I should like to express my appreciation to Deputies on all sides of the House for the manner in which they have put their points of view and I am greatly obliged to them for the fact that they have directed my attention to the several matters about which people feel there is some reason to complain in relation to the general administration of the services. In raising these matters they have done a great service to the people and a great service to my Department and to myself. Naturally, we, not being everywhere and not being omniscient, do not hear of all the complaints that may be made about the services. The only way in which we can fulfil our purpose, which is to give the people of this country the finest health service our resources will permit, is when the disadvantages and its defects are brought to our notice.
Of course, no health service is perfect. I pay a great deal of attention to medical literature and study the papers which are available to me from the other side. However, with all the money they are expending in Great Britain there are just as many complaints voiced in respect of that service as is the case with our own. Many of our difficulties, most of the defects which we have had and which have been mentioned here, arise from the fact that we are endeavouring to superimpose a modern health service upon an old and outmoded system of what one might describe as medical relief. That was not done just arbitrarily. It was imposed upon us by our circumstances. We had to adapt the system which was in existence here to the new demands, to the circumstances of the time. It is only in the last three years that the health services have been brought into operation on a general scale. That was done by my predecessor in 1956, and it does take some time even for a well-integrated and co-ordinated service to run itself in. It takes perhaps a longer time to get things running smoothly when you have to graft a new plant on an old stem and that is one of the difficulties which we have to face and which, I think, we are solving.
One of the principal complaints which have been raised here has been about this question of the medical card. The difficulty there is to see what other arrangements we could have than this which is traditional in our country to regulate inscription upon the medical register. It has been and was the custom in the old days to issue red tickets to certain classes of patients. Those tickets were issued in very many cases without any regard to the legal requirements which provided that they were only to be given to those who could not by their own industry or other lawful means provide the necessary medical care for themselves or their dependents. The cards were issued rather lavishly and in the majority of cases they did not entitle a person who received the card to very much and often indeed the person did not get as much as he was entitled to.
The possession now of a medical card entitles a person to a very much wider and a very much higher grade of service. It entitles him to specialist and hospital treatment of a very high standard, specialist and hospital treatment which as we know from what has been said here costs the State a great deal of money. Therefore, if the burden is not going to become intolerable we must be very much more circumspect and rigid in the application of the regulations and conditions which govern the issue of these cards. Deputy Wycherley and other Deputies said the services were costing us a tremendous amount of money but how much more would these services cost us if the cards were to be given out in the lavish and careless way in which they were issued under the old dispensation? We would simply not be able to face up to the financial burden. Therefore, there must be much more careful scrutiny of the circumstances of the person who applies for inscription on the medical register.
As well as that, the tradition also was here that the old poor law authority was more or less autonomous in its own district. It was the authority to determine whether the circumstances of the applicant were such, having regard to the circumstances of the applicant's neighbours and fellow ratepayers, that he should be given the red ticket and should have a claim upon such medical services as were then provided.
That was the traditional system in operation here. When the health services were brought into operation the whole system had to be adjusted to the fact that the health authority, say, in County Leitrim, had the control over the manner in which and the liberality with which these medical cards would be issued, just as the health authorities in Limerick had the same control and the health authority in Cork and the health authority in Dublin. But the circumstances varied in the area of each of these authorities. A comparatively rich community like Dublin, Cork or Limerick, could issue these health cards much more freely than the health authority in a poor county like Leitrim where, if great care is not taken to ensure that only those who really require them get them, an intolerable burden might be imposed upon their fellow-ratepayers. It is the ratepayer who really has to be considered in regard to the manner in which the cards are issued.
It would be very nice and, from the Minister's point of view, much less trouble, if we could get uniformity throughout the country in a matter of this sort but we just cannot, because we know how varied conditions are. We know how different the circumstances and the resources of the various health authorities are. Therefore, I would find it exceedingly difficult to formulate any regulation of countrywide application which would not impose, I think, excessive burdens upon some local authorities and reduce very much the burdens upon other local authorities who might very well be able to carry them.
Again, you have the difficulty between those counties which have a very large urban and industrial population and those counties which have not. Take Louth as an example. I am leaving Dublin out. Take Louth, which has two very large industrial centres—a third, perhaps, developing. Its circumstances are very different from the circumstances of a neighbouring county such as Monaghan or Leitrim where they have not got an industrial population and where, perhaps, on the whole, people are healthier than those living in urban areas or are not so prone to avail of the services of the doctor because they have not got the same convenient access to him as they have if they are living in a town or in an industrial area.
