrying on with a scheme which we know does work well such as our T.B. or Fever Hospital Scheme or the Maternity Scheme on the free, no means test principle, in a simple uncomplicated way without all the frustrating anomalies to which the blue ticket is subject, and to which the Voluntary Health Scheme will also be subject, if put into operation.

Could I also ask the Minister to consider again the problem of those people admired by him, I think, and by Deputy O'Higgins—the thrifty type of individual, the conscientious parent or father in the middle income group who, through the years, has paid contributions to a group scheme for himself and his family and who, I understand, will no longer be able to contribute to such a scheme. I do not know whether the new idea or proposals will have retrospective effect in the coming year. Will anybody insured at present be forced to give up any insurance scheme in which he is engaged, or will it merely concern those who intend to insure in the years ahead? If the Minister would clarify the position in regard to that point, I should be glad of it. My own feeling is that if there are people who have been far-sighted and enterprising enough to engage in such schemes, their enterprise should be rewarded by allowing them to carry on in a scheme which is as good as, or possibly better than, anything proposed by the new board.

May I recommend one small point to the Minister in relation to a matter raised by Deputy O'Higgins in regard to medical education? Of course it would be a terribly serious thing if what Deputy O'Higgins referred to—and it is possible; I suppose he would know more about it than I do because of his position in recent years—were so, that our medical practitioners were to be excluded in the years ahead from the British hospitals and health services. I understand that there are serious suggestions on those lines. I hope it will be possible for the medical schools to make the necessary alterations in order to comply with the provisions which the British Medical Association has apparently laid down and I hope the Minister will find it possible to help them to do this.

While it is true that we produce far too many doctors in this country, it is, at the same time, very important from the point of view of the young men themselves and also from the point of view of the standard of our medicine generally, that there should be free interchange of medical practitioners as between here and Great Britain and that there should be no curtailment in any way. I wonder would the Minister consider a proposal I once put forward and which did not materialise or mature, in relation to St. Kevin's Hospital. Is there any likelihood that there could be any direct association established between St. Kevin's and the city medical schools? Is there any possibility that a university college hospital could be established, in association between the professors of the universities and St. Kevin's?

St. Kevin's has now become, as I said, a magnificent municipal hospital and a vast amount of clinical knowledge is available there. I think both sides would gain from any amalgamation of interests, if that could be devised. I found it too difficult to do; I found the difficulties insuperable. But the Minister may be able to overcome the difficulties. I think it would be of advantage to St. Kevin's and of great advantage to the medical schools themselves. It would enhance the status of the hospital and provide increased opportunities for students to see more and more of the medical conditions which are to be found in St. Kevin's and would be of great benefit to them as part of their training. I wonder would the Minister consider that idea? He may consider it too thorny a problem, but I think it is something very desirable.

I want to make only one further point in conclusion. The Minister is not responsible for these Estimates, but he will be forming his policy in the years ahead, and I should like him to consider an argument of Deputy O'Higgins which I thought was a good one in regard to the attempt to give a free choice of doctor to all sick people. Deputy O'Higgins is quite right—that is a very important element in creating an equitable and efficient health service from the patients' point of view.

There seems to be some confusion in people's minds on this question of the persistence of people like myself in asking for uniformity of treatment in relation to health services generally. I assume that the Minister for Health was perfectly honest in his contention recently when he said, on the Health and Mental Treatment Bill, 1957, that he did not think a statement of mine was true to the effect that people who do not pay in dispensaries or hospitals are not treated as well as they would be, if they were in a position to pay. It is quite possible for somebody to hold that view, but it is a very undesirable view for a Health Minister to hold, in the light of the tremendous influence which he has in shaping the pattern of our health services.

He must bear with those of us who still hold that there is only one way to achieve equal opportunity and an equal standard of health service all round and that is to organise them as they are organised in our own T.B. services and fever hospital services and as they are organised in Great Britain under the National Health Service so that a person who falls sick has the right to go to a doctor of his own choice and get treatment, with whatever medicine is required until he is well again and that he pays—it is worth emphasising that he pays—in-directly through taxation. I emphasise the point that he pays, that everybody pays, because it is suggested that one of the undesirable aspects of this so-called free health service is that people do not like others to get something for nothing.

I have never understood why this has related only to health services. It does not appear to relate to children's allowances, to housing grants, fertiliser or lime grants, land rehabilitation grants or to free primary schooling. They are all permissible, but why is there a ban on carrying out exactly the same principle in relation to our health services?

Of course, everybody pays for these things to the extent of which he is capable in the form of taxation. Everybody contributes to the Central Fund and that is disbursed by the Minister to pay for health services provided in different ways. I do not think it is a valid contention that people get something for nothing and that their attitude in this respect is undesirable. If it is undesirable in health why is it not undesirable in all the other aspects of our life in which we observe exactly the same principle?

Equally, I have never heard any medical argument put forward against the free no means test principle in the provision of health services. If there are any such arguments, I should like to hear them. Indeed all the arguments are on the other side. All the arguments were made last night by the Minister when he read out the statistics in relation to the tuberculosis scheme in which it has been fairly demonstrated that it is possible to use this free no means test principle and provide a highly efficient health service. There are no medical arguments against it. We have seen the British health service in operation. The patients are satisfied with it. The doctors, while they have occasional financial objections—and I think it would be agreed that it is the right of any professional union to question the amount of money its members are paid —have no other objections to the principle of running a scheme on this basis.

The principle is accepted in the case of our mother and infant scheme, our tuberculosis and fever schemes. It seems to me there can be no other valid arguments. Many obscure and curious arguments have been put forward in the last five, six, seven or eight years, but it seems to me they are blown sky high by the very fact that this principle exists already throughout our legislation in the provision by the State for the community in relation to all aspects of our life and, in particular, to our health services.

There are no medical arguments against it. There are no professional or medical ethical arguments against it. There are no statistical arguments against it. There are no what you might call behind-closed-doors arguments that could stand any examination, as far as I can see, against it. Why then is it that where it is a question of saving lives, preventing preventable pain and avoiding the hardship that illness brings to any family, we do not use the method readiest to our hand as shown to us in the different schemes which we have operating already?

It has been suggested that there is no difference between the two types of scheme, the scheme where the person pays and the scheme where the person does not pay. If that is a true argument then there can be no justification for my persistent attitude over the years. There can be little justification, possibly, for the tremendous expense of introducing the British National Health Service. But I contend it is not a valid argument and it is not in accordance with the facts. To support that point of view, I should like to give a couple of quotations which show that there is an important and significant difference between the standard of care and treatment given to different people, a higher standard to those who pay, and a less high standard of service to those who do not pay.

There is an article here by Fr. Coyne in the March, 1953, issue of Studies, the Irish Quarterly Review, in which he deals in great detail with the 1952 Health Bill. I hope I am not in any way misinterpreting what he says. I would not wish to do that in the slightest. This is merely a statement which he conscientiously holds and seems to believe. He is perfectly welcome to hold that point of view and I am not quarrelling with it at all in that regard. I am merely quoting the attitude of one intelligent, highly-educated individual who has considered this matter in very great detail and who says this at page 7 of this publication:—

"Will the type of hospital or nursing home service for mothers be uniform all through where the service is free? There is a type of service that women of this middle income group and still more those in higher income groups, desire and have been accustomed to."

He talks about private rooms, special nurses, a different type of cooking and general amenities:—

"Presumably these will not be supplied free to mothers in the middle income group."

I think he is quite right. I believe there is a quite different standard of service available to those who pay. I am not attempting to controvert that in any way but I do say that it helps to show that at least one person who has given a lot of thought to this matter does share my point of view that there are different standards for those who pay and those who do not.

Again, it is only one aspect of the problem, but I would refer the Minister to his own statement about the means test in relation to the middle income group person. I do not know what word he used—"inquisition", or some such word. However, the general impression given by the Minister was that he recognised that means test medicine had an undesirable content, that it did bring some degree of humiliation or degradation on the person who availed of it. It seems to me that that is a reasonable interpretation of his suggestion that a means test is something which an ordinary person who could avoid it would not undergo.

There is another witness in this regard, a particularly valuable witness and a particularly competent witness, a man of very great and wide experience in this question of health services, particularly in relation to the city, that is, the former Senator Professor Dr. Cunningham who, in the debate in the Seanad on the Health Bill, 1952, as reported at column 1074, Volume 42 of the Official Report, said:—

"The whole theme in this Bill has been a levelling down of services. What is being offered to everybody is the out-patient department of the hospitals and the public wards of the hospitals; in other words, the type of service which is given to poor people..."

Again, he is quite right—the service that is given to poor people—and he was objecting to what he called the levelling down of the service for the middle income group to the level which he saw all round him. He is a man of considerable experience and wide knowledge. I know him to be right. I agree with him. He knew well the service that was being provided in the out-patients' departments, in the dispensaries and in the public wards of our hospitals.

Dr. Cunningham was in no way anxious, I have no doubt, to help my case. At the same time, that was a frank admission of the fact which seems to me to leave little doubt, if there is any real doubt in view of the evidence of our own eyes, that there is a considerable disparity between the standard of care given to the poor and to those who can afford to pay.

The simplest test is this: if you really believe that there is no difference between the non-paying and the paying patient, will those who hold that view tell me that when they next fall ill—I hope that will be very long delayed— they will go to a dispensary and queue in the dispensary or the out-patients' department, or will they find their way into the public ward of a public hospital in the ordinary way, or will they go to a nursing home or get a private bed in a private ward or semi-private ward, or go to the doctor's consulting rooms? Which do they intend to do and why do they intend to do it?

It is about time that we ended this double thinking in this country in relation to our people. I cannot see any difference at all between one man and another when he gets sick. If he is sick, he should get the best possible care that medical science can provide. There should be no discrimination between the wealthy and the not so wealthy and the poor. The community has a responsibility to provide from its resources to ensure that this equally high standard of care shall be made available to all. We know that this standard is not being made available to all at present. I have shown that it is not made available to all and it cannot be made available equally to all of our people until we get to the stage of accepting the principles of the 1947 Health Act, which have not been bettered since and I think you would have to go a long way to better those principles, that is, the free, no means test principle of treatment and care in our general practitioner service, in our hospital services and in the whole gamut of services for sick people in the community as a whole.

I would be happier if Deputies were honest about this question, if we could get rid of the many red herrings that have been introduced over the years by the profession, by the politicians and by other sections of our society, in order to deprive our people of what is their just right. I believe also that the medical profession would gain from proper rationalisation of our health services. I believe, indeed, that the majority of general practitioners would be delighted to be in a comparable position with their fellow practitioners in Great Britain, where they would have some sort of assured income, where they would be in a position to engage in group practice, if they wanted to, which would give them an opportunity to take holidays, to go on study leave, to fall sick without feeling that their practice was disappearing.

There is no trade union which would tolerate the conditions of work which an unfortunate general practitioner has to endure, the 24 hours a day, seven days a week, 365 days in the year, which the majority have to put in because of the absurd medical system which is in operation in this country at the moment. There are tired overworked doctors, with no security of tenure, who have to face difficulties when they fall ill and lack peace of mind, if they go on holidays. The patient loses and the doctor loses by our present health scheme.

Any objections to that proposition, of course, come from a very limited, small, extremely wealthy group of specialists who, in the ordinary way of democratic centralisation which they operate, control what is a so-called democratic organisation. I would prefer that Deputies who oppose equal opportunity in our health services should say that they oppose it for the simple reason that they will not pay, that they do not want to pay, that if they can prevent illness, disease, pain and sickness, they will not do it, if it costs them too much or if they have to pay for it. Let them be open and honest. Let us have an end to the humbug of these digressional arguments that are introduced in order to try to pretend that we are not like the rest of men, that we are more Christian than our neighbours who have provided what I believe is the ideal in Christian medical services. I would prefer if the plain blunt argument were put to me: "We think we can reduce the death rate; we think we can reduce the disease rate; but we will not do it because we will not ask the people to pay the taxes or the rates which we feel it would mean."

I would say this for the people that if one were to go to them now and say: "We can take away the free services— and they are costing you a lot—and we can give you back the money that you are paying in taxes and rates for those services," I do not think that they would thank you for that. I hope I do not misjudge our people; I should be sorry to think I was doing so. I think they are proud of the fact that they have provided these excellent health services; I think they are proud of the fact they made it possible for the Minister—and it is their money made it possible for the Minister—to come in here and claim the magnificent figures which he claimed last night. This is a tribute to the generosity of the people. I feel they are just as generous as the people of the Six Counties and of Great Britain, and if asked to make sacrifices in the name of the sick people, the people in pain and suffering, the people who may die from preventable disease, I feel they would do it gladly, and I would be very surprised indeed if they would not.

