First of all, I think I might say that the impact which the Minister's speech made on me personally is the fact that, whether we like to admit it or not, we cannot at present afford in this country, apparently, the type of comprehensive health service that we would all in this House wish, I think, to see available to our people. That being so, we must, of necessity, decide what priority we shall give and what type of service we shall allow in strict order of their necessity to the individuals concerned. In other words, I think, as the Minister suggested in his statement, we should be prepared to face the fact realistically that to spend all the money that might be required on a certain service might do a disservice to another and possibly quite as important a section of our health services.
We have to some degree reached the position where, having exhausted the Hospitals Sweepstake Fund and being in the situation that the Exchequer is unable to pay into the health services fund, we must of necessity spend what we have in the best possible manner. It is unfortunate that we have reached this situation at a time when there are certain services crying out for financial assistance. Several of those were mentioned during the discussion last night.
The question of mental defectives is one to which every Deputy who spoke referred. It is a matter on which I should like to add my voice also. There is no doubt that the position, generally speaking, of mental hospitals throughout the country is unsatisfactory, to put it mildly. The position with regard to the availability of accommodation for treatment facilities for child mental defectives is deplorable at the present time. I referred to that fact last year when speaking on this Estimate and, I think, the previous year. A number of other Deputies referred to it also. It is a fact that the number of beds available for these unfortunate children at the present time is completely inadequate to cope with the demand.
I am sure there is no Deputy who does not know of a number of cases where a family has the tragic situation of a small child, mentally retarded, living amongst other children and causing deep, distress to the parents at home. I hope that, when the Minister is deciding on the priority to give to the funds available to his Department, he will put very high on his list the question of mentally retarded children.
In the course of his review, the Minister referred to the work being done by voluntary rehabilitation societies. I do not think he laid particular emphasis on the good work being done by the societies. He did say that some of them secure a State subvention for the work they carried out. I think I am correct in saying that the amount of State subvention in these cases is a very modest one compared with the subventions paid to other sections of our health services. I should like to avail of this opportunity to pay a tribute to the various bodies that have undertaken this type of work in its various phases in this country.
The Minister devoted quite a substantial part of his speech to the question of the operation of the health services and to various complaints that have reached his Department. Naturally, the question of medical cards is one with which any public representative, be he a Dáil Deputy or a county or city councillor, comes very much in touch. There is no doubt that there is generally over the various health areas a very great variation in the interpretation of who is and who is not entitled to a medical card.
I think it is quite understandable that a county or city manager, being a human being, must, of necessity, do the best he can and give his interpretation in the light of the facts put before him. That must again give rise to various interpretations because every city and county manager will not assess a person's entitlement on the same basis. He may go as near as he reasonably can but we are bound to have these variations, not only from area to area but actually within individual cases in each area. That is what is happening. From my own experience, I am satisfied that there is substance in the complaints that people not entitled to medical cards will get them, whilst those entitled are not in some cases being treated as fairly as they should be. I think the situation is bound to continue as long as we have this—what I might describe as—half-way house State medicine. We are bound to have these anomalies until we can afford an all-embracing comprehensive health service.
The Minister said also that complaints in regard to dental services were reaching his Department. I feel that it is again a question of priority. If we cannot afford to give free service to everybody who is unable to pay for it, it is only right that we should lay emphasis on prevention rather than cure and, to my mind, prevention of decay of teeth in the child should come first. From my own experience I know very good work has been done through the school medical service in regard to the preservation of teeth but, due to understaffing, children are not being examined as often as they should. The whole business of preservation of teeth is not being tackled as it should be. I suggest that if the Minister's Department would investigate the schools medical services in the different areas as regards the operation of the dental service for school children, it would be well worth the trouble involved. The same applies to a lesser extent in the ophthalmic services.