These are the things which make it very difficult to devise any sort of regulation which will ensure that there will be that degree of flat uniformity governing the issue of medical cards which would seem to be the ideal many Deputies think we should aim at. Having said that I want to say that I will ask my departmental officers to examine this question again to see if we cannot find some minimum standard below which a person will more or less get a health card automatically. But remember that that—in my view, at any rate—will be a very low standard. One of its effects may be to exclude people above that standard who are already in receipt of medical cards and that we shall have perhaps even greater complaint under a system of that sort than we have here today.
A question was raised by Deputy Dillon about the desirability of, as he said, refurbishing the old county homes and trying to adapt them as suitable institutions for accommodating the chronic and the aged. I think, in the slashing attack he made upon this proposal, Deputy Dillon was a little bit confused. I think he overlooked the fact that in proceeding to carry out this programme of the adaptation of county homes—I think Deputy Giles also forgot it when he was speaking—we proposed to take out of these county homes, when we do it, all those other classes which are at the present moment housed there, such as unmarried mothers and the hoboes whom the Deputy spoke of, and so on. Our aim will be to make them homes for the treatment of the chronic sick and aged who perhaps because their families have left them, and life has left them behind, have no person left to care for them but who are decent, respectable people and are, therefore, entitled to have, shall we say, comfortable surroundings and circumstances at the end of their lives. That is the type of county home we envisage.
There may be something to be said for the smaller type of home in small towns. That, I am afraid, will be a rather expensive project. It will mean that we might not be able to give the old people in these small homes the same sort of reasonable medical care and attention which they would get in other places. At least, we certainly could not do it without imposing other charges upon the ratepayers and the exchequer.
I do not want the House to think I am ruling out of consideration the type of home Deputy Dillon and Deputy Giles referred to but it would take us a good deal longer to provide it. We will have the difficulty of finding suitable buildings. Then we have the difficulty of finding suitable staffs. In the existing home we have the shell of the structure. In most cases it is very sound, which merely needs a degree of adaptation inside. In addition, we have the nucleus of a suitable staff. That would mean we would be able to get ahead rather faster with the adaptation and reconstruction of the county homes than if we were to adopt an entirely new approach—at least, an approach that has not so far been adopted in this county, such as Deputy Dillon and others suggested.
My predecessor, Deputy T.F. O'Higgins, in the course of his very helpful and constructive speech, for which I should express my indebtedness, referred to the fact that he had contemplated the provision in Dublin city and elsewhere of a choice of doctor for those in possession of a medical card. I should like to be able to do that, too. I doubt whether we can do it without a great deal of consideration. I think we might have to abolish—indeed that is what Deputy T.F. O'Higgins rather hinted—the dispensary system altogether, so far as Dublin is concerned. I think we would have to adopt, say, the panel system such as they have in Great Britain, a system whereby persons in possession of a blue card would have themselves entered on the panel of some particular doctor.
We could not have a patient going to a doctor one month and then, not being satisfied with the treatment given, going off to another doctor. You would have to have a reasonable period involved. The patient, or the person, would perhaps have the choice of a doctor but he would have to remain with that doctor for a certain period, 12 months, or something like that and it might have to be on a fee basis.
But that is a complete departure from the system which has been in operation here for so long. It would be an adaptation of the system in Great Britain with perhaps a couple of modifications necessitated by our special circumstances here. That again is something that I certainly would not like to do in a hurry. We have trouble enough getting the health services to work smoothly on the basis of an existing organisation. If we are to have this other system brought in it would, with the negotiations involved with doctors, health authorities and so on, take an appreciable period of time and I should not like to start the process of introducing that system unless I were satisfied that it would give us better results and that it would not—and this is the overriding factor —involve us in any great additional expense.
There are so many things we have still to do in the existing circumstances for which we have not got the money, and for which nobody wants us to find the money, that we could not think of embarking on anything likely to involve us in any very substantial additional expenditure.
There was one other point to which Deputy O'Higgins referred and which I think I ought to mention. He indicated that he disagreed with the policy which I had been pursuing in relation to the building of hospitals and the general management of the Hospitals' Trust Fund. Well, there is a difference of approach there. I hope that my approach will in time be found to be better justified than that which had characterised the general policy of the Department for some years before I came in. I do want to make it quite clear that I think it would be the height of folly for us to initiate any programme unless we have a very substantial reserve so that if anything should happen the Hospital Sweepstakes, to reduce substantially the income from the Hospital Sweepstakes, we shall at least be able to complete whatever projects we shall have embarked upon.
