I found the Minister's speech on this Estimate a fund of statistical data, interesting material and informative detail. Much of it was information on current topics such as smallpox and lung lancer, both of which came in for quite a lot of discussion during the past year. I found in the speech, also, I am sorry to say, the ability of a good politician to say nothing.
There was no indication of policy which is, of course, what a Minister for State is for—to propound and implement policy. I am aware of course that there is a Select Committee enquiring into future policy in regard to health services but the circumstances in which that Committee was set up must be recalled. It was set up by an amendment to a motion set down by members of this Party seeking to alter the policy in regard to health. In fact, that Committee will preserve the majority of the Government in their findings because there is a majority of Government Deputies on the Committee. Accordingly, the position is that any report which disagrees with the findings of that majority in practice will have to be a minority report. The opinion of the minority here has been stated already during the debate on the motion on health policy.
Be that as it may, the existence of the Select Committee does not free the Minister from the responsibility I have mentioned—that of propounding and implementing health policy, and no fund of information, no mass of statistical data, no matter how interesting and informative, is an excuse for the job the Minister has been set to do. I do not want to discuss at length desirable changes in the health services because anybody who wants to investigate the suggested changes can read the reports of the debate on the matter.
I shall say, though, that, at first, the operation of the British Health Act was expensive and partly a failure, but in its amended state at the present moment gives a much better service to the ordinary individual than our Act does, for a very good reason: it is based on the old adage that the customer is always right. The customer can sometimes ask for too much and that is where the amendments became necessary because the situation at the start of the British Act was one in which, if I may coin a somewhat impossible phrase, the customer was always too right.
However, the British have now succeeded in getting a much better approach to their health services and that should have been mirrored here had there been an acceptance of the reasoned arguments put forward by this Party and if that acceptance had resulted in a decision by the Government rather than an amendment to set up the Select Committee.
The Minister is responsible for our existing health legislation but he has not proposed here any changes in it. The existing legislation, as I see it, whether or not one enjoys certain privileges, is related to extraneous matters such as valuations, the level of the rates struck by the various local authorities, the level of the rates in various counties and the degree to which the rates affect individuals.
All these matters must affect county managers in their decisions on health expenditure and this is one of the problems created in the 1953 Health Act. I am sure the House will agree with me that these matters of valuations which are historical matters except when they are revised, and the level of the rates, vary from county to county. According as they vary so does the administration of the health services from county to county. For instance, there may be a county in which there are many industries. If one were to take any reasonable size of business one could apply to it a rate of about £500 a year but in the case of that business that rate would be proportionately nothing in relation to the other over-heads. On the other hand, take a rating area in which the vast majority of the people are farmers. If a farmer pays a rate of £500 each year, that amount, in relation to his output, may be his greatest expense.
Consequently, if there is a large number of farmers in a local authority area, when the local authority sits down to strike its rate it can give less money in relation to the demands of that area for the health services. Is it fair and just that a citizen, because he happens to live in one local authority area, should have a different judgment upon him as to the degree to which he shall enjoy the benefits of the Health Act?
Let us take the example of which I have best experience. Deputy Tully and I disagreed on this matter before and, while keeping to the rules of order, we may now be able to discuss it again. In Louth the population is 69,000. In that county a penny in the £ yields £1,000. When the 26 county councillors sit down to vote the amount for health services they do it on the basis that a penny will get £1,000. In Deputy Tully's county, Meath, the population is 67,000 and a penny in the £ there yields £2,300. Must not the decision of the county manager be conditioned by these variable conditions and is not that the reason for the failure of the Health Act? Is it not the reason there is complete dissatisfaction with it? The Minister came in here and gave us statistical data and information on lung cancer and smallpox infection, all interesting material which I should love to see circulated in a White Paper. I have already said that it is the Minister's job to propound and implement policy.