I had rather hoped that when the Minister was introducing this Estimate he would have given the House a general review of the health services, their cost and operation and the value, not in £s. d. but from the point of view of return to the community, of the health services since the introduction of the 1953 Health Act. Complaints continue to arise out of the operation of that Act and one oft-repeated complaint is that the Act costs taxpayers and ratepayers considerably more than the modest estimate of—I think—2/- in the £ which the then Minister for Health, Deputy Dr. Ryan, estimated for 1952-53. In most health areas, I think it is a fact that the cost to the ratepayers for the services introduced by the 1953 Act is two or three times the estimate of five or six years ago. I think nobody at that time seriously believed that estimate to be realistic because the cost of health services and everything else is going up continually. Some allowance must be made for the fact that costs in 1952-53 and costs to-day are very much at variance but, having said that, it still strikes me that the estimate then made was very inaccurate and this has been borne out by our experience.
The Minister referred at some length to the charge by hospitals of what was intended to be a maximum figure of 10/- per day. Like medical cards, that charge is a matter about which public representatives are frequently approached. Another aspect of that charge is that in a number of cases the hospitals have difficulty in collecting the 10/- or less per day from the patient. In theory, the hospitals are entitled to levy a charge according to a patient's means of up to 10/- per day but I know of no means whereby the hospital authorities can compel the patient to pay the 10/- or less. Actually I know that a number of hospitals have not collected it and when the time comes to submit the figures for their annual deficit the Minister's Department declines to accept the excuse that these charges cannot be collected from the patients concerned. This all stems from the fact that we have a half-way house system and we are bound to have these anomalies. I think we must put up with them and expect them until we have a more comprehensive health service.
Several Deputies, particularly Deputies T.F. O'Higgins and Dr. Browne, referred to the dispensary system. I agree with the sentiments expressed by them in regard to that system. I think we should regard the dispensary system as a dying one and any effort to maintain or continue it is, in my view, a step in the wrong direction. The view put forward, I think by Deputy O'Higgins, that we should visualise a system whereby any general practitioner should be encouraged and naturally rewarded for examining any patient should be put into effect, if necessary, gradually, over a number of years. Any person who is ill should have the right to see any doctor he chooses and confining him or her of necessity to the dispensary doctor is, to my mind, a violation of the rights of the individual. The mere fact that he cannot pay, or can only pay a certain amount, should not preclude him from going to any doctor he chooses or wants to regard as his family doctor. I think that in the future development of our health scheme we should aim at bringing into a comprehensive scheme the whole body of medical practitioners in the country. I am sure the Minister will agree with me in paying tribute to that body, particularly to the G.P.'s who have done trojan work in looking after their patients over the years.
I am sorry that this year again the Minister could not see his way to extend the free polio injections to all children within a specific age group or groups. I agree with the principle he enunciated when introducing the present scheme that those who can pay should pay and that those who can pay something should pay something but I think in actual fact it is easier to introduce a free scheme for specific age groups than do what he has done —try to divide it into the three categories I have named. I do not think there would be anything fundamentally socially wrong in that.
I am sorry also that in his review of the general health services the Minister paid so little attention to what I would regard, and what he has described, as one of the greatest killers of our day, cancer. The Minister might have given us some indication of the plans of his Department to deal with cancer in future.
No Minister has to my knowledge over the past ten years referred to the work of a body with which I was associated as Chairman for some eight or nine years and from which I resigned, for reasons which I do not wish to discuss at this juncture, some two or three months ago. I refer to the Cancer Association of Ireland. Deputy T.F. O'Higgins made a reference to that body last night and, while I have no intention now of going into details on the subject he touched on, I should like to point out that if one wants a voluntary body to operate effectively in the interests of any particular health service, there are certain conditions that body must enjoy.
First, they must have the confidence of the Minister for Health of the day; secondly, adequate funds must be put at the disposal of the body; and thirdly, there must be a reasonable degree of independence to permit of the body carrying out the work for which it is set up. If the body does not enjoy these three fundamental conditions, it cannot operate effectively or carry out efficiently the task for which it has been established. As one associated with the Cancer Association over the past ten years, I can at least claim that that body did in fact carry out the work committed to its care, although it did not enjoy the three fundamental conditions to which I referred a moment ago.