That is the fundamental principle upon which I am operating. I want to say that we have got to remember that the income from the Hospitals Trust Fund comes from a great many countries outside this country. In the present international situation we have no guarantee that we might not find ourselves in the same situation as in the period from 1939 to 1945 and 1946 when, because there was a war raging outside this country, the income from the Sweepstakes suffered a very great decline. That I think is a fact which we have always to keep in our minds.
I have no doubt whatever that the reputation of the Hospital Sweepstakes grows higher every day. I have no doubt about the energy and enterprise of those who manage the sweepstakes, and I know that so long as conditions in the world remain normal their income is not likely to be reduced and may in fact increase. But we cannot, and we should not, as prudent people, particularly in the world in which we live today, overlook the fact, or ever leave it out of our minds, that there may be such a cataclysm that the sources of income of the Sweepstakes would be very drastically curtailed. That is the insecurity I referred to last year and to which I referred again this year and which I always keep in front of me.
For those reasons I am anxious, before we start any sort of building programme or resume our hospital programme again, to ensure that, as I have said, once we start a project we shall be reasonably certain of being able to carry it through. We do not want to find ourselves in the situation, for instance, in which the hospital authorities found themselves in 1956 and that, let me say, was not due to any defect of judgment on the part of my predecessor. He had continued the policy initiated very many years before but we just found ourselves, by reason of the circumstances, unable to continue that policy. So long as I am Minister for Health I do not want to find myself, or to place the hospital authorities, in that position.
Deputy Healy in his speech this morning mentioned a matter which I think calls for special comment. He referred to the fact that in certain Cork hospitals patients were being referred to specialists by house surgeons. If this practice does in fact exist, it is quite wrong. House surgeons should refer patients to a specialist only where specialist examination is clearly necessary. If there is any evidence that the contrary practice is in any way general, I am afraid we should have to take very sharp notice of it because the whole basis of the arrangement made in relation to the establishment of these specialist clinics was that the hospital which conducted a specialist clinic would at the same time conduct an ordinary out-patient department and that people in the out-patient department would not be given specialist attention unless that was absolutely essential.
Many Deputies referred to the grave deficiencies which exist in the accommodation for mental defectives. I think no Deputy is more conscious than I am of the vast gap which exists between the accommodation which we have available and the demand for it. Over the years we have been endeavouring to close that gap. I think I should give the House some figures to show that some progress—perhaps not as rapid as any of us would like but nevertheless such progress as it has been possible for us to make—is being made.
Prior to the commencement of the post-war building programme in 1948 approximately 1,000 beds were available for mental defectives. Under the programme a total of 1,300 beds has been added, so we have now 2,300 in all. At the present moment an additional number of approximately 450 beds are in course of preparation. As well as that, we have premises at Woodlands, Galway, and Croom, Limerick, in prospect. In one case, if we can get the necessary permission from the Ordinary of the diocese, we may be able to find a religious order who will be prepared to open Woodlands as an institution for mental defectives. In the case of Croom, I do not think we shall have any difficulty. We have both these places in view and they will add between 150 and 200 beds.
As institutions become available, one of our purposes will be to try to utilise them as homes or centres for mental defectives. The problem, however, is not just as easy of solution as people think. Reference has been made to the fact that many religious orders devote themselves to the care of persons falling within this category, but even the religious orders, we have found, cannot always meet the demands made upon them. It has been necessary for us to try to attract religious orders from abroad to take over some of the vacant institutions when they become available and utilise them for that purpose. I can assure the House that, as far as the officers of my Department and myself are concerned, there is not anything we can do to grapple with this problem that will be left undone.
We are very sensible in the Department of the deplorable condition of many of our mental hospitals. They are not all in that condition. This morning Deputy Collins referred to the changes which have been made under an energetic R.M.S. and visiting committee in the Limerick Mental Hospital. There are other mental hospitals where improvements have also been made, but there are many where conditions have been static for a very long time and where little has been done even to maintain the existing fabric. But—and this is the point I want to make—Deputy Dillon suggested that these conditions were unknown to members of this House. He seemed to suggest that, in some way or other, we were trying to cloak or conceal the state of affairs which exists in certain of our mental hospitals. That is just nonsense.
The report of the inspector of mental hospitals is published every year, and I have taken the opportunity of circulating to Deputies whom I thought might be able to do something in their own areas, extracts from that report in the hope that, where conditions seem to be worst, something might be done to get improvement. There is no secrecy about the conditions; the facts are published. The only difficulty is that we just have not got the resources, either in money or personnel, to produce startling or spectacular improvement. We could do with some of the money that was expended some years ago but that is water under the bridge and there is no use talking about it. We just have not got the financial resources to tackle this job as we should like to, nor have we got the personnel.