I hope the Minister will bear in mind some of the points I have made or will try to recall the great ideals which it was clear he and those of his colleagues in Fianna Fáil must have had in 1947 when they introduced the magnificent health charter of 1947, the Health Act. It was greatly needed and it has done wonderful work, but its major work has been due to the fact that it has made it possible for the medical profession generally and the nursing profession generally to seek out, to find and to treat without any difficulty the diseases which had affected our people, particularly tuberculosis and the fevers of one kind or another.

Mr. Carty

Many Deputies are also members of local health authorities and, as a result, get a fairly good knowledge of the health services and the operation of the Health Act. One of the most important features of the Health Act was the establishment of consultative health committees in each area to advise the local authority on the operation of the services. By regulation, the Minister decided upon the people who were to have representation on these committees. I think it would be very wise if the new Minister were to widen the representation on such a committee by allowing for representation of dentists, nurses and chemists.

Members of these ancillary medical services rather resent the fact that they have been excluded. Of course a reply I am sure the Minister or his officials will make is that they are not excluded, that members of the local authority may resign in their favour; but I think the Minister should make it a statutory obligation on the health authorities to allow these people representation. I know in my own area that the dentists, nurses and chemists claim, and rightly claim, they should be represented on the consultative health committee.

I understand that this committee was set up to advise the local authority on the operation of the health services. An extraordinary situation has arisen in County Galway. Our county manager, when given advice by members of our health authority with which he does not agree, has threatened to leave the meeting of the consultative health committee. He did that on Saturday last when every single member of the committee, as it is constituted, gave him specific advice with which he could not agree. I do not know whether or not he was within his rights in deciding he would not stay on at the meeting, but I think that point should be clarified by the Minister. If the county manager is to be advised, he must listen to those who have been deputed by statutory instrument to advise him; and if the advice is not the advice he was expecting, at least he should be forced to remain and listen to it.

Mr. McQuillan

Suspend him.

Mr. Carty

Because of our membership of the consultative health committee, many of us have acquired a certain knowledge of the health services. There is one service that is gravely perturbing the people in my county. It is the application of the regulations with regard to the disabled persons' maintenance allowance. That allowance is usually called the disability allowance. In my county, we feel that neither the Minister nor the Department has the right to invest our county medical officer of health with absolute infallibility in medical matters so that he can decide whether or not a man is substantially handicapped, in the teeth of advice given to him by competent and eminent medical specialists.

This has led to a High Court case and the High Court judgment has cost Galway County Council nearly £800. I do not think that either the Minister for Health at the time, whoever he was, or his advisers, ever contemplated that one man should have absolute medical infallibility and decide on his own opinion whether an applicant was substantially handicapped or not for the purpose of granting or withholding a disability allowance.

I may tell Deputies that Mr. Justice Davitt, when he gave judgment in the High Court, commented on the fact that county medical officers of health, by reason of the office they hold, have very little knowledge of clinical medicine and very little experience of dealing with patients in the ordinary sense of the word. I appeal to the Minister to review the regulations with regard to these allowances, to set up some kind of appeal machinery and to afford some protection to people, other than the High Court, against the tyranny of these autocratic administrators, whether they be medical or lay.

Another matter which has concerned us in my county is the failure of the county manager to give effect to a recommendation of the Minister's predecessor. He recommended, and, I think, rightly, that those who were in receipt of the maximum old age pension and the widow's non-controbutory pension should be entitled automatically to free institutional treatment. Deputy O'Higgins, when Minister for Health, addressed a meeting of the Galway County Council and of doctors in the county on the health services, shortly after the Health Act came into operation. In reply to a question put by me, he said that he had made that recommendation and that he had sent a circular to all health authorities. The Galway county manager, for reasons best known to himself, refused to carry out that recommendation. The county council directed him by an ordinary resolution to give effect to the recommendation, but he stated that he would not do so.

Subsequently, we summoned a special meeting of the county council and directed him under the County Management Act to give effect to the Minister's recommendation. Every member of the council voted for the resolution. No later than last Saturday, a member of the Galway County Council showed me a hospital bill which had been served on an old age pensioner. I do not know the law with regard to this, but I think if a county manager refuses to give effect to a resolution of his county council, which is right and proper, that the county manager should be suspended. It is the Minister's wish and the unanimous wish of the local authority of which I am a member that old age pensioners and widows in receipt of the maximum allowances should be entitled to these free institutional services.

As the House is aware, before full pensions are granted, a trained investigator from the Department of Social Welfare visits the applicant. He has authority to inspect premises and property and, I think, to inquire minutely into the financial status of the applicant. When that trained investigator decides that a person is entitled to the maximum old age pension or the maximum widow's noncontributory pension, is it not very stupid to send out a home assistance officer, who is well qualified for his own job but who cannot claim to be a trained investigator like a civil servant from the Department of Social Welfare, to reassess the means of an applicant and to decide whether or not he or she is able to pay a hospital bill. I ask the Minister to have that matter looked into.

We have in our county very fine hospitals and excellent services, but there is just one fault that I find with them. When the Department of Health and its advisers decided to build these hospitals, they should have had some idea of the expense involved. We have an excellent regional hospital, but many people comment on the fact that it is too grandiose and more than the people can afford and they point to institutions in other parts of the country built by medical and nursing orders at a lower cost. In my opinion, our regional sanatorium was very badly designed because buildings are scattered all over the place and the nurses rightly complained that they could not operate a cafeteria system because these units where they work are scattered over 15 or 20 acres.

I would appeal to the Minister, if he has to commit himself to any future hospital building programme, not to be guided or unduly influenced by these advisers or architects who take no account of cost or how long the sanatoria will be used as such. As everybody knows, thank God, tuberculosis, thanks to medical science, is on the way out and I hope that it will be possible to convert these sanatoria for the treatment of diseases other than tuberculosis for which they were originally designed. Looking at those buildings and the way they were originally planned, it is very difficult now to understand to what use they can be converted.

In the very fine Merlin Park institution, they have about 12 or 14 units. Each unit has an Aga cooker which is never used because there is a central kitchen which serves the whole hospital. It is very hard to understand why there should be an Aga cooker going full blast to keep a couple of kettles on the boil, having regard to the high cost of fuel and the high cost of installing these cookers. People ask themselves have the architects and specialists who advised the Minister any regard at all for reality when they plan in that fashion.

I am delighted that a man like the present Minister, who is a realist, is now in charge of the Department of Health. He is a man who will keep an eye on these things and who from his vast experience in the Department of Finance and other Departments will realise that people who give him advice should be checked and counter-checked so that the conditions which have obtained in regard to hospital planning and design will not be allowed to continue in the future in further hospital building schemes.

I would also like to ask the Minister to investigate the right of a county manager to direct patients to particular hospitals. In my county, we have a regional hospital and another hospital in the east of the county which has made arrangements with the health authority. The Galway county manager has taken it upon himself to direct doctors in certain areas to send patients to certain hospitals against the wishes of the patient and against the wishes of the doctor. It should be left to the doctor to decide what hospital can best cater for the ailment of his patient and not to the county manager. It is a rather extraordinary state of affairs and one that has caused much comment.

I have always regarded the medical officer of health, the general practitioner, as the most important man in the health services. He is the only one who stands between the patient and the local authority. He is more often than not the friend and counsellor of the patient and if he is to be directed as to what he is to do with his patient or where he is to send him, then I am afraid the fine relationship that has existed between doctors and patients in this country will be greatly impaired, much to the detriment of the patient.

I have particular knowledge of the school medical service, as I am a teacher, and I ask the Minister to make some radical change in that service. He should place the school medical service under the care of the local medical officer of health and not under the county medical officer of health or his assistants. Who knows more about the patients in his area and their children than their family doctor? The Department of Health and the Minister can advance the argument that the local doctor cannot arrange to visit a school on a particular date because he might be called away. But he is entrusted with the immunisation scheme and the vaccination scheme and all the other schemes operated by the local authority and if he is considered good enough to carry out these, why should he not be good enough to visit the school and carry out the medical examinations?

The medical examination, as we know, is carried out yearly as a result of the 1953 Act. New entrants to the school must be examined before the end of the school year, but what about the children who have not been examined for three years previously? Who will see that any of the defects that have cropped up in the meantime will be remedied? How can you claim to have a school medical service when children are seen by a doctor only once every three years? Is it the duty of the teacher to notify the county medical officer of health that one child appears to have defective vision and another child has something else wrong with it? If it was arranged that the local doctor would visit the school periodically, once every six months or once every year, it would be a far better system and a less costly one.

In my county, a great number of the schools are up to 50 miles from Galway. As far as I can see, a lot of the doctor's time is taken up with travelling from Galway to the school itself. Generally a doctor does not arrive at the school before 11 o'clock and he has to go again at 3 o'clock.

The defects I have mentioned in relation to the school medical service are also relevant to the dental services. I have to laugh when I hear people claiming that we have a school dental service. I think most of the teacher Deputies in the House are familiar with the pattern. The school dentist arrives at a school once every three years or so and the children know what is going to take place. No teeth will be filled, but a lot of teeth will be extracted and the younger children dread the visit of the school dentist. I am not alleging that the dentists are incompetent, but by virtue of the fact that they have to devote most of their time to extracting teeth rather than doing preservation work, there is established in the children of Ireland to-day a dread of dentists that lasts through their whole lives.

This once in three years visit of the school dentist is not a dental service at all, nor is it any substitute for a school dental service. I know the Minister has decided that priority must be given to the school dental service and I agree wholeheartedly with that, if it is found not possible to extend the service to the lower income group or middle income group for financial reasons. If it has been decided to concentrate on the schools, the Minister should consider giving a proper service to the school children. If necessary, the services of local dentists should be employed and an arrangement made with them whereby a child can go into the local dentist's congenial and comfortable surgery and have done whatever work is deemed necessary. This would be better than having the work carried out sometimes in a cold school and often in the hearing of other children, of little tots. I have seen the school grounds and the schoolroom covered with blood which has a serious effect on the minds of young impressionable children.

I respectfully ask the Minister to attack this matter now and save the local authorities the expense of supplying expensive dentures later on by having the preservation work done now and teeth filled as required. If proper dental services are carried out in the schools, the local authorities and the Exchequer will be relieved of large expenditure in later years.

I must refer to another matter that has cropped up in my county. It is the supply of surgical and orthopaedic appliances. I was listening to Deputy Dr. Browne some time ago when he maintained that different standards of service obtain for people who are unable to pay and for those who are able to pay. From my experience of the supply of surgical and orthopaedic appliances in my county, I believe that what Deputy Dr. Browne said is a fact. I am not exaggerating when I say this, and I can give the names to the Minister or his Department of people who have been examined and certified for surgical and orthopaedic appliances, such as limbs, and who had to wait in my county for periods in excess of two years. Why? Because they were in the dispensary class and I make that statement advisedly, because if they were able to pay, they would have been supplied with these appliances.

That is a very serious allegation to make, but I am prepared to substantiate it. I know a girl working in my town who was examined for an artificial limb. She had to give up her work and go into the county home in Loughrea and await the arrival of the limb. She was 486 days there and still the appliance has not arrived and the local authority is responsible for the cost of her maintenance in St. Brendan's Home at Loughrea at a cost of about £2 a week. She lost her job also and, all in all, the cost amounted to something about £220 and when that is added to whatever the actual cost of the artificial limb will be, I put it to the House that it will be a very dear limb.

There is another case. I know of a man who applied for an artificial limb and he was two years and three months waiting for it. When he made his application for the artificial limb, he also applied for a disability allowance. The county medical officer of health stated that if this man had a proper artificial limb, he would not be substantially handicapped. The limb arrived after a period of two years and three months. The man was advised that he should then make retrospective application for the disability allowance to the local health authority because of its failure to supply him with the leg. The local authority will pay him and will have to pay him.

These are matters which the Minister for Health and the Department should investigate with a view to having them remedied. In my county, we have had at our consultative health committee meetings many complaints about drugs, In the first place, it has been complained that there is a delay in supplying the drugs and then there is the more serious complaint which was made by a doctor, that very often the drugs were of inferior quality and not up to B.P. standards.

I have seen a demonstration myself and nothing is more effective than an actual demonstration of these things. A doctor came into our meeting with a pill that was supplied to dispensary patients or to the holders of medical cards. The pill was supposed to dissolve in water in fifteen minutes. The doctor had a glass containing water and the pill in question. He assured us the pill had been in the water over a fortnight and that, as yet, there was no sign of its dissolving. The doctor stated he believed the drugs supplied through the combined purchasing section were inferior to those that could be obtained in the local chemist's shop. He made that allegation seriously. I understand that some of the drugs in question were sent for analysis by the public analyst.