Let us consider the matters that are affected by these variants which are permanently to remain. During the coming year, the issue of the green cards means an acceptance by the local authorities of certain financial burdens. The issue of the green cards is conditioned by the variants I have mentioned. Consider also the position of the county manager and his officials. He must pass judgment every day of the week. In a situation in which the breadwinner in a house becomes ill and will be in hospital for the next two or three months, if he has not got a green card his case must be dealt with by the officer, who must deal with it on the basis of approximately the same number of people and on the basis of the £1,000, £2,300 or other odd figures obtained in the different local authority areas from the 1d. in the £. Non-holders of green cards may also contract a disease which calls for the use of expensive drugs over a long period, and their case may also have to be adjudicated.
There is another matter related to this matter and it shocks me that it was not mentioned by the Minister, but it exists. I refer to dental provisions under the Health Act. Let us consider the position in Louth. We had made no dental provisions under the Health Act because we could not afford them. Possibly Deputy Tully and his counterparts in Meath County Council have been in a position to do so—I hope they have—but is it right, is it just or is it fair that we could not? During the past year, I devoted a certain amount of attention to the fact that there is a class of patient who, I feel, should have dental facilities available to him, even though we cannot afford them generally. The type of person who needs them most is the green card holder whose wife is expecting a child.
As everyone knows, at that stage a lady's teeth must be attended to or they will fall out of her head. There is a numerous class in my constituency, namely, the farm labourer and his wife. She has been married a year before and is now expecting a child. They have had the expense of the wedding and setting up house. They will have the expense of getting a complete outfit for the child. There will be expenses in the confinement which are not provided by the Health Act. That unfortunate girl cannot possibly say to her husband: "I want to go to the dentist". If she is a decent girl, she will not do so, preferring to let her teeth fall out of her head. That is what is happening.
I discussed this matter with the county medical officer of health. He said something was brewing and asked me not to go any further, and I did not. To my horror, I discovered that what was happening was that someone in Galway sued the Galway County Council for dental services. That matter was not mentioned by the Minister when introducing his Estimate. In Louth we got a circular from the Department and we had to provide a token sum for dental provisions so that the people of Louth could not sue us. The county manager advised us that we had no choice but to vote £1,000 and we did so.
I thought we should devote it to those people I had discussed and I asked the county manager for the figures. There was a great consultation and it was discovered that we could not give this £1,000—I nearly used an adjective—which we had voted, even though we could not afford it, to those expectant mothers but that it was first come, first served. The Minister gave us no facts on that matter, either. He gave us excellent information and statistics on other matters but not on that.
There is also the question of the dispensary doctors. Our county is about 50 per cent. urban and 50 per cent. rural and I have probably had as good an opportunity of assessing this situation as anyone else. My view is that the position regarding the dispensary doctors will have to be changed. More people are now living in some dispensary areas and there are various extras brought about by the advances in medicine so that dispensary doctors in particular areas are completely overworked. Some of them are not and, in fact, it might be said that a few are underworked. A vast number of the dispensary doctors are exceedingly good but there is an occasional one who is not overworked.
We put down a motion which the Minister cancelled by amendment through the strength of his vote in this House. We wanted, in the urban areas at least, to have a choice of doctor on a panel system. The Minister did not discuss that on his Estimate. Under a panel system, if the number of patients gets too large, the doctor would appoint an assistant, and if the number again got too large—we could follow the line in Britain or think up a better one—he would appoint a partner. If the service was not satisfactory at the end of the year, the householder could remove his five, six or seven cards and go to another doctor and, of course, the income of the first doctor would be reduced by that amount. That is something else the Minister might have discussed but did not.
I shall leave that aspect of health for the moment and discuss the problem of mentally retarded children. The Minister told us that the institutional treatment available was largely handled by people with vocations. They were not his exact words but that was his meaning. I should like to pay tribute to the wonderful men, the Brothers of the Hospitaller Order of St. John of God, who do so much work in looking after mentally retarded children. My colleague, Deputy Faulkner, and I live quite close to one of their ins itutions and we both know the wonderful work that is done there. How they do it, I do not know. It can be done only for the honour and glory of God. The Minister has indicated, as have other Ministers for Health, that so far as equipment and accommodation are concerned, he would put on no brake. We must then leave the matter to God. I hope more people will find in themselves a vocation for that extraordinarily high calling.