It will not be easy to get the personnel for the carrying out of new treatments and the staffing of these hospitals as we should like to see them staffed. But we are not unique in that. I was reading the other day, again in a medical journal, about certain conditions in Great Britain. In Great Britain, with the remuneration and conditions being offered in that country, they were complaining they could not get the number of people to devote themselves to this particular branch of medicine they would require. I read indeed of a university in England where there is a Nuffield Psychiatric Foundation and they were saying they had not been able to get sufficient students to fill the course. The fact that we find it difficult to get personnel for our mental hospitals is not unique. We are just sharing that condition with, shall we say, the rest of the world. There is little use having our buildings without money. There is little use having them unless we are able to staff them properly. However, what we can do with our resources in staffing and in finance we shall endeavour to fulfil to the utmost.
Unfortunately it happened last night when Deputy Dr. Browne was talking that I had to leave the House because I had another engagement which called me out and I did not hear him fully. I should like to say I appreciate his anxiety in regard to both lung cancer and poliomyelitis. But my temperament is just not his temperament. Certainly in relation to lung cancer my psychological approach is rather different to his. I do not believe you can get very much done by continuous advertising and pamphleteering in relation to smoking. I think that in general the knowledge that smoking, and particularly cigarette smoking, is likely to be a cause of the incidence of cancer is generally very well known throughout the community. The only thing you can do is rely on those who have care of the young to induce them by precept and, best of all, by example to refrain from cigarette smoking.
Casting my mind back to the days when I was young, I think that when I was told not to do a thing and it was dinned into me, I was sometimes inclined to kick over the traces and do it. I am perfectly certain that is the general view among a great many of the young. An advertising campaign might appear to be very spectacular and might secure for the person responsible for it the reputation that he was trying to do something very drastic or novel, but I think the only effect would be to build up a bogus reputation for himself and that it would do very little to induce people to abstain from smoking.
Again, with regard to polio, it is a very dreadful disease; but it is not so common and it is not so likely to be fatal as many other diseases are and gradually treatments are being evolved for it which are likely to be able to overcome the sequela to the disease, the disablement which it leaves behind. Again, one has to deal with the problem calmly and coolly and there is not anything to be gained by trying to work up a sort of hysterical approach in the minds of the public to it. We have done a great deal and have gone a very long way to make it possible for any persons who wish to have it done to have their children vaccinated against polio. If persons wish to avail of the public service, in the vast majority of cases they will get the vaccination free and if they happen to be in a position to contribute towards it—and I think it is not too much to expect them to do something for their children in this regard—they can have now a full course of vaccinations at the rate of 7/6 per child if there are more than two children vaccinated and at the rate of 10/6 per child if there are only one or two children vaccinated. I do not think that is an undue burden to impose upon any persons who is able to pay it. If persons are not able to pay even the 7/6 or the 10/6, they can have their children vaccinated free and, not only that, they can have them vaccinated up to the age of 18 years. That is a fair contribution to ask the general body of the public, the ratepayer and the taxpayer, to make towards ensuring that other people's children, in many cases, are safeguarded against the disease.
Deputy O'Higgins referred to the change which had taken place in the chairmanship of the National Cancer Association. Here, again, I should like to pay a tribute to the speech which was made by Deputy Russell. Deputy Russell was for many years chairman of the Cancer Association of Ireland. It is possible that the sort of ministerial or departmental control which had to be exercised over the very energetic activities of the association and the expenditure which inevitably followed on them may have nettled Deputy Russell somewhat and, in any event, perhaps, he may have found that other considerations compelled him to resign from the chairmanship. I would just like to say that, whatever differences of view there may have been between himself and myself, I very fully appreciate the great service which he rendered to the association from the day upon which he became chairman and I should say that all successive Ministers for Health, not excluding myself from that category, owe him a debt of gratitude.
The fact is that there was a fundamental mistake made when the Cancer Association was organised because, not merely was it made a sort of directive, consultative body for the whole of the country, but it also was made the managing authority for the St. Luke's Cancer Hospital, which it built. There happen to be other institutions dealing with cancer cases—other cancer hospitals as well as St. Luke's—and I think the arrangement whereby the Cancer Association, which was supposed to co-ordinate the activities of all the hospitals, was at the same time the administrative authority for the newest of these hospitals produced a situation which was illogical and not likely to lead to the smooth development of the cancer services in this country.