I am glad to see that in this year's Estimate the Minister has provided for the expenditure of more money on county homes. The care of the aged sick should not be neglected. Money should be spent and is being spent on big improvements in our county homes and I hope the Minister will be able to continue that good work. I have not the Book of Estimates before me, but I think the figure has gone up from £5,000 to £7,500. Any money spent on these homes is money well spent. In my county, very fine work has been done on improving the amenities of our county home, on making it a better and a more pleasant place for the aged who spend the last years of their lives there.

Last night, Deputy T.F. O'Higgins referred to medical education. That question has been agitating our minds on the county council for the past 18 months, by virtue of the fact that we must ensure that we keep the services in the regional hospital which is a teaching hospital, up to standard. The previous Minister made us see things according to his light by sending us down a sealed Order. I hope the necessity will not arise for the present Minister to indulge in the same tactics. If the Department can work in harmony with a local authority, it should strive to do so, rather than antagonise the members of the local authority by sending down sealed Orders to do something which the local authority think should not be done.

My council has always been eager and willing to preserve the link that existed between our regional hospital and the university, but we deplore and will deplore any highhanded action taken by any Minister or the Department of Health. The sealed Orders of the former Minister were particularly repugnant to us, because, at the time the sealed Order was sent down to us, the Minister's colleague, the Minister for Local Government, was making a grand tour of the country promising us that democracy was around the corner and that the county manager would be curbed in his powers and functions. He assured us that no office would be created except by the members of the local authority; it was a reserved function of the members of the local authority. Hard on his heels came the sealed Order of his colleague, the Minister for Health. I hope the harmony and good relations which have always existed between the Minister for Health, the Department and the council in my county will continue.

Mr. Kyne

Naturally, when we speak on the Health Estimate, I, as a Labour representative, have to deal in the main with the 1953 Health Act as one of the important Acts. That Act contained many good features. It has served a very useful purpose but certain flaws, which I think can be mended by regulations, are developing or have developed.

An Leas-Cheann Comhairle

I am afraid the Deputy cannot discuss the merits of the Act. He can refer to administration.

Mr. Kyne

It is the administration I have in mind. The last speaker put his finger on one of the flaws in the Act and advocated a change in it. I had that point down, but I realised that a change would involve legislation and so I decided not to go ahead. However, county managers have the right to decide on medical cards. Normally, and rightly so, I suppose, they fix a certain income level from all sources in the family that comes within the Act. That is all right should the breadwinner, the person who is the main source of income, remain well. Should he, however, become ill, the income level which formerly deprived him of a card automatically drops and, instead of being in receipt of £7 or £8 a week while he is ill, he must depend on National Health Insurance. Automatically, that puts him below the income level which, if he had been on it prior to his illness, would have entitled him to the medical card.

Some Cork Deputies, speaking on the Health and Mental Treatment Bill, said that, in County Cork, that is adjusted the following week. That is certainly not the case in my constituency. Once you get ill, if you have not got a medical card, you have to pay for whatever treatment you get from whatever doctor you employ and for whatever medicines you need. Some adjustment should be made if either the breadwinner himself or somebody who is bringing in an income becomes ill. It is all right, I suppose, if one of his children gets ill who is not providing an income, but if it is someone who contributes to the house and if his wages drop to such an extent that it interferes with the amount of money they would normally have, then I suggest the case should be revised on the second week of illness. If the Minister would recommend such action to county managers, it might be of assistance.

There is one point in relation to administration where the Minister could help. It concerns the hours worked by attendants in our county hospitals and homes. Unlike the nurses, these attendants have to work for as long as 60 and 70 hours per week. They do not get any recognised period of time even for meals. I feel it is scandalous in this year of the Lord that local authorities should expect of and demand from their servants such periods of employment as 60 and 70 hours per week.

In my constituency, we have made representations to the county manager that that system should be changed and that the attendant should enjoy the same working hours as nurses, that is, a 48-hour week. We even had an inspector from the Department of Health down to arbitrate between the county manager and the trade union involved. Notwithstanding his intervention and the application of the union, I regret to say that we have got very little satisfaction. In fact, a recommendation made by the county manager to employ extra attendants so as to permit a period of 48 hours per week being worked was turned down by the Minister's Department. I would suggest that a 48-hour week should be sanctioned by the Minister in all our county hospitals and county homes.

There is another matter in which I am interested, that is, the difficulty of getting admission to suitable hospitals or homes for mentally deficient children. Whether or not the same difficulties exist in all the counties as exist in Waterford, I do not know. It has come to my knowledge that very often periods of from six to eight years have to be waited before places can be found in homes for mentally deficient children. Something should be done to change that position.

It is often absolutely essential that these children should be sent away to be trained at as early a date as possible. Both in their own interests and in the interests of the parents and the other children in the house, these mentally deficient children should be segregated from the normally balanced children so that too great an attachment will not grow up and so that when separation has to come later it will not have an effect both on the mentally deficient child and the other children.

That is pretty well all I have to say on this Estimate, except one or two things with particular emphasis in regard to County Waterford. One of these matters concerns the dental service as carried out under the Health Act. While we have some 500 people who got their teeth extracted under the Health Act, we are unable to get permission from the Department to employ, even on a temporary basis, a part-time dentist for one year. It is shocking that 500 people will probably have to remain for the rest of their lives without any dentures because of the fact that some economies have to be made in a Department. It is not the particular Minister who is in office at present who made that decision. It was made by the previous Minister and was endorsed. I disagreed with the former Minister and I disagree with the present decision. While economies must be made—and that is quite understandable—it is only reasonable to say that those whose teeth were extracted on promise of replacement should be entitled to these replacements. If economies have to be made, let it be clearly made known beforehand that if you do avail of these medical services, you avail of them at the risk of never getting any dentures supplied by any board at all. I ask the Minister to give his earnest consideration to the question of giving temporary sanction to enable the waiting list of 500 people to be caught up with. From that on, we would be satisfied to have teeth extracted on the understanding that it might be in years to come that any dentures would be supplied.

Mr. Manley

The Minister, when introducing his Estimate, gave us some very interesting information and the figures he quoted are well worth recording because they dispel many of our misgivings about the health services.

We are all edified to hear that there was a significant drop in infant mortality in recent years. We are equally edified to hear that our birth rate and our natural increase in population here is higher than in Great Britain. That is some compensation for our losses through emigration. We were also very pleased to learn from the Minister that there was a drop of approximately 25 per cent. in the numbers notified as suffering from tuberculosis in the past six years. Whoever contributed to that success are to be congratulated and it is some compensation for those who worked so zealously to achieve these results.

Nevertheless, the Minister mentioned with a certain amount of misgiving the fact that he is seeking approximately £16,500,000 for health services in respect of this financial year. He posed the question, which it is natural for anybody to pose: Are we getting the proper results from that vast expenditure? Let us go further and ask: Can we continue to meet that vast commitment in this small island of ours, with our limited resources?

Personally, I think that we have made a fetish of health in recent years. We all realise the health services are necessary, but, in our anxiety to provide these health services, have we lost sight of the basic factors that go to ensure good health? I think that a good house and remunerative employment for the breadwinner in that house are the prerequisites of good health in any ordered State. Had we these, the other benefits would follow in course of time. Any money that we could have spared over the years should have been devoted to these two fundamental matters.

Again, while we talk about hospital-isation and health services, we lack knowledge on the question of foods. Personally, I think our lack of knowledge is appalling. We have no idea at all of the value of foods or of the constituents necessary for the building up of our bodies. Science has now taught that scientific feeding for animals is indispensable to a vigorous growth and the development of bone and health in the animal world. I doubt if we, too, should not have a balanced diet. While we have no conventional meals of any kind and while we have variety in our foods, I wonder if we consume the food necessary to build up bone and muscle. These are factors which would counteract a tendency towards disease. History records that we were a very healthy race up to the time of the Famine, but because of the ill-nourishment in the Famine days, the health of our people began to deteriorate. I do not know if we are any worse than any other nation, but we would like to maintain our traditional standards in that respect.

I wonder if we have had any research at all on the cause of premature dental decay. I had recently contact for some weeks with a clerical student from Spain, who was here doing a course. I could not help admiring his magnificent teeth—they were just perfect. He never had a filling of any kind, or an extraction. He told me that in Spain and in the adjacent countries they have very little dental trouble. Theorists tell us that dental decay is traceable to our over-consumption of soft food or cooked food. I do not know whether that is correct or not, but surely something could be done to provide some check on the premature dental decay which is so very common amongst our people, especially amongst our young people. It is a national loss to our people to have to suffer these disadvantages. I put it to the Minister that he should advocate some research in that respect.

The Minister is to-day in a position to propagate a doctrine for the health of our people in a vigorous way, that is, to lay emphasis on the consumption of milk. Milk, we are told, is the greatest food of all. It is the product of our own cattle, from our own soil. Increased consumption of milk would have a double advantage. Now that we are faced with a surplus of milk, it would be one way of disposing of that surplus. In the last analysis, it is the cheapest food of all. Our consumption of milk per head of the population is phenomenally low, which is extraordinary in a milk-producing country like Ireland. Our people waste money on patent foods and foods which have no comparable value with milk. Now is the opportune time, when faced with this situation, to make our people realise that there is no better food than milk. It can be supplied now in the purest and most uncontaminated form.

The question of drugs, which was raised during this debate, was very forcibly brought home to me when I visited a friend of mine in his own home. He was being treated by his own doctor. He was not a health patient at all. He showed me on the table in his room a little box of pills costing ten guineas for 50 pills. He took six per day, so that 50 would last a little over a week. There were other bottles of drugs on the table as well. Even a man with the most remunerative or most lucrative source of income cannot now provide himself with these amenities, even if they are indispensable. Drugs which are so indispensable to the preservation of life should be under some sort of international control. I respectfully suggest to the Minister that he take up this question. I do not know how that can be done. Perhaps the Red Cross might be of some help. If these drugs are available for the use of mankind, they should be within the reach of all, so that they would get the necessary drugs in time of illness.

Hospitals have been mentioned here. I disagree entirely with the ex-Minister about the Cork Regional Hospital. I am perfectly convinced and state quite emphatically that it is not necessary. It is 20 years since that hospital was spoken of first. In the interim, the people have got all the hospitalisation they need in Cork City and County. Since that hospital was first spoken of, a new orthopaedic hospital has been erected in Cork City; a very spacious sanatorium has been erected in Glanmire, six miles from Cork; the Erinville hospital in Cork has been extended; at present a maternity wing is being built on the Bon Secours Home in Cork; and minor adjustments are being made in the voluntary hospitals. All that goes to prove that the sick needs of Cork City and County are already very well cared for.

On the question of the voluntary hospitals, we have three of these in Cork. I believe they have given great service over the years. Long before any health services were thought of, those hospitals served a very useful purpose. If they had the fees from every patient who was treated in those hospitals, they would not have to-day to go to any Hospitals Trust Fund for moneys to expand or extend their own hospitals. Some of them are run by voluntary boards and some are under the care of communities. Considering they gave such service in the past and considering that, with little minor extensions now, they would cater assuredly for any emergency which might arise in the sick needs of Cork City and County, it would be nothing but downright discourtesy and gross ingratitude if they were not thought of and if a new regional hospital were erected in Cork in competition with those hospitals, which gave such valuable and faithful service over the years. I hope the Minister will see that those hospitals will be properly thought of in the future.

Even to-day, in this midsummer period, if a survey of the hospital beds were made in Cork, it would reveal that there are beds vacant in every hospital in Cork City at this moment— and not alone in every hospital, but in some of the wards in every hospital. That bed accommodation is never exhausted, except in the depth of winter and then only when there are minor epidemics in the respective localities.

The Minister did not mention anything about the Voluntary Health Insurance scheme. I hope that, in winding up, he will refer to it. Deputy Browne—or some other Deputy—mentioned that it was doomed from the start. I feel it was doomed from the start because it did not take precedence of the Health Act which we had in recent years. Had it got a fair chance, I believe it would have succeeded, as benevolent health services through vocational bodies in this country have succeeded.

I was amazed recently in a particular case regarding an organisation here which has its own private health service. It costs nothing to anyone except the participants in that service. For the small sum of £2 3s. a year, when a breadwinner in the family dies the widow is able to get £50 mortality benefit and practically all the cost of a major operation, on that small contribution. There is no service as valuable as a voluntary health service, when done through a vocational group or through organised trade unions. It is a pity we did not rely more on that, before we embarked on this expensive health service we have now.

Deputy Browne mentioned, time and again in his remarks, the British National Health services. It is a pity we do not rely on ourselves. I fail to see why we should ape so slavishly the types of legislation provided in other countries. Have we not enough initiative and genius to work out our own salvation according to our own means? When the health services were first announced in Great Britain the annual cost envisaged was £80,000,000. To-day I believe the cost if £500,000,000 a year. Of course, Great Britain can afford that, but we, in our limited circumstances, cannot. When the Health Act was introduced nobody here foresaw the ultimate cost and I think there is much disappointment to-day in regard to that Act. I am an unrepentant critic of it because I believe it created injustices for the people.