When the Association was set up in 1950, there were something like 1,300 people or 1,500 people dying every year from cancer—people who had received no treatment for the disease. There were something like 100 beds available to deal with the problem of cancer patients generally. There was an acute shortage of beds. There was also a shortage of expert medical personnel. Some seven or eight years later, the position was completely reversed; and two or three years ago, we had reached the stage where there was no shortage of bed accommodation and anyone requiring treatment for cancer could be taken into any of the three cancer hospitals without delay. In those hospitals, there were trained personnel in sufficient number to deal with every patient. The best facilities possible were available in all three. All that was done at a very modest cost to the State.
I touch on this because the Minister, quite rightly, stressed in his review the exceptionaly heavy cost to a small country like this of providing our present health services. If any Deputy wishes to examine the cost of providing a national cancer service, he will find that it represents only a very small proportion as compared with the cost of dealing with the tuberculosis problem over the same period of years. I like to think that one of the reasons the cost was so modest was that the Minister of the day entrusted the problem of providing this national service to a small voluntary body. It is along those lines the Minister might find the answer to some of his other problems now, and at a far lower cost as against trying to provide services directly through the agency of his Department.
There is one aspect of the cancer problem that has not so far been tackled at all. It is one to which, I think, the Minister should give his early attention. I refer to the question of providing facilities for those who are beyond cure. This is, of course, largely a welfare problem. It is one that has not so far got any serious attention from the Department of Health. In England, the problem has been tackled very largely again through the agency of voluntary bodies. They collect funds through public appeals. They provide homes where trained personnel look after those who have passed beyond the point of treatment by any of the modern forms of anti-cancer research. I should like to see the problem tackled here on the same basis. From my own experience, I am satisfied that a voluntary body would be best fitted to cope with the problem, provided, as I pointed out previously, it has the help and encouragement of the Minister, sufficient independence to enable it to carry out its work efficiently, and sufficient funds. Those moneys might be found by the body itself through public appeals or, in whole or in part, from the Department of Health.
Another matter upon which the Minister touched last year, but about which nothing has been done since, is the question of education in regard to the treatment of cancer. As I mentioned, we now have all the necessary facilities here to treat cancer, but we still lag far behind other more advanced countries in the provision of a proper educational system to encourage people to avail of the facilities that have been provided. Last year, I suggested to the Minister that this might be handled, too, on a voluntary basis, by the Cancer Association itself, through some other body appointed for the purpose, or even through the Department. I am aware that certain steps were taken to deal with that aspect of the problem while I was associated with the Cancer Association. To my knowledge, nothing further has come of them. If I may quote Great Britain again, the position there is that they have found over a period of years that the public respond to a certain type of education and propaganda, provided these are well organised and directed.
I do not know what the Minister's future plans are in regard to cancer care and treatment. The task for which the Cancer Association of Ireland was set up is to a large extent complete. As I am not now associated with that body, I should like to take this opportunity of paying tribute to those dedicated men who over the past eight or nine years have bent all their efforts and their energies, given their time and taken the trouble, to providing cancer sufferers here with the opportunity of securing treatment and alleviation of pain. To a small number in particular, I should like to pay a special tribute. I only wish we had more men prepared to devote their energies and their abilities to helping their fellow citizens so generously and so humanely.
The trouble about voluntary organisations is that, unless they are encouraged and helped, they will not carry out the work for which they are appointed. In some regards at least, I am afraid that considerations other than the welfare of the sufferers have entered into the dictates of the Minister and his Department in dealing with one particular body. I shall say no more on the subject of cancer. I have talked about it for a long time because, to me, anything I could do in that regard was a labour of love, and any small contribution I have been able to make towards the alleviation of suffering has been one that has given me no small degree of comfort.