The chairman, Deputy Russell, having resigned, it is possible for me to make the change which I satisfied myself over a year ago was desirable and, in order to enable the necessary amendments to be made in the memorandum and Articles of Association, I have appointed an officer of my Department, who has had very considerable experience in relation to the whole question of cancer treatment, for the time being, chairman of the National Cancer Association. I have already conveyed this to the other hospitals concerned—my ultimate purpose will be to have St. Luke's administered by a separate authority but to have, over and above St. Luke's and representative of the various hospital interests and the other interests, the Cancer Association. Probably it will retain that name but, if not, whatever the name may be, to have it, as I have said, much more a representative organisation, one in which no interest will feel that it is prejudiced because some of those represented on the body have a sort of predominant place in the treatment of cancer.
Deputy Wycherley mentioned the question of the Bantry Hospital. I regret that the Bantry Hospital is closed. I regret that it has not been possible for us to have it opened but it would be opened—at least I should have hoped it would be opened—if it had not been for the advertisement which the I.M.A. put in the papers asking people to boycott the competition, which had been advertised, for the posts of County Physician and County Surgeon to the hospital. It is all very well to say that we should meet the I.M.A. I have agreed to meet the I.M.A. provided that they withdraw the bar which they have imposed upon members of the profession in regard to these particular posts and, until they do that, I am afraid, unfortunately, and it is greatly to be regretted the Bantry Hospital will remain closed.
There is a very much bigger issue at stake than the mere opening of the Bantry Hospital. Deputy Wycherley has been complaining about the tremendous cost of the health services. It is my job to keep the cost of the health services within moderate bounds and it is my job to try to ensure that when fair conditions are offered in matters of this sort the will of the Oireachtas prevails. I am not going to have a pistol held to my head by the I.M.A. or any other professional organisation. I feel that the terms and conditions which were offered for these posts were attractive and I have no doubt that if the I.M.A. lifts its ban on the competition for these and other hospital posts we shall get ample competition from first-class practitioners at the salaries and under the conditions we are offering.
Before I sit down, I think I should deal with the question of the dental services. I think it is the one thing I have not referred to. The position in relation to the dental services is very much like that in relation to the mental services. There again it is a question of money in the first case and in the second case, a question of being able to secure the requisite personnel.
So far as the personnel is concerned, here is the position. In the past few years, it has become increasingly difficult to fill approved posts in the local authority dental services. That, of course, is due to the fact that there is still an unfilled demand in Great Britain for dentists. That has left us with the situation that last year 16 vacancies were advertised and it was found possible to fill only two of them. Of the 81 permanent dental posts in the local services, which up to the present have been approved, only 61 are filled. There are, in addition, 13 temporary posts, so that between those who are permanently appointed and temporary officers, we have still only 74 people to fill 81 dental posts. Therefore, it would be quite impossible for us, until this situation rights itself, to extend even the school medical services further.
There is the financial aspect of it. If we were to employ dentists in private practice and pay them at the same scale of fees as they are paid for the Social Welfare services, the additional cost would be something of the order between £750,000 and £1,000,000. I ask Deputies to consider where, in present circumstances, we could get £750,000 or £1,000,000 without imposing further burdens upon our whole economy, upon our agricultural and manufacturing industries, making these industries less competitive.
There was one other issue which was raised and to which I think I should also refer and that was the fact—I think it was Deputy Russell mentioned it—that we were less generous than he thought we should be in regard to the allowances to disabled persons. I think it was he or some other Deputy who suggested that because there was a disabled person living in a house in which his brothers or other members of his family were earning, the local authorities were inclined to refuse to grant any allowance.
The position in relation to disabled persons is that they are costing us all but £750,000. That is a very much higher figure than was anticipated when the Health Act of 1953 was being introduced. It is quite obvious that we cannot go very much higher in a matter of that sort without again imposing the obligation upon the health authorities of increasing the rates and without my having to go to the Minister for Finance to try to get some more money from the taxpayers. Again, it is just a case that, no matter how sympathetic we may be, the general body of the people are doing just as much as they can afford to do in present circumstances in relation to this service.
Certainly, I cannot see any justification for the brothers and sisters or the parents of a disabled person having recourse to the local authority if their own means do not make it absolutely necessary and essential for them to do so. There is not any obligation upon the rest of the community to support any person simply because he happens to be disabled. There is a claim in charity on the community if the person is not only disabled but if he and his family are in such necessitous circumstances that they are not able to support him; but where the means of the parents, the brothers and sisters of a person who happens to be disabled are sufficient to maintain him in frugal comfort, I do not think they have any right to have recourse to the public purse to relieve them of what are their own filial obligations.
I should like to say again how indebted I am to all the Deputies who took the trouble to participate in the debate and raise the matters which have been agitating themselves and their constituents in relation to the administration and scope of the Health Act.