An Leas-Cheann Comhairle

The Deputy may not proceed along those lines.

Mr. Manley

I only mention it because it means possible degradation for our people. Deputy Dr. Browne advocated free health services for all. I think that is quite illogical. How can we have them? How can we pay for them? He mentioned grants of various kinds. We have to bear in mind that State grants are made only to help the economy of the country, only to help persons to build up their individual economies so that ultimately they will be independent.

The question of disability allowances was raised. At the moment county managers have the very unpleasant duty of sitting in judgment on those who apply for these allowances. Nobody likes that and nobody is more upset about it than the city managers and county managers. Many people who suffer from paralysis, particularly from the effects of polio, are not qualified for allowances. I know a man of 35 years of age, the victim of an attack of polio when four years of age. The disease was not known at that time. This man is a complete cripple but, because he lives with his brother who is in fairly good circumstances, he is deprived of an allowance. I think polio victims should be placed in a special category for the purposes of disability allowances.

The Minister is new to his Department. He has a very formidable task. The Department of Health is one which has been severely criticised over the years. It was, accordingly, refreshing to listen to the debate and to appreciate the calm tenor of the discussion and the objective way the points were put. We should all be very pleased with that. I wish the Minister every success in his new office. I believe he knows that the more care and the more reserve he shows the greater will be the success and the better will be the results he will achieve during his term of office.

Mr. Corry

I am afraid I do not know how to deal with the statement made by Deputy Manley in connection with the hospital position in Cork. I do not know whether Deputy Manley has the same access to the people of his constituuency as I have in mine. I would be slow to think that he has not, but I should like to let him know that at the present moment it is impossible to get a bed in St. Finbarr's Hospital.

Mr. Manley

I did not deal at all with St. Finbarr's.

Mr. Corry

I can say as much about the others. I handed to the Minister a hospital bill while we were discussing a Bill amending the Health Act. I do not know what his findings were on this question of hospital charges. At some of the hospitals to which Deputy Manley has referred you are told there are no beds except in semi-private wards. If you agree to go into one of these wards you enable the hospital authorities to tack on to you the type of bill I gave the Minister when I cited the case of an unfortunate widow with 25 acres of land. She was sent a hospital bill for £77, £25 of which was paid by the health authority. She was faced with a bill for £52. Of course that woman had never seen £52 together in her life.

I had to remain in Cork yesterday for the purpose of endeavouring to get from the tuberculosis committee accommodation for patients in the Orthopaedic Hospital. We have 400 such patients on a waiting list and we succeeded in relieving the pressure only slightly. Looking at the Estimate for the Department of Defence, I noticed a figure of £105,000 for the payment of 112 doctors and 100 nurses to look after 11,000 men.

An Leas-Cheann Comhairle

That would be a matter for the Minister for Defence. It could have been raised during the debate on that Estimate.

Mr. Corry

The point I am bringing to the notice of the Minister for Health is that those men have also got medical cards and are entitled to the health services available outside the Army. I do not believe there should be such a duplication of services—that those 11,000 men should be thrown as a burden again on the ratepayers and taxpayers of this country. I am asking the Minister to look into this matter. One of the two Estimates must be wrong. If we are paying doctors to look after Army personnel, we should not have the added burden of providing for those men in our ordinary health services.

An Leas-Cheann Comhairle

The question still seems to be a matter for the Minister for Defence.

Mr. Corry

It is a matter for the Minister for Health to see that this duplication of services is not carried on.

An Leas-Cheann Comhairle

The Deputy might come back to the Estimate under discussion.

Mr. Corry

I have before me a notification in regard to the dispensary site in the South Cork Board of Assistance area. It seems now that every dispensary site taken over by the South Cork Board of Public Assistance since 1953 was illegally taken over. The South Cork Board of Assistance is an autonomous body made up of members of the Cork County Council and the Cork Corporation. If that joint body want to get a site to build a dispensary they must go to the county council and the corporation who must get the site. All the sites that were taken over in the past were illegally acquired. That is the information I have here from our county solicitor, Mr. John Carr.

We had in South Cork area a considerable number of dispensaries that were outdated and we have been endeavouring for the past ten or 12 years to get from the Department some ruling on this so that we could go ahead. We were told that they were regrouping the dispensary areas. That caused a delay of three or four years. Anyway the position is that somebody else must look for the site for us and the board of assistance can then operat as the agent for the health authority. I say that is bringing bureaucracy a little bit too far. Three men are doing the work of one in every Department and under every instruction sent down by each Department of State to the local authorities.

First of all the board of assistance must decide on a suitable site. Their secretary must then write to the secretary of the county council and the corporation. Following that, either singly or jointly, we go to see whether the site is suitable and then somebody is bound to condemn it. That is the manner in which time, labour and money are wasted under one heading alone.

In looking over this Estimate I find there is a provision of £7,000 for local authorities in respect of the improvement of county homes, and for the provision of alternative accommodation for certain classes hitherto maintained therein. If the Minister expects to cover that item with £7,000, I can tell him that he could give us ten times that amount in Cork and it would not do. We have endeavoured for a long time in Cork to get suitable places to which we could send those aged and infirm. We picked out the Kinsale Hospital which was under our control. We went down ourselves with our engineer, inspected it and found it a suitable place. The brass hats from the Department of Health then came down and said it would not do, that we would have to build a new one. We went down to Youghal, where there is the fine bracing air of a seaside resort. The brass hats again came down and said that would not do either.

We have frequent visits from officials of the Minister's Department. We have always found them courteous. They are all right until they get back to the Department and then the old story starts. This change and that change has to be made and that goes on for about 12 months with nothing being done. If we could get the aged and infirm removed from St. Finbarr's Hospital in Cork and the premises that is occupied by these people reconstructed a little, which would not cost so much, we would not want any regional hospital in Cork. Thanks to the generosity of Deputy Dr. Browne we had a guarantee of £2,000,000 for that hospital. The building of this regional hospital has been under consideration for about 25 years. In 1948 Deputy Dr. Browne met the county manager and myself as chairman of the board. We got a guarantee for the cash and that is a very treasured document. I think we nearly framed it.

Mr. T.F. O'Higgins

You should cash it.

Mr. MacEntee

I am afraid it will not be met.

Mr. Corry

The only people who have succeeded in drawing any money from the regional hospital scheme are those who drew up the plans. I think they have received about £50,000. Many plans were discussed. At various times we got a message from the Department that a new move was being made, and each time it turned out to be a false alarm. Every five years the whole aspect of hospitalisation here is changed. Therefore, the plans which cost about £20,000 are paid for and thrown away and a new plan is produced. At any rate, in respect of Cork regional hospital the designers and the architects have already collected in the neighbourhood of £50,000. That is the only bill against it. Under the former Minister, I think, we got another move on, and we started digging.

I would agree that the regional hospital is not required if common sense is used, but there must be common sense in this matter. It would not cost an enormous amount of money to convert either Kinsale, Youghal or Midleton hospital to hold practically the whole of our aged and infirm people at present in Cork City. I am certain that the whole job would be done in any one of the three for less than £100,000. That would leave St. Finbarr's free to be used as a hospital and treated as a hospital. But every time we endeavoured to do anything in St. Finbarr's during the last 20 years we were immediately told by the Minister's Department: "Stop—the new regional hospital will be going ahead." The £2,000,000 carrot was dangled before our noses whenever we endeavoured to make any improvements which we considered absolutely essential.

The nurses' home, God save the mark, at St. Finbarr's to-day is something into which you would not like to put anybody for whom you had any respect. For the past 12 years we have been endeavouring to get the Department to agree on a nurses' home. On the last occasion on which the officials were down we mentioned the regional hospital and they told us to forget all about it for the next couple of years because there was no money. When we asked for £25,000 or £30,000 out of the £2,250,000 or £2,500,000 that was tied up in regard to the regional hospital, they did not have that either and we do not know where we are.

If the job I suggest were done I believe that for less than £500,000—I would nearly be prepared to settle with the Minister to-morrow for £500,000 of that £2,500,000 that was promised—we would get what we want done in the way it should be done, considering that the palaces that are being built in that line are such that the ratepayers will not be able to keep them going. I hope the Minister realises that.

I want to pay Deputy Dr. Browne this tribute. He did succeed in handling the situation as regards tuberculosis in County Cork. He did a powerful job of work there. He went around, not looking for new hospitals, but he begged from North Cork Board, from the South Cork Board and from the West Cork Board, the hospitals that were lying idle, and he used them before we succeeded in getting St. Stephen's at Glanmire. Tuberculosis is well on the wane so far as Cork County is concerned, thank God. As a matter of fact the position now is that some three months ago we were considering closing down two of the hospitals we had taken over and handing them back to the local authorities. We have handed over the tuberculosis hospital at Doneraile to the Mental Hospital Board and it has room for a couple of hundred patients. Yesterday we agreed to hand over another one. We were able to do all that and still take a number of patients from Limerick in our tuberculosis hospital as it stands at present.

My personal opinion is that there will be several blocks of that hospital idle within the next ten years and that is a shorter period than it would take to build a good regional hospital. Why then come along and build a new regional hospital in Cork at a cost of £2,500,000? Mark you, that estimate is fairly old; I think it is a 1948 estimate, and I do not know how far things have climbed since then. The guarantee given was that it would be built and equipped without one penny cost to the ratepayers. We hold that written guarantee and I think that guarantee would have a pretty good bargaining power with the Department even at present.

I suggest to the Minister that he should send down some of his officials to Cork and let us go into the whole question of the position in Cork County and thrash it out. But before he sends such officials I want a guarantee that something will be done as a result of their visit. I want some guarantee that if we look for money for a nurses' home—his officials know the present condition of the nurses' home at St. Finbarr's and they can come there and go through it again—and if we look for a home for our aged and infirm patients who are at present occupying at least two or three blocks of St. Finbarr's, and seek alternative accommodation for them, we do not want to be told that it cannot be done and that we must build new premises. The times for building new premises here are gone. There is no money. Whatever ha'pennies are left in the Treasury or can be gathered in, have not only been spent but have been pledged by the boys who had a spree over six years. We now have to settle down and see what can be done with the resources we have available.

We have to come to a decision and see how far those resources can be used now, and not in ten or 20 years' time. It is now these things are required. We have spent something over £500,000 on St. Finbarr's over a period of years. It is a first-class hospital, a fine hospital, in many respects. If we could convert the balance of it into a hospital, and it would not cost an enormous sum, the major problem as regards hospitalisation in Cork would be solved. In a very short time, we will have two vacant hospitals, one in Skibbereen and the other in Macroom. These are at present being used for tuberculosis patients. Unfortunately these hospitals are too small for the purpose we had in mind, namely, a home for the aged and infirm. In the three towns I mentioned—Youghal, Midleton and Kinsale—there is plenty of space and there are buildings which could be converted very easily and very cheaply for that purpose.

There is no use in the Department telling me something to the contrary. We have our own engineers and I think as highly of their opinion as I do of anybody else's. The Minister will have a difficult task. I believe he will make a success of it if he can bring his Department to stop thinking in millions and come down to thousands. If he can do that, we shall get somewhere. He must put a stop to this procrastination and see to it that when a local authority makes up its mind that something is required, it will not be put off with a wave of the hand and "Oh yes, that is all right; but we will be putting up a regional hospital". That game is played out. It has been played on the people of Cork for the past 25 years.

One individual benefits. It is not the man wielding the spade or the shovel; it is not the man handling the mortar and the bricks. It is the fellow who draws little lines with a pencil on paper. He gets his haul and, if things go on as they are going at present, he will have three or four more hauls without the day coming any nearer when the people of Cork will have a regional hospital.

I have given the facts as I know them. I should like the Minister to let me know what he has found out in connection with the bill I gave him. When I say that our health services are open to abuse, I could add that these services have, in my opinion, been availed of especially by medical practitioners to draw double pay and double salaries. They are drawing salaries under the Health Act from the local authority, which is reimbursed to the extent of 50 per cent. by the State, and they are drawing again from the unfortunate private patient before he ever gets out the door.

Mr. T.F. O'Higgins

That seems a most uncalled for remark, unless the Deputy is prepared to substantiate it.

Mr. Corry

It is true.

Mr. T.F. O'Higgins

I should be most surprised if it were.

Mr. Corry

The Deputy knows it.

Mr. T.F. O'Higgins

I should be most surprised if it were true.

Mr. Corry

Read the Official Debates of a month ago and the Deputy will see there a bill for surgical services for £33.