There are other factors which must be discussed, however. I received this morning in the post a copy of Caritas which is the spring issue of the organ of the Hospitaller Order of St. John of God, and on page 3 of that publication, there is a brief survey of “The Mentally Handicapped in Ireland” by Brother Damien O'Shea. I found it extremely informative. Brother Damien produces figures in regard to the number of mentally handicapped children on page 5. These are: mildly retarded, for non-residential care, 17,000; requiring residential care, 7,000. Of those, 2,000 are mildly retarded, 3,800 are moderately retarded and 1,200 are severely retarded. This figure surprised me inasmuch as it showed me that the number that could be treated outside institutions was relatively very large and that there was a vast amount of work that could be done.
On page 11, there is a Table giving the number of day centres for mentally handicapped children available in the country. This number only totals seven institutions. I know one of them very well. It is run by a committee in Dundalk. To give you an idea of the situation, in four of these seven centres, there are large waiting lists. In one, there is a waiting list of 64; in another a waiting list of 100; and in another a waiting list of 16; while in yet another there is a waiting list of six.
That leads me to believe that the position is that the question of nonresidential care has not been faced up to as yet, except of course by voluntary groups, and that there is a great field of endeavour to which the Minister could profitably address himself. For instance, the St. Dympna's centre in Dundalk is entirely voluntary. To give the Dáil an idea of the effort made in Dundalk to maintain a system which at the moment is catering for 19 handicapped children at home and going to school every day, a function was held not long ago attended by over 1,000 people who subscribed to this committee over £1,000. That is in just one town with a population of 21,000. It is a question of mea culpa, tua culpa and everybody's “culpa,” that in Drogheda, 20 miles away, we have not got any such organisation and the town has almost the same population as Dundalk.
That is the situation all over Ireland. This question of voluntary organisations is one that must be fostered. As far as I know, no real help or financial fostering has been given. I feel the Minister might possibly address himself to the matter and I hope that when he is replying, he may have something to say about it. I should also like to quote from page 6 of Caritas where day centres are mentioned:
A limited number of Day Centres providing facilities for the education and training of mentally handicapped children have been provided by voluntary effort. Moderately and severely handicapped children are catered for at some of the centres and at others mild cases are also accepted on the basis of an appropriate school curriculum.
The accent is on "voluntary." I believe the voluntary organisation is the one that will do the job, but if the Minister could help financially, and initially provide officers and trained men and women who could assist those voluntary organisations, he might get very far with little effort.
There is the question also of the recognition of certain institutions for the mentally handicapped by the Department of Health. The Minister politically, of course, and I mean this in no disrespectful way, is a seagreen conservative. There is not the slightest doubt about that. If you were to provide the wings of the Fianna Fáil Party, he would be on the right wing tip. In certain cases, he has been too conservative in the adoption of institutions, which means it is then possible for local authorities to send people there and be responsible for part of their expenses while they are there. In one County Kildare institute run by the Rehabilitation Association, namely, Knocknallen House, I know, from meeting one or two people who had friends there, of the wonderful work of rehabilitation that has been done by occupational therapy and other modern methods. I feel that particular institution could be adopted by the Minister. He should look at himself in the mirror and say to himself, "Remember when I make these decisions, I am a seagreen conservative and therefore I could loosen up a little bit". He could do with a certain amount of loosening up in this regard.
Another matter is the question of capital expenditure. Deputy Dillon dwelt on the fact that we have, by the use of modern drugs and the provision of beds at a time when they were unobtainable, reduced the dread disease of tuberculosis to a very small level. We have got to have a rationalisation of our hospital beds situation. That is quite clear. In every local authority you not only have that particular problem but also the problem of too many small institutions. I feel it is so easy to decide to build splendiferous county homes and hospitals where a little rationalisation could do the job just as well. The building of new institutions with present interest rates and building costs at no time means the reduction in the cost of the maintenance of patients. In Louth we have built an excellent county hospital, and I approved of the action, but we now find that a major factor in maintenance costs of patients is repayment and interest charges. The adaptation of old buildings and changing from one activity to another is something we must face up to, not only in one individual authority but in one as against another when they are neighbours. A bit of rationalisation and a liberal and easy approach could save a considerable amount of capital expenditure and provide a better service.