I was glad to hear from the Minister that he has decided to continue with the scheme for renovating and reconstructing county homes. That is something which is very good news, particularly to Deputies living in the rural areas, where, unfortunately, the only hope for the aged person is to go into one of these county homes. I hope also that the name "county home" will be removed when carrying out the necessary reconstruction on the various buildings and that, for the future, the aim will be to provide some place where the old people can live the remainder of their days in a degree, at least, of comfort, in friendly and decent surroundings. It is, unfortunately, too much to hope that the old people can any longer be accommodated with their families. That would be the most desirable thing of all, but we must have regard to modern conditions, and we must appreciate that nowadays the younger people with families find it difficult enough to manage, without the additional worry and responsibility of the older people.
Several Deputies paid tribute to the voluntary health insurance scheme and I should like to join them in that praise. The only thing that worries me is: Is the voluntary health insurance scheme the answer to the provision of health services for all those who cannot afford to provide the necessary finances from their own resources? I should like to think it is. I should like to see a great expansion of the whole idea of voluntary health insurance, but, having regard to the history of our health services over the years, and looking around to see what is being done in other countries, we must admit to grave doubts as to whether or not we will solve our difficulties through the voluntary system.
We might be well advised to have a closer look at what is happening in Great Britain and Northern Ireland to see whether some adaptation of their scheme might not suit our conditions. That might be worthwhile, but in saying that, I do not wish to be taken as advocating an all-out State medical service. In fact, if at an earlier stage, we had encouraged our people to adopt the voluntary system, we might have been able to solve our problems along those lines. We have now gone too far on the road to State medicine to turn back, and it seems to me the solution must be found on some basis of State-aided hospitalisation and State-aided medicine.
If we could conceive a scheme whereby hospitalisation, perhaps not in its entirety, but with certain exceptions, could be taken over by the State and operated either by a joint health authority or regional health authorities which would be given reasonable freedom of action and which would be subsidised either wholly or partly out of central funds—and the general practitioner should be kept outside this scheme and allowed freedom of action, while, at the same time, being put in a position to see all patients, irrespective of whether they were holders of medical cards or otherwise—we might be able to evolve something which would be economic in terms of pounds, shillings and pence and, at the same time, give a worthwhile service to the community as a whole.
I know it is a very tangled and difficult question, but I am satisfied that the answer is not a complete all-out State medical service. I suggest to the Minister that it might be worthwhile having a look at our neighbours across the Channel. We copy them in so many matters that in this case it might be worthwhile having a look to see if we can take out of their scheme anything that would be capable of adaptation to our conditions.
In his address, the Minister referred in trenchant terms to the fact that he would not be cajoled—he almost suggested "codded"—into financing projects for the extension of existing hospitals or new hospitals, or for schemes for which he had not given prior sanction. He said he would keep rigidly to his decision in that regard. That is a very proper attitude, having regard to the limited funds at his disposal but the Minister might have given some indication as of this date, first of all of the commitments of the Hospital Trust Fund and, secondly, of exactly what hospitals are planned over the next five or ten years.
We should have an agreed scheme for the next five or ten years so that a change of Government or a change of Minister would not necessitate a change in the plans made and agreed on. The Minister would be doing a service to the House if he indicated what, in his view, should be the priority of the schemes to be tackled and if he gave an estimate of the cost of those schemes for the next, say, five years. That would tell the House exactly where we stand in regard to our resources for financing these schemes and what schemes the Minister felt should be tackled. It would also give an opportunity to the House to criticise his views and to put forward their own views as to what they regard as "first things first".
I have criticised some parts of the Minister's address and I would like to end on a note of congratulation on the progress that has been achieved over the past 12 months, and over the previous years. In this House we may disagree on various aspects of what Ministers for Health do but, by and large, we do give them credit for the best intentions. As I have said, we have not got the necessary funds to do everything we want to do, but we owe it to the Minister for Health to offer him constructive criticism and assure him that, in his efforts to alleviate suffering and pain, he will have the support of every side of the House.