Mr. T.F. O'Higgins

The Deputy is referring to a particular case.

Mr. Corry

Thirty-three pounds for surgical services—that was the bill tendered to an unfortunate widow down in Ballymacoda with 25 acres of land, and there was £25 from the taxpayer and the ratepayer, plus 6/- a day. Add it up.

Mr. T.F. O'Higgins

The Deputy made a general observation which did not appear to be well-founded.

Mr. Tierney

As one who is very keen on the operation of the Health Act, I was very pleased to hear earlier speakers state that tuberculosis is almost wiped out. It was pleasant to hear that we are within sight of closing down some of our sanatoria.

Notice taken that 20 Members were not present; House counted, and 20 Members being present,

Mr. Tierney

Recently, I discovered that it costs close on £10 10s. to maintain a patient in a sanatorium. When a patient is discharged, however, the allowance is only £1 10s. per week. One can imagine the position of a discharged patient trying to live on 30/- per week, maintaining himself, paying rent and everything else. Does any Deputy believe that that man can get back his strength to go out and earn a week's wages?

The money spent in sanatorium treatment should be followed up by more generous allowances to ex-patients in the convalescent stage. That is a matter mainly for county councils but when there are members of county councils who, like some Deputies, are not in full agreement with the Health Act and who are not too anxious to grant money for these purposes, the State should step in and provide that people who are discharged from sanatoria should receive sufficient for their maintenance over a certain period so that they may regain their strength and go into the labour market.

As a result of the Health Act, many people, school children and so on are now attending clinics. Increased accommodation has not been provided, with the result that people come long distances by bus and wait all day at the clinics, only to be told to go home and to come back the following week. Facilities should be provided in hospitals to ensure that people will receive attention when they attend.

Prior to the enactment of the Health Act, an insured worker got free hospital service. His insurance paid for his treatment. Under the Health Act, such a worker has to pay £3 10s. per week. The Minister is not responsible for that but I would ask him to look into it very carefully.

Mr. Davern

For a certain number of weeks, he got free service.

Mr. Tierney

Over a long period. Now the treatment is not free for any period. He has to pay £3 10s. a week. I want it to be quite clear that I am not blaming the Minister for that. It is a matter that the House should consider.

I have heard Deputies suggest that there are too many hospitals. I do not subscribe to that view. I remember a time when there were more hospitals in North Tipperary than there are now. There was a hospital in Borrisokane. It is my view that a system of additional cottage hospitals with one or two big hospitals where surgical treatment would be provided would give a better service. In North Tipperary there is a waiting list of 30 to 50 people for Nenagh hospital. It is a new hospital but apparently there was more bed accommodation in the old hospital. Only the most urgent cases have been called in and some patients have been waiting for eight months.

On the question of medical cards, I find that people who, prior to the Health Act coming into operation, received free medical treatment, have to pay the medical doctor. I speak on behalf of people who are not able to pay. I know cases of labourers living in cottages who, because they have sons earning, have been refused medical cards. Possibly the father may be above the age at which he would be entitled to the maximum agricultural rate of wages and the son may not hand up even one-quarter of his earnings but the county managers assess the full rate of wages for the father and the son and the medical card is refused. When these old people fall sick they have no medical card. The doctors, in their generosity, have attended those people but payment is demanded.

As far as workers and small farmers are concerned, the Health Act is not working in the way I anticipated. A small farmer whose valuation is under £50 is supposed to be entitled to free medical service but that is not the case. Farmers whose valuations are £9, £10, £11 and £12 have been refused medical cards and are getting no service whatever except what they can pay for. Deputy Corry stated the case of a poor widow who had to pay £75. There is a case of a farmer in North Tipperary who has to pay £2,500, in respect of his brother, for whom he had no responsibility. I went to the former Minister in regard to that case and was told that the Minister could do nothing about it, that it was a matter for the county manager. Can any Deputy imagine that anyone could be liable, in respect of a member of his family for whom he had no legal responsibility— he may have had a moral liability—to pay hospital expenses amounting to £2,500? The result is that that man is selling his farm and house in order to try to pay that bill.

There is a case of a blind pensioner who is drawing 24/- a week blind pension and who has been refused a medical card. I went to the Minister about that case and was told that there was no appeal from the manager's decision. When this man was very young his father died and willed him a small farm. He lost his sight some years after that. One of the family married into the farm and when the person concerned applied for the blind pension, the maximum pension of 24/- was awarded. When he applied for a medical card the local authorities carried out an investigation and discovered that on paper he was the owner of this small farm and, consequently, was not entitled to a medical card.

I believe that there should be available to Deputies and members of the general public an appeal from a decision of a county manager. There are cases in which a county manager may make a mistake, but members of the House have no right to appeal to the Minister. I think that is bad law. I can assure the Minister that if members had such a right of appeal from a county manager's decision, it would not be abused. I have already given to the previous Minister the cases of the man who has to pay £2,500 and the man with a blind pension, and I will give them to the present Minister to see if he, in his generosity, can do anything to help those people.

Personally, I believe the Minister has no power to do anything because the Dáil, in their wisdom or otherwise, allowed the Health Act to go through without putting in a clause providing for the right of appeal for members of the House or the general public against a decision of a county manager. I ask the Minister to go into this matter very carefully and see if it would be possible to have an appeal to someone when a wrong decision is made.

I find that in many parts of the country our hospitals are understaffed. I do not know whether or not this is due to the fact that we think the Health Act is costing too much and we try to make a saving, such as in the case I mentioned of the tuberculosis allowance of only 30/-, or that we try to make a saving by understaffing our hospitals. In any event, I find that, on the whole, our hospitals are understaffed. The result is that many nurses are leaving our hospital service and going across the water where they can get better conditions, both as regards salary and working hours.

Before concluding, I want to make this point also. We were all delighted to read about the Health Act, but perhaps we are not so pleased with it when we see it working. The white collar worker and the farmer up to £50 valuation and over now have to pay up to £9 9s. when they go into hospital. In addition, they also have to pay the amount carried by the rates in respect of the people who qualify for treatment under the Health Act. I believe there is an injustice there. Their children are entitled to free service while going to school, but if those people become ill themselves, or if it is a case of their wives and children of 16 and over becoming ill, they have to pay the full rate of £9 10s. I believe there should be a little more elasticity. I know farmers under £50 valuation— not many, I admit—who could afford to pay, and I know farmers of over £50 valuation who are a lot poorer. It all depends on the family conditions. So long as we pass legislation giving power to one man, and one man only, and allowing no appeal from his decisions, we will always have complaints and always have injustice.

Major de Valera

The last speaker made some remarks that prompted me to intervene, perhaps only to ask a couple of questions. This subject has been thrashed out in considerable detail over the years. The question I would like to ask is this. Here is a Deputy from the far side who says that the situation, from the point of view of the community, in regard to getting health services freely, is worse now than before the passing of these Health Acts. If that Deputy were to make that statement in an isolated way, or if any other Deputy were to do so, he would be immediately challenged, but the reason I intervened is simply this. We have frequently heard similar remarks in other places about the futility in many directions of legislating for health and about the difficulties that have come out of the new legislation rather than the reliefs. I would like to ask the Minister would he sometime at a favourable opportunity be able to give us some authentic information about the working of the Health Act?

I know that practically all Deputies —certainly very many of them—have got a number of complaints about the operation of the Health Act. It is very frequently said that the situation is worse now in certain directions, from the point of view of people seeking service, than it was before. It is very difficult to assess the value of such complaints because the people who make them are making them from a particular point of view. I would welcome a comprehensive statement sometime from the Minister as to how the Health Acts—the legislation over the last ten years in regard to health—have been working.

I have absolutely no doubt myself that in certain directions there has been a considerable and favourable advance. I think another Deputy mentioned earlier on—and it is a good point—that fevers were eliminated by the organisation of health services in the past and that, to-day, tuberculosis has been to a great extent eliminated by similar concerted action. I have no difficulty, personally, in accepting that case. There are specific problems to be solved and specific tasks to be done in regard to health, as there are in regard to other matters. I have no difficulty in accepting the proposition that a specific attack on a well organised line will give results. What I do query is this purported blanket provision for all contingencies which seems to inspire some of the approaches to health services.

In the light of what the last Deputy said and in the light of what other Deputies have said, I question whether what I might call a completely socialised State service will give the advantages that are claimed for it. I know that at present, apart from things such as those mentioned by the last Deputy, there are services which were available and which are not so readily available now. I know, for instance, that the voluntary hospitals are in difficulties in regard to funds and in regard to the provision of services which they gave heretofore. I know that a logical argument can be put up on the grounds that there are certain disbalances in these things. But the fact remains that in the past, particularly in the City of Dublin, services were given, and there are now complaints that it is becoming increasingly difficult to give these services. I am talking about general illness, not about specific diseases such as tuberculosis. Our efforts heretofore and our efforts recently to amend that situation do not seem to have given general satisfaction.

When I pose these questions, I do so as a layman and merely to ascertain the answers to them. Is it a fact that by and large, as far as the public is concerned in regard to what I might call general dispensary services and general health services, they are, say, in the City of Dublin, getting as good, better or worse services than they were before the Health Act? In saying that, there is no questioning the good work done in certain specified directions. Is it a fact, perhaps because of hesitant thinking, that the services which are at present being given, and have been given efficiently in the past, by voluntary institutions are in jeopardy because their capacity to give these services is not what it was? One would naturally also ask the question—as a layman, I cannot answer it—what are the repercussions in regard to the service given by the medical profession in the past, is it the same, better or worse? I pose these questions, first of all, because of the remarks of the last speaker, who stimulated me to remembering a number of things which have been said to me in my capacity as a Deputy and, secondly, because of representations which have been made to me over the past six years.

Notice taken that 20 Members were not present; House counted, and 20 Members being present,

Mr. Desmond

We all realise the important connection between health services and the everyday life of our people. Because of that, I consider this Estimate is one of the very important Estimates to be discussed. I think it is fair for me to pay tribute to the Minister's predecessor because during his period as Minister, he approached these problems—it is true that many of them were individual cases—in a manner befitting a Minister for Health. The first problem I should like to concentrate on is the whole problem of the dispensaries, whether in rural areas or built-up areas. One of the most noticeable failures we have to recognise is the very bad dispensaries in every part of the country and it is a fact that in other areas there is much too great a distance between these buildings. In answer to a question which I put a few weeks ago, the Minister stated that during the past four or five years, about £5,000 was allocated to a very large county like Cork for the erection of dispensaries. I consider that it is most important that we should concentrate on the erection of many dispensaries to replace some of the existing ones which are at present in a disgraceful condition.

I also deplore the fact that, of late, the tendency seems to be to hold up the building of dispensaries in many areas already earmarked for them. I would ask the Minister to speed up the erection of these buildings and to have the claims of the various local authorities, including Cork, who have submitted plans for sanction, dealt with at the earliest possible moment. Many of us, whether we are in favour of regional hospitals or not, realise that the outstanding difficulty seems to be the reluctance of many people, particularly in rural areas, to visit the local dispensaries because of the terrible conditions of those buildings.

The ultimate result seems to be that the patient, instead of calling on the local doctor in the dispensary in the early stages of illness, waits until the doctor has to be sent for and the next step of course is the patient's admission into the local hospital. Possibly at that stage the patient's illness has gone too far for anything to be done for him. I believe that with a proper dispensary service and with understanding and co-operation between the local dispensary doctor and the people, such a service being offered in proper buildings would automatically result in fewer admissions to the hospitals of cases that could have been treated if dealt with in the early stages.

Coupled with that is another point which I believe must have a direct bearing on the services of local dispensaries and that is having the services of a general trained nurse available in every dispensary district. For many years, we have been striving to have this system put into operation and while it has been in operation for the past four or five years, it is only to a limited extent. It is not alone necessary to have a qualified doctor attending in a well-constructed dispensary, but also to have a general trained nurse at the disposal of the people, particularly for those who, having spent a short period in hospital, return home to find it necessary to have medical treatment there. It is essential I believe to have a general trained nurse in the district so that this service can be placed at the disposal of isolated cases. It will mean giving a health service in rural areas where at the present time facilities are not available for transport to towns for medical purposes. It will give to outlying rural areas an advantage from a medical point of view which is most important.

Deputy Tierney, Deputy Major de Valera and many other Deputies spoke on the question of medical cards. My view is the same as that of the other speakers. We did support the Health Act. I am sure every one of us believed that in doing that it would provide certain advantages but, unfortunately, one of the problems still remaining is that of medical cards. I shall not bore the House with individual cases except to say that in my constituency road workers with families, who had no difficulty in the past in getting the local dispensary doctor's services free, or having the local dispensary doctor call to their homes if necessary, in a large number of cases now can point out to public representatives of all Parties that, whereas under the old system they had certain benefits, these benefits at present seem to be denied to them. The only suggestion I would offer to the Minister is to have this whole question examined from an angle different from that which members have already suggested.