In that respect, I might mention that I detect in county managers, county officials and Department of Health officials, as well as Ministers, this great conservatism in relation to institutions. I am aware that if you have got an extensive institution in a local authority area then it has got to have full beds because if people go to another hospital it will raise the costs and you cannot have empty beds. I am aware that you have to be a conservative on this point but there is another matter which could be discussed. I find everybody from top to bottom is worried about voluntary hospitals. They love to encourage them and to give them all the help they can but when it comes to sending local authority patients to them then everybody's eyebrows suddenly go up and do not come down for a month. But by that time the patient has paid the 10s. per day for exercising choice of hospital or is either well or dead.
If we are to get the best value, the greatest comfort and the best approach for both patients and local authorities, we should take in when considering, rationalisation, the beds in voluntary hospitals. If we can employ both those beds and the local authority hospital beds rationally, then we shall be doing a good job. It is clear that, as soon as you begin to put one stone on top of another, your costs will go up. Even if we do get the major portion of the health services made a central charge we shall still have the situation in which the Minister will have to go to the Exchequer, so that we shall still be operating on a shoestring. But my object is to have the shoestring the same for everybody, whereas at present there are a lot of shoestrings of varying lengths based on the variables I have discussed. In discussing the various medical, orthopaedic and obstetric units, we must seek rationalisation, and that rationalisation must ensure that, both in the voluntary hospitals and local authority hospitals, every bed is employed in the right way. There has been too much conservatism in that regard.
Mental health has been widely discussed here. The establishment of extern clinics where, once or twice a week, people living at home can get treatment or be kept under observation is an excellent development. I received this morning from the Department of Health—somebody must have known I was going to speak on health matters—a copy of the address given by the Minister to the conference of managers and resident medical superintendents held on 13th-14th December last. I observed that the number of people per thousand in mental homes is seven here as against 2.12 in Denmark and 4.51 in the Six Counties. I am sure the strain of modern life is no worse in the Six Counties than here. We must therefore accept that figure as an indication of a different approach. There is no doubt that over the years our approach to mental health has been bad. You had the situation in which people went into mental homes and were forgotten about. Any irregularity of behaviour was regarded as a reason why they should stay there. While the days of utter confinement are gone and while life in mental homes has been made more pleasant, we did not approach the problem of mental health in the best way. Happily, we now seem to be doing so. I would regard this figure as merely indicating we are behind. I do not throw that at the present Minister or any Minister: I merely state it as a fact. During the course of his remarks, the Minister did impress on the managers and the resident medical superintendents that they should address themselves to this problem. That is the correct approach. We have got to press forward. Each of them in his own institution has got to get nearer to the cure and further away from ordinary confinement.
I should like to discuss the question of voluntary health insurance, as distinct from the institution bearing that name, and health insurance. The policy propounded by this Party in our motion, to which the Minister put down his infamous amendment, is really one of health insurance. It proposed that the State should provide one-third, the employers one-third and the employees one-third, and that the individual would be defined by category. If he were an employee, he had to pay; but he was defined by category, not by income, and he enjoyed certain privileges. He had the choice of doctor, if at all possible. That brings us back to what I was talking about at the beginning: that the customer must be right. That situation must evolve.
I should like now to say something extremely political. If politicians do not do that, they will be put out of where they are and somebody else will be put in who will do it. Who these people will be, I shall leave you to guess. We have propounded that policy. We might not get the opportunity of putting it through, and, if we do not, somebody else will or those there at present will have to change their tune. You will not continue to live in this fairyland where you have an approach such as I have described with people being treated differently. At the same time, you cross the Border and you find this other situation.
There is a leavening out. London is only two hours away. It means that another couple of hundred thousand of our people can leave or can go over there, as they do, to get their health looked after. Politics is the science, as I have always said, not of what you want to do but of what you can get away with doing. My sincere judgment is that over the next ten or 15 years, whether the Minister, the Government, the officials of the Department or the county managers like it or not, the situation will evolve in which you will have some sort of contributory health scheme, a scheme under which the customer will be right.