When the Health Act was put into operation conferences of the county managers' association were held and the figures submitted by them seem to have been accepted by the Minister and the Department. Unfortunately the schemes that were to have been put into operation were based on the views of a number of men, which while perhaps well-intentioned, were not elastic enough to give benefits to those people who should get them. I would suggest to the Minister to have this whole matter reinvestigated, in view of the fact that members on all sides of the House are finding difficulty in relation to the rights of some people to secure medical cards and the refusal of the local authorities to give them to other people. That shows, that though we may have advanced our medical services under the Health Act, in this particular instance we seem to have gone backwards.

In view of the fact that Deputy Corry spoke so long and so ably about one problem in Cork this evening, I suppose most Deputies would like to hear no more about it. However, I think it is but fair for me to ask the Minister for Health to have immediate attention given to the problem of the nurses' home at St. Finbarr's Hospital in Cork. It is true to say that these girls, probationers trained in this hospital by an excellent staff, are compelled to live under appalling conditions.

As Deputy Corry rightly said, the problem is well known to the officials of the Department. The situation was well known to Deputy O'Higgins when he was Minister and he examined this particular case. When we are discussing an Estimate like this it is more important that we approach it from a humanitarian, rather than a political point of view. I would ask the Minister not to be misled by any suggestion in relation to the possibility or probability of the erection of a regional hospital in Cork, in dealing with this matter.

The danger is that if the present situation is allowed to continue at the nurses' home in St. Finbarr's Hospital, Cork Deputies will find, not alone to their disappointment but to the great expense of the ratepayers of Cork, that they will not be able to get probationers trained there, or nurses to enter the medical service in Cork, owing to the fact that their parents will not allow their daughters to live in such conditions. I hope that by this time 12 months, not alone will the Minister have something to report on this particular item, but that a start will have been made, long before the 12 months has expired, on the erection at that hospital of something that can be called a proper nurses' home.

In passing, I should like to pay tribute to the officials of the Department who attended conferences in Cork. They brought back to the Department a clear, concise picture of conditions there. I shall not go as far as Deputy Corry in laying blame on the officials of the Department, though perhaps he did so unwittingly. I would ask the Minister to get the views of the officials on this matter and proceed with the erection of this important new structure.

I should also like to direct the Minister's attention to the appalling conditions in Cork Mental Hospital. All the facts in relation to the requests of the Cork Mental Hospital Committee seeking sanction to proceed with the erection of additional buildings at that institution are in the Department. Therefore, there is no need for me to say anything except to ask the Minister for Health to concentrate on dealing with this problem of terrible overcrowding in that hospital.

I suppose it is not surprising that there is something upon which I disagree with Deputy Corry. In this case, Deputy Corry had the support of a Deputy on my left. Whether it is a case of the just man being between two thieves or not I cannot say, but I do not agree with his views in relation to the regional hospital in Cork. I know regional hospitals cost a lot of money to build. I know that no matter what priority new hospitals may have there is always the problem of finance. It may be an important problem but, unfortunately, the situation in Cork is a very old and very bad one.

I took very little notice of Deputy Corry's remarks about "All the boys", to use his own words, spending all the money. It is his belief that a considerable sum of money was spent, but some of us saw very little of it going into our constituencies. In spite of Deputy Corry's remarks, the position is that it is impossible at the present time to get a patient into any of the hospitals in Cork, be it a general hospital, cottage hospital, Cork City hospital or the voluntary hospitals, because of overcrowding. If anyone here is to advance an argument against the erection of a regional hospital in Cork he must be prepared to have a long waiting list either at the local authority hospitals or at the voluntary hospitals.

Again, this is to be a regional hospital and not meant solely for the benefit either of Cork City or Cork County. It being a regional hospital, Cork City and Cork County can get only a proportion of the beds. If Deputy Corry wishes to say there is no necessity for the regional hospital, I would point out that, as well as condemning the people of Cork City and County to an inadequacy of beds, he is also condeming the people of other cities and counties who, not having a regional hospital of their own, would also be able to benefit by the erection of a regional hospital. Already we have gone too far and spent too much money, whether by way of architects' fees, and so forth, to go back. A very fine site has been acquired. It would be very poor consolation, after the expenditure of thousands of pounds, to drop the whole thing now. I do not believe it would be the right step. The erection of the regional hospital is essential. I know colleagues of Deputy Corry who are on the local board, as I am, and who have expressed views exactly similar to the views which I now express.

In the voluntary hospitals as well as in the local authority hospitals in Cork City and County, there is unfortunately complete overcrowding at present. The only remedy is the erection of the regional hospital. We should give the people the benefits which can undoubtedly be made available of an up-to-date system with an excellent staff of Irish doctors and Irish nurses who are continuously proving their ability, whether here in Ireland or in other countries.

Speaking of staff, I think we should mention the outstanding ability of the nurses in the voluntary and the local authority hospitals. Very briefly, I suggest the Minister should consider their present position in relation not just to their working hours but to their salaries. Their working hours are a matter for their union, but the Minister should consider their salaries in consultation with their organisation. It may be possible for him to improve their present financial situation. Many of us know that the bargaining power of the doctors is such that they are never left with the wrong end of the stick. They are never in the position of looking for a few "bob". Unfortunately, the practice in this country always seems to have been that, while the medical staff were well able to protect themselves, the nurses in these hospitals who do trojan work always seem to be left out.

Deputy Corry mentioned St. Finbarr's Hospital. I agree that a large amount of money must be spent on its improvement. I fear the present Minister may be inclined to follow a line, which undoubtedly would be dangerous, in relation to the continuation of the services in St. Finbarr's Hospital versus the erection of a regional hospital. I believe, as many members of the local authority believe (1) that it is essential that we should get the regional hospital and (2) that St. Finbarr's Hospital must still be maintained. It is on the records of the Department that there is the danger that St. Finbarr's Hospital cannot be recognised as a teaching hospital. Should that happen, probationers cannot be there. The hospital would have to employ a fully qualified staff. There would, of necessity, have to be a higher number of fully qualified nurses who would have to receive their appropriate salaries.

There is the further point that at present St. Finbarr's are offering the benefit of technical advances in medical services which have been so noticeable over the past six or seven or eight years and even since the war. It is essential that these services should continue, not, naturally, on the basis of regionalisation, but on the basis of providing in the future for the people of South Cork—which includes the South Cork area and Cork City—the services which they have found helpful in the past.

Some people have stated that we have too many hospitals. This theme seems to be spreading from different angles. It seems to be more an individual claim than the line of any particular Party. It is strange that when people tell us we have too many hospitals, they seem to forget the appalling conditions of mental defectives in this country. If we have too many hospitals, why not use some of them for homes for those little boys? Those of us who have visited, for instance, the Brothers of Charity Hospital in Cork, can realise the tragedy of the life of those children. The conditions under which these religious brothers must labour day after day are appalling. If we have too many hospitals, why not offer better facilities to these religious brothers and to the religious community in Cabra whose institution I have not had an opportunity of visiting, but about whose work I know a great deal? If conditions can be made a little easier for these children by placing homes or hospitals at their disposal—buildings which some people now allege are not needed—then perhaps, after that, we may consider where we shall go. With the present position in relation (1) to overcrowding in the few homes we have and (2) to the impossibility of permitting many children to enter these homes, owing to their already overcrowded state, it ill-behoves any member of any Party in this House or any member of the general public to tell us we are spending too much on medical services.

Deputy Corry and Deputy O'Higgins apparently crossed swords on the question of charges. I will not condemn all the practitioners, but it is essential that we should speak plainly and that we should say what we know to be true. If one compares the position in different hospitals with the conditions prevailing in them some few years ago before the introduction of the Health Act, one must wonder why extra private beds have been made available in so many hospitals compared with some years ago. The answer, at least as far as Deputy Corry and myself are concerned, as well as many other members, is that we believe the practice is growing all the time of a local doctor, when treating a local patient, suggesting that, instead of going to the clinic where the patient can get not alone advice but, if necessary, admission to hospital under the medical services, the patient should go to the home of a private consultant.

What happens very often is that the doctor will send the patient up to the home of a private consultant. As soon as the patient shows his nose inside the room of the consultant, he is treated as a private patient. The next move is to send him into a private room in a hospital. That is not good enough. While we may differ on many points in this House, the one thing upon which we did not differ in the 1952-53 period was the question of giving better health services. Did any member of the Labour Party, when trying to provide that service in 1953, ever visualise the day when advantage would be taken of an Act to send people to a private consultant's room and into a private room in a hospital?

I would ask the Minister to have this matter investigated, to consider the overall picture in relation to the number of private beds being made available in hospitals since the introduction of the Health Act and to compare it with the position prior to that. That does not apply to all medical practitioners, but even if it applies only to a minority, it is essential that the matter be investigated and the result made known to the members of this House and the community as a whole.

Mr. M.J. O'Higgins

There is only one point I want to deal with fairly briefly on this Estimate. It is a question of the machinery for payment by local authorities of payments under the Health Act. I asked the Minister some questions on this subject and he gave me his replies to them. I do not want to trespass by being taken as advocating legislation, but I do want to recommend to the Minister that it might be well worth while making a comparatively slight change in administration, with a view to assisting him and his officials in whatever inquiry or review they may be undertaking in connection with these payments.

The Minister may recollect that the point I wanted to bring to his attention was the fact that where patients are treated in a hospital following injuries sustained as a result of an accident and where, subsequently, the local authority accept responsibility for the institutional services provided for that person, if the injured party at a later date recovers damages against the insured person, the present position is that, although the local authority will have paid out for the institutional services provided for the injured person, the local authority, through the machinery which exists under the Health Act, have no way of recouping themselves for the amount paid out.

I have no idea what the total cost to local authorities of such payments over the past 12 months would have amounted to. Apparently the Minister is not in a position to give that figure to the House. The reason he is not in a position to do that is given in a reply to a question which I asked him last week or the week before. I asked the Minister if he would state in relation to the City and County of Dublin, the amount paid under the Health Act, 1953, by the appropriate health authorities for hospitalisation for persons injured in accidents during the 12 months ended 31st May, 1957 or the nearest convenient 12 month period. The Minister's reply was that the information requested by the Deputy was not available in his Department. The form of application for services did not disclose the nature of the complaint, nor did it indicate that the patient met with an accident. It was not, therefore, possible to ascertain the amount paid by health authorities to hospitals in respect of services provided for persons who had been injured in accidents.

I do not want the Minister to misunderstand me. I am not suggesting for a moment that the particular form of application for services which is used now should be altered in such a way as to disclose the nature of the patient's complaint, but, without disclosing the nature of the patient's complaint, I think it would be quite proper and prudent that local authorities should be asked to make provision in the application form for ascertaining whether or not the services are being sought by reason of an injury following an accident.

The reason I think that information should be obtained is, as I have indicated in my questions to the Minister, that, as the matter stands at the moment, it seems there is no machinery whereby the local authority can recoup themselves. In cases where a third party has been proved before the courts to have been guilty of negligence and an award of damages is made, in such cases I do not think there is any point in not speaking quite freely about it. Most of such cases will arise because of road accidents and, in most of such cases, some unfortunate insurance company will ultimately pay out the damages that are awarded. So long as the present system is allowed to remain unaltered, it seems to me, in any event—and I think I am quite correct in this—that the local authority can be said to be subsidising to a certain extent the insurance companies, because the local authorities are obliged, under the health scheme as it is at the moment, to provide these institutional services, and it is left at that.

No machinery is provided whereby they can be recouped in the circumstances which I have outlined where there is a successful litigant who secures an award for damages in court. The Minister was good enough to indicate, in reply to the first question I asked, that this matter was one which is being kept under review. The alteration I suggest should be made is simply for the purpose of enabling the Minister and his Department to find out to what extent payments are being made by local authorities in respect of accident cases, because it is a fair bet that quite a large amount of money paid out by them in respect of accident cases is money which could and, I think, should be recouped.

It seems to me to be very necessary in connection with any review or any consideration which the Minister and his Department are giving to the subject that he should at the earliest moment ensure there will be some system whereby that information can be made available to the local authority. The only system that I can think of is that the question should be asked on whatever form of application or questionnaire that has to be completed when these institutional services are being requested. I would ask the Minister to give that point his earnest consideration.

It is only a matter of a few days or at most a few weeks since the Minister was in the position of coming to this House to increase charges for patients under the Health Act and the total saving—put it that way—it was hoped to make as a result of that increase was somewhere in the region of £180,000. For all the Minister knows, for all the information he has given to me, the suggestion I am now making to him might result in a saving of a very substantial amount and might, if it were operated at an early date, make possible a reduction in the charges which the Government found it necessary to increase recently.

Minister for Health (Mr. MacEntee)

I think I should not do less than express my appreciation of the way in which this Estimate has been received by the House. In that connection, I mention particularly the speech made by my predecessor, Deputy O'Higgins, and the speech made by an earlier predecessor, Deputy Dr. Browne. The tone of the debate indicates that the question of health services has risen now above the range of political polemics. That is not to say, of course, that a Minister's policy will be above criticism or that a Minister's administration will be above criticism; but it is clear that a greal deal of common ground has been established between those who have spoken in this debate.

We are all concerned to ensure that the health of our people is preserved, that if they should be stricken by illness, we will see that the best treatment within the power of the community is made available to them and that those who are born into this country will be able to grow to manhood and enjoy a long and fruitful life. We may, of course, have some reservations as to the manner in which this can be accomplished.

Deputy Dr. Browne devoted a large part of the latter portion of his speech to a statement of his position in relation to the means test—or, as he said, a free-for-all medical service. I have given a great deal of consideration to that and I still feel that Deputy Dr. Browne's logic is not impeccable. He argues that if a person pays, he gets better treatment and service than if he does not pay; and as a consequence of that, he suggests that nobody should be allowed to pay. It seems to me that the logical conclusion should be that, if you want everybody to have the best medical service obtainable, then everybody should be asked to pay.

I think the fundamental weakness in Deputy Dr. Browne's argument is that he confuses, I think, the question of medical treatment proper with the surroundings and the amenities which patients may enjoy. It is undeniable that those who can afford to go to private nursing homes, retain the services of private nurses and so on, will endure their illness in surroundings which are more comfortable than the surroundings of those who have to go to a public ward and cannot enjoy the seclusion, the privacy and the quiet of a private ward. I do not think it is contended that it will be within the means of any community, let alone this community, to provide every patient with a private nurse, a private ward and all the comfort which usually goes therewith.

What we can do and what we are endeavouring to do is to ensure that the greatest possible measure of high medical skill will be available to everyone, whether he is rich or poor. Even there again, we cannot all have equal treatment, as not even the highest qualified practitioners are equally efficacious as medical attendants. There are questions of personality, as well as of skill, which make one doctor more acceptable to a patient than another. No matter what one does, one cannot give equal treatment to everyone, whether they are asked to pay or not. What we should aim at ensuring is that those who, by reason of the fact that their own resources do not permit them to do otherwise, have to avail of public assistance—and I use that term in a general way and I am not using it in the sense in which it is used in the public assistance code—that is, those who have to ask for such services as the community can provide for them, will get the best that is within the power of the community to afford. That is what we can do.

We are striving to do that and we allow those who cannot afford to pay anything to secure the services free. In the case of those who can afford to contribute something, I think it is only right, just, fair and equitable that they should contribute. In the case of those who can afford to pay the whole cost of treatment, I think it is also only just, fair and equitable that they should pay the whole cost, so as to lighten the burden on the general community and make those services more readily available to those who are in dire need of them. That is my position, at any rate. I do not think we need continue the controversy which has been going on for such a considerable time on this question of a means test.

I do not think there is any analogy or any true parallel between what is done in relation to tuberculosis, infectious diseases, mother and child services and the services which are provided in treating acute illnesses; nor can we say, as Deputy Dr. Browne has argued, that the reason why tuberculosis services have been so efficacious is that they are provided gratls. To assume that is to ignore the other very great factors—the improvement in housing to which Deputy Manley referred, the rising standard of living, the development of new treatments and of course the better diagnostic and preventive treatments which are readily available. These all have combined to reduce the mortality and the incidence of tuberculosis amongst us.

I think that we cannot ascribe, as Deputy Dr. Browne seems continually to do, the progress which is being made in overcoming infectious diseases merely to the single circumstance that the community, for its own protection, has made the preventive services available free of charge. It may be a factor but I, for one, do not think it is the predominant factor; I do not think, if we were to make all our medical services free of charge to everyone, that we would secure the general improvement in those services which Deputy Dr. Browne is so anxious to secure.

Another matter to which he referred was the opinion I expressed that we can no longer afford to maintain the same lavish use of space and materials as characterised the hospital building programme since in fact the Irish Hospitals Sweepstakes were first established. I would very strongly deny that my approach to this problem of providing hospital accommodation for all those who are in need of it is that the sick are too well housed. I want to say that as far as I am concerned there is no justification for the innuendo in that statement.

I think we can provide hospital accommodation by using space economically and by reducing, generally, unnecessary and unessential frills and adornments without imperilling high standards of treatment and reasonable standards of accommodation. Deputy Dr. Browne said that if he had been in on the early planning of sanatoria he would not have accepted the pavilion idea, that he would have preferred multi-storey hospitals.

I was in at the early planning stages of the sanatoria. I have to admit that I was responsible, in the ultimate analysis, for accepting the general pavilion plan upon which the regional sanatoria were built. They were, of course, in a very early stage of planning then. The initial planning was initiated under the Department of Local Government and Public Health. I may say that, having regard to the position in which we now find ourselves in relation to the problem of providing hospital accommodation, I very bitterly regret that I was not sufficiently farsighted to foresee what the ultimate result of this very spacious, very elaborate, highly desirable planning from a monumental viewpoint might be.

If I had to do it all over again and try to set a headline I certainly would not have encouraged the erection of buildings which would endure for many generations, because during the past ten or 12 years there have been such striking advances made in chemotherapy and medical treatment that it is very questionable whether we should build hospitals that would last for several lifetimes ahead. It is quite possible that within a couple of generations some of these large hospital structures will be standing as deserted as some of the big houses are.

I have not come to a definite decision in this regard. It would be folly to do so after only three months in the Department. I should like to consider the problem at greater length, to let it ferment in my mind. I have not even seen some of the institutions mentioned here to-day, but my general feeling is that there is such an urgent demand for accommodation that it would be better for us if we could build very much more cheaply, not to last two or three generations but 20 or 30 years. That might be the best approach to finding an early solution for our difficulties. If we build to last, we build slowly and expensively. The position we find ourselves in now is that our resources do not permit us to build expensively.

To come back to some of the detailed points raised in the course of the debate, perhaps I had better deal with a question raised by Deputy T.F. O'Higgins. He asked the very important question as to what was the present position in relation to poliomyelitis and the extent to which the preventive measures have been availed of since the vaccination campaign began. The age groups included in the scheme are, as I said in reply to a parliamentary question by Deputy Dr. Browne to-day, from one to three years as at 30th June, 1957. The number in that age group is about 125,000 children, approximately. The number of eligible applications for vaccination which have been received is about 10 per cent. of that figure, 12,299. We are about to undertake an extension of the scheme to the three to five age group. We are, in fact, seeking financial authority in that matter and I feel sure it will be readily granted. The number of eligible persons to which this extension applies is 124,000.

I cannot add anything to what I have already said as to the general acceptance of the view that vaccination against poliomyelitis is a very valuable precautionary measure and that it should be generally availed of, particularly by those responsible for the upbringing and care of children and, indeed, by adults as well.

Mr. T.F. O'Higgins

Could the Minister give some information about the cost?

Mr. MacEntee

Quite frankly, I cannot give the total cost.

Mr. T.F. O'Higgins

What was the estimated figure for the 125,000?

Mr. MacEntee

We had £20,000 available altogether. I do not think it will be necessary for us to ask for more until we see that the scheme is being availed of. I suppose the people are naturally hesitant. It might appear to those who are not fully informed as to the actual results elsewhere, that in view of certain incidents which occurred some years ago, they had better wait and see how the vaccination goes with others before they submit their children to it. Out of 100,000,000 vaccinations which have taken place elsewhere there has not been a known case of the occurrence of poliomyelitis as a result of the vaccine treatment. I think that is the position and it should be very reassuring to us.

Deputy O'Higgins also mentioned the question of the Ardkeen dispensary. We have been trying to persuade the Waterford County Council to accept it as a general hospital, but while they have accepted our proposal in principle, they have attached conditions to that acceptance which will be very difficult for us to agree to. I do hope they will agree to take our point of view in the matter because if they do not it will mean they will be without a general hospital for a very long time. There is a very fine building there which could be readily adapted and which would give them, within a very short space of time, the institution which they require to meet their needs. It would be better for them to take it as it is offered to them and at least allow those who require hospital treatment to have the benefit of its use.

In regard to the few questions which Deputy O'Higgins and Deputy Dr. Browne put to me as to the institutions within the provisional programme upon which work would begin at an early date, I have not come to any decision in that matter for the reason that the financial position is so uncertain that I want to see quite clearly that it will be possible for us to complete these institutions once they have begun and that there will not be any unnecessary hold up. That means we must have a certain amount of cash reserve in the Hospital Trust Fund before we can start any building operations. There are preliminary works which could be done and which would not cost a lot, but then the undertaking of preliminary work generally involves a commitment which it is not always possible to fulfil. I want to make quite certain that once we give sanction to any of these schemes, they will go ahead.

Deputy T.F. O'Higgins and Deputy Dr. Browne referred to the question of medical education, and so also, indirectly, did Deputy Carty. This, of course, is primarily a matter for the medical schools themselves. We are very interested naturally because we wish to see that the medical qualifications of our practitioners are very high. We wish to see that they are properly educated for their job, but the law provides that universities come within the purview of the Minister for Education and, in addition to that, as I have said, the question of medical education is really one for the medical schools themselves.

So far as the utilisation of institutions like St. Kevin's is concerned, if any suggestion is put forward to associate St. Kevin's with the medical schools, I certainly shall be prepared to consider it very sympathetically in so far as I have any control. However, I want at the same time to make it quite clear that no arrangement which would jeopardise the independence of St. Kevin's would be acceptable. Great progress has been made with that institution in the past ten years, progress that has been made very largely because the institution has been free and independent of any other consideration except its responsibility for providing institutional treatment for the poor of Dublin. I wish that position to be preserved and maintained.

I cannot join with Deputy Carty in his criticism of the Order which my predecessor made in relation to the Galway institution. I must say if I had been in that position and the responsibility was conferred upon me as was conferred on my predecessor, Deputy Thomas O'Higgins, when he was Minister for Health, I should have made precisely the same Order. I would have felt that it was in the national interest that the Galway Medical School should be preserved, and that is what was in issue. We must not shut our eyes to the fact that reports of certain visitors to our medical schools contained very severe strictures upon the clinical accommodation and facilities which are afforded to our medical students, and those reports contained also a fair warning that unless conditions were considerably improved in the very near future, our medical degrees would not be recognised in Great Britain. That would have a very serious effect upon the economy of a great many families in this country who, at considerable sacrifice to themselves, are trying to equip their sons and their daughters for the medical profession. We cannot allow the position of these schools to be jeopardised merely because of local considerations. Galway Regional Hospital was provided at great expense to the rest of the community and it was provided with the idea, among others of course, of ensuring that the Galway Medical School would have adequate clinical facilities. We must make certain that that objective is not lost sight of.

Deputy Dr. Browne referred to the position of the mental hospitals and of the inadequacy of beds for mental defectives. I have that very much in mind. It is clear from developments which have been made in this sphere of medicine in recent years that a great deal can be done to alleviate, and perhaps to cure, the condition of many people who were formerly regarded as hopeless mental cases. In that connection, we have been urging health authorities and mental hospital authorities to provide greater facilities, more clinics to afford preventive and early curative treatment in cases of mental disorder. The importance of these clinics for early treatment is very well recognised and I am glad to say that I think considerable progress has been made in developing the out-patient service for mental cases.

In 1944-45, 75 clinics were in operation in various centres such as county hospitals and county clinics and the attendances totalled 4,800. In addition, my predecessor recommended in 1956 the establishment of a psychiatric consultant service so as to ensure that elderly patients would not be required to enter mental hospitals, unless it was established that they required institutional care.

We have had the same approach to the question of accommodation for mental defectives. All of us in the Department—I mean the officials of my Department as well as myself—are very conscious of our deficiencies in that regard. Much progress has been made in that direction in recent years, although it cannot be said that the position is satisfactory. In 1949, at the start of the post-war building programme, 1,317 beds have been provided this type of case. As part of that programme, 1.317 beds have been provided and accommodation for a further 240 beds is in course of construction. Our bed provision, therefore, under this head, has been more than doubled since 1948.

Deputy Dr. Browne paid a very well deserved tribute to the work of the Brothers of St. John of God and nothing that I am about to say should be taken as detracting in any way from that tribute, but I think also we should mention that excellent work is being done elsewhere for mental defectives by other Orders, such as the Brothers of Charity at Lota, Cork, and at Kilcornan, Galway; by the Sisters of Charity of St. Vincent de Paul at Cabra, by the Sisters of Charity of Jesus and Mary at Dalgan, County Westmeath, and at Moore Abbey, and by 'La Sagerse at Sligo. All this is of comparatively recent development, so that I think the House may rest assured that everything we can do within our resources—not everything we should like to do—is being done to try to cope with this very distressing problem.

Deputy Dr. Browne also referred to the position of resident medical superintendents in mental hospitals and asked why should we not bring in a lay administrator and leave the resident medical superintendent to do medical work. One would say, in theory, that this procedure has very much to recommend it. I think, many years ago, we did try to introduce lay administrators into certain larger hospitals, but they were not always received with open arms. Some degree of prejudice and resentment on the part of medical and nursing staffs at the prospect of a layman interfering with them made the experiment rather difficult.

There are, of course, naturally two different schools of thought as to the best form of hospital administration, both in relation to mental hospitals and hospitals generally. It is true that there is a very heavy burden upon the medical superintendents of these institutions, but a great deal has been done, I think, in varous ways in recent years to lessen the burden upon them. Without making any very drastic change, for instance, the appointment of land stewards has gone far to relieve medical superintendents of duties in relation to the farms. More recently, the duties of chief clerk have been expanded with the effect, I think of relieving medical superintendents of a great deal of clerical administrative work.

There may be other things which could be done, but in any event I think that Deputy Dr. Browne may rest assured that we are very conscious of the position of resident medical superintendents of these large institutions. The changes which have taken place in the general approach to the question of institutional management have, I think, made it much easier and will make it easier as time goes on, to remedy many of the present difficulties in what was the old system.

I do not think I need say that we are all greatly aware of the fact that many of the mental hospitals are very much overcrowded and one of the things we hope to be able to do is, by the adaptation of some of the buildings which may become vacant, to convert them into homes for aged and infirm which will, perhaps, enable us to withdraw many patients from the mental hospitals with benefit to the hospitals and the patients who will be removed to more suitable surroundings.

Deputy Corry referred to sub-head I, and said that the £7,000 for county homes would not go very far. I agree with him that £7,000 would not go very far, but if he reads the sub-head carefully, he will see that the provision is in respect of recouping over 50 per cent. of the loan charges on moneys already borrowed for county homes. It has no relevance in connection with future borrowings. If the money was in the Local Loans Fund and if Deputy Corry's board of assistance wished to borrow it and if he could get sanction for borrowing it for the purpose of improving county homes, then no doubt the £7,000 would be considerably greater next year; but it is only in relation to past borrowings that the money is provided and it is not any indication of what the situation is likely to be in the future.

Deputy de Valera—I did not have the advantage of hearing his speech— suggested there were many complaints about the working of the health services. I should be very agreeably surprised if there were not, in the course of a debate on an Estimate which ranges so widely as this, some complaints about the administration of some of the services and particularly of the services which were introduced under the Health Act of 1953. After all, some of them have only been a very, very short time, comparatively speaking, in operation, and it is only when one actually tries the machine out that one discovers whether or not it can be improved. But, taking it by and large, I think there cannot be any foundation for the suggestion that the general public are worse off in relation to the health services under the 1953 Act than they were before its introduction. Every fact that one examines in relation to the position prior to the 1953 Act and in relation to the present position indicates the contrary.

Deputy Tierney referred to the position of tuberculosis patients in County Tipperary. He said that when a patient leaves the sanatorium he is granted an allowance of only 30/- per week. That, of course, is the infectious diseases maintenance allowance and the rate of that allowance depends on the circumstances of the individual. The allowance can, in certain circumstances, be substantially more than 30/- per week. I might mention that the cost of these allowances last year amounted to, roughly, £600,000.

With regard to accommodation and overcrowding in Grangegorman, that situation has been relieved somewhat by the provision of new units for about 250 patients in Portrane. We are also trying to persuade the Dublin Board of Assistance to take over Crooksling for senile patients from Grangegorman. That should make accommodation in Grangegorman for about a further 250 mental patients proper.

Deputy O'Higgins and Deputy Dr. Browne referred to a choice of doctor. Deputy O'Higgins suggested that he would like, particularly in the Cities of Dublin and Cork and the larger centres of population generally, to give Section 14 patients a free choice of doctor. That would be very desirable but it would cost a great deal of money so far as we have been able to ascertain or estimate as to what the actual cost might be. Until our financial position becomes more secure and the Minister for Finance and the public generally are able to afford more money for health services, we shall have to defer doing anything to give effect to the suggestion which Deputy T.F. O'Higgins and Deputy Dr. Browne put forward.

Deputy Dr. Browne referred to the Voluntary Health Insurance Board. He appeared to be under some misapprehension as to what is the actual position in regard to that board. First of all, the board was set up by statute. It was set up under an Act passed by this House for the purpose of having a specific job done. That Act was passed quite recently. The board has been constituted. A technical task has been imposed upon it and, so far as I am concerned, I would not propose to interfere with the experiment which is being tried. It may prove to be a very valuable one. I should like to say that such moneys as have been placed at the disposal of the board have been advanced to it by way of loan and in due course, if the members are able to produce a workable and practicable scheme, I assume that loan will be repaid and nobody will be any worse off for the fact that this experiment is being tried.

With regard to difficult children, there is, as Deputy Dr. Browne mentioned, an officially sponsored child guidance clinic in Dublin, run again by the Brothers of St. John of God. It is a new service and I should like it to be fully tested before I could permit myself to a decision that we should go further. I have little doubt in my own mind that the results will be satisfactory but it is better to await the actual outcome of the experiment which is being tried.

With regard to the point raised by Deputy Carty as to the supply of surgical and medical appliances, I do not understand how the position to which he referred wherein long delays have taken place could have arisen. There does not seem to be any valid reason why a person should have to wait for such prolonged periods and there is no information in my Department as to why that position exists in Galway. If Deputy Carty would be good enough to give me details of the cases to which he has referred, I shall have them investigated.

On the issue of medical cards to old age pensioners, the position is that my predecessor recommended that all old persons in receipt of full pensions should be given medical service cards, but that recommendation is not binding on county managers. Some have accepted it and some have rejected it. It is entirely a matter within the responsibility and discretion of the local authority.

Another point which Deputy Carty raised was the right of the county manager to direct patients to a particular hospital. The county manager acts in this matter for the local authority and it is incumbent on him to make the best use possible of such hospital accommodation as may be available to him. The Act provides that patients will be sent to recognised hospitals, that is, hospitals with which there is an arrangement for keeping such patients. I understand there are two such hospitals in County Galway and the manager must make the best and most economic use of the accommodation in both of these institutions. He is bound to do that and, if he does not do that, he may find himself in serious trouble with the Local Government auditor. Therefore, as I say, it is his responsibility and it is he who has the duty of ensuring that the beds which are available to him will be utilised in the most advantageous way possible.

With regard to the attendance of the county manager at meetings of the consultative health council, to which Deputy Carty referred, there is no statutory obligation on the manager to attend any meeting of the consultative health council. He can get the advice through the record of the proceedings at the council meeting, as, indeed, the Minister himself does in relation to the National Health Council. There is something, I think, to be said for the Minister and the manager not being present on these occasions. There can be freer discussion. Charges and counter-charges, unpleasant controversies cannot arise if the person who has the ultimate responsibility for accepting or rejecting recommendations does not happen to be present. All I have to say is that the question of attendance or non-attendance is entirely one for the county manager.

Deputy Carty mentioned that a doctor had suggested that the drugs which are supplied through the combined purchasing section are not up to standard. If there is any complaint in this regard, I should be glad if the matter were reported to the Department, which will take action.

On the question of the local consultative health council—Deputy Carty also raised a point in that connection— the position there is that there must be at least four members of county councils on the local consultative health councils. Then the county medical officer of health must be a member. The county surgeon or a senior medical officer of a health institution must be a member also, and two other practitioners nominated by a body representative of the doctors of the county. This gives a total of eight members altogether and the other two members may be nurses, chemists or anyone else.

In fact, it is believed in the Department that in many cases the members of the council are appointing their own members to the other two vacancies. If it is desired to give representation to nurses or other members of the ancillary hospital services, it is a matter for the county councils to arrange this among themselves. It is obligatory upon them to appoint eight members drawn from certain sources, but they have discretion in relation to the two remaining members of the council. Accordingly, it is a matter for those who have the power of nomination to come together and decide whether they will give representation on the councils to nurses or chemists or other members of the hospital staff.

Deputy Kyne raised the question of hospital attendants. The position there is that we are looking into that matter but we must look into it from the point of view which I stressed in my opening speech, that is, that we cannot afford to increase in any substantial way the existing costs of hospital services and, until the financial position rectifies itself, I shall be very reluctant to concede anything to hospital staffs as a body which would significantly increase the cost of the services. What would be done in the case of one institution would have to be done in the case of all.

Deputy Carty, who made, from my point of view, a very useful speech because he directed my attention to many details which normally might not come before me, suggested that the school medical examination should be conducted by the local dispensary doctor. That has something to recommend it, undoubtedly, but there is just the difficulty that in many dispensary districts there is more than one doctor. Not all the school children would go normally as patients to the dispensary doctor. Thus under Deputy Carty's suggestion we might have a practitioner in a particular area inspecting in school the children of families who would be patients of other doctors.

Taking it all in all, even though it does mean a longer interval between inspections, I think it may be better on the whole that an outsider should come in and inspect all the children, without any bias in favour of those who might be his own patients as against those who might be his rival's patients—shall we put it this way?— examining with a more lenient eye when he is looking upon his own patient and a more searching eye when he is looking on the patients of his rival practitioners.

Deputy Carty also raised the question of school dental service. Let me say again, quite frankly, there are many imperfections in our health services. They are imperfections which we are gradually remedying but the progress has to be gradual. If I were to give effect to the various suggestions that have been made here for improving these services, the Minister for Finance would have to find roughly a couple of million pounds extra in next year's Budget and I do not think any of us is prepared to face up to that. That is the position. We have to carry on all the services of the State as a whole. We have a limited amount of money at our disposal and it has to be spread over many Departments. It cannot all come into the Department of Health, no matter how desirable the activities of that Department may appear to be to us all.

Deputy Manley made a very useful speech. He suggested that we should try to do a little bit more to induce people to take care of their teeth. It was not the only suggestion he made. He made a great many others but he will forgive me if I do not deal with them all because I have, perhaps, touched in a general way on the topics which he raised.

On the question of the preservation of teeth, the Department did produce a film some years ago on the care of teeth and school dentists are instructed to advise children on the care of their teeth. There is a committee to advise on the fluorinisation of water supplies in the interests of the preservation of teeth, particularly children's teeth.

Deputy Desmond suggested that there should be a speeding up of the building of new dispensaries. This is a matter rather for the local authorities themselves. Once the purchase of a site has been approved, I understand, no further approach to the Department is necessary. A special system of grants, designed to encourage local authorities to build dispensaries, was in operation for a number of years. At least 220 new dispensaries have been built and about 20 more are under construction.

The question of the nurses' home at St. Finbarr's is under consideration. Regarding the regional hospital, I think the best thing for me to do is to get all the Cork Deputies together in one room in my absence and let them settle the question.

Mr. T.F. O'Higgins

I would advise the Minister not to do that.

Mr. MacEntee

Opinions appear to be held very strongly in relation to the Cork Regional Hospital and these appear to be almost irreconcilably divided.

I think I have dealt with everything except Deputy Corry's reference to the Defence Vote. It may be that we misunderstand the Estimate, but it is a useful thing to have drawn my attention to it and I will look into it. With reference to the other matter which the Deputy raised in connection with the general Mental Hospitals Act, about a patient being presented with a bill for 25 guineas for surgical attendance, I have written to the Deputy on that matter and I have explained the circumstances. The patient was a Section 25 patient who was sent to a private nursing home, had a private room there and was charged accordingly. If the Deputy will look up his correspondence—he may not have reached it yet—he will find there is a letter from me to that effect.

Mr. Corry

I would like the Minister to have a look at some of the cardboard private wards put up in those hospitals lately to get over the provisions of the Health Act.

Mr. MacEntee

That might be. If the Deputy can give me any information on that, I can look into it.

Mr. Corry

Go down and see it— cardboard partitions.

Mr. MacEntee

I might not get away, you know. With regard to the point raised by Deputy Desmond on the question of the appointment of district nurses, all I can say is that such appointments have been sanctioned in cases in which proposals were submitted by the health authorities, but only if the volume of work in the districts warranted the appointment.

Mr. T.F. O'Higgins

Has the Minister any information now as to when it is likely that the health insurance scheme may be available?

Mr. MacEntee

We have not that information.

Vote put and agreed to.