Dáil Éireann díospóireacht -
Thursday, 31 Mar 1966

Vol. 222 No. 3

Committee on Finance. - Vote 48—Health (Resumed).

Debate resumed on the following motion:

That a sum not exceeding £17,337,000 be granted to defray the charge which will come in course of payment during the year ending on 31st day of March, 1967, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain Services administered by that Office, including Grants to Local Authorities, miscellaneous Grants and a Grant-in-Aid.

—(Minister for Health).

Mr. M.J. O'Higgins

I think I said most of what I wanted to say with regard to the White Paper last night, but there is one matter on which I should like to ask the Minister for further information. It is in relation to the Government proposals for financing the proposals in the White Paper. I should like to urge the Minister to consider again adopting the insurance principle. It is a sound principle, even on grounds other than the purely financial one. It enables the State to do what the State should do in matters of health: it enables it to supplement rather than supplant the rights of individuals. If the insurance principle is adopted, the rights and responsibilities of individuals in relation to matters of health will be preserved.

In connection with the White Paper, the Minister indicated that one of the matters causing general concern at the moment—it has also caused fairly widespread criticism of the present health services—is the question of deciding who is and who is not eligible for a medical card and the Minister proposes to deal with this difficulty by defining by regulation the classes of persons who will be eligible to participate in the services in future. I think the Minister should tread just a little bit warily here. So far as I am concerned, I dislike the present system. It gives rise to all sorts of misunderstandings and all sorts of confusion. A person living in one health authority area in particular circumstances with regard to family and income is entitled to a medical card covering himself and his family. If, however, he moves into another health authority area, he may find that, with the same income and the same family circumstances, he is excluded from getting a health card. That is certainly an undesirable situation and, generally speaking, I agree it is better that people should know where they stand.

Probably the Minister's idea, which appears in paragraph 51 of the White Paper of defining these categories by classes would be an improvement on the existing position, but I want to suggest to the Minister that, in drafting his regulations, he should ensure that any definition he gives should not be too rigid. There should be an element of discretion left to the health authority because, in any dividing of people into groups, classes and categories, there are bound to be a certain number of hard cases. There are bound to be the borderline cases where, if the regulation is interpreted too rigidly, a person who most people would agree should be entitled to the concession will not get it. To my mind, what the Minister is doing now should improve the position and I would like to appeal to him to leave the element of discretion to the health authority in order to deal with the borderline case and the hard case.

The White Paper deals also with the dental, ophthalmic and aural services. With regard to these I think there is no justification for any further delay on the part of the Government. It is pointed out in the White Paper and well known to Deputies that provision for these services was made as far back as 1953. Section 21 of the 1953 Act made provision for these services and all that is necessary to put them into operation is that a regulation be made by the Minister. The introductory part of the White Paper sets out the difficulties the Minister sees in implementing these proposals speedily. The plea is made that the changes proposed are complex and fairly costly and that their complexity rules out any chance of their introduction in the immediate future.

That does not apply to the dental, ophthalmic and aural services. The legislation is enacted and the necessary provision contained in section 21 of the Health Act of 1953. That was enacted 13 years ago but the regulations are not yet made. If the Minister wants to do anything quickly, there need not be any more delay with regard to these services. All he has to do is to make the regulations.

The final matter to which I wish to direct the Minister's attention is a constituency one. The Minister is aware, because he has correspondence from the Rathdrum Development Association, that there is a need and a desire for a doctor's residence in the town of Rathdrum. The association wrote to the Minister last month with regard to this problem and in the course of their letter pointed out that they had been in constant correspondence with the county council on the subject and had written to the Minister on 30th July, 1964. Their letter to the Minister points out that the attitude of the county council had been that the lack of a house in the town had little to do with the difficulty of getting doctors to stay in the town. Later that attitude changed and a site was obtained.

They point out that in a recent letter which they had received from the county council they were informed that in view of impending changes in the health legislation, the council, at the advice of the Department, had decided not to proceed with the acquisition for the time being. I want to ask the Minister to reconsider his Department's decision in this matter. It seems most unfortunate that proposed changes in the law which have no prospect of being made in the immediate future should be used as a justification for postponing the building of a doctor's residence in Rathdrum or for any other improvement in the general health services in the country.

It would be a different matter if the Minister's position were that he was coming to the House and saying that he proposes as quickly as possible to introduce the necessary legislation. That is not his attitude. His attitude is that he sees no prospect of these changes coming into operation in the immediate future. I would strongly urge on him not to allow any delaying tactics to be attempted where the question of improvement, even in a small matter, is proposed.

Our attitude to the Minister's proposals is that we want to encourage the Minister to go ahead as quickly as possible. I believe that in 1961 when concrete and comprehensive proposals were suggested by this Party, some of which are now being adopted by the Minister in this White Paper, it should have been possible for the Government of the day to come in with a White Paper of this sort and have the necessary discussion at that stage and have the decisions taken at that stage. Five years have been wasted. We do not want the Government to waste any more time and the sooner they get on with the job the better. A few years ago they had an election poster which asked the people to let them get cracking. Let them get cracking now as far as the health services are concerned.

Mr. Mullen

It has been very interesting to hear and read the various speeches as to what brought about this White Paper. There is no doubt whatever that the Labour Party can claim tremendous credit for it. We have only to read the various statements of policy issued by the Labour Party years ago to see that, and if we put these statements of policy beside the White Paper and compare them, we will understand the part that the Labour Party have played in this matter. The only thing I can say in relation to the introduction of the White Paper is that it is very fortunate for the people that the Government changed their Minister for Health. There was no indication of any kind prior to the last general election that such a thing was coming about.

We can also pay tribute to the people who issued a mandate to the incoming Government to do something about the health service. And I am not forgetting the manner in which the present Minister set about his task but I am wondering how much support he will obtain in bringing about the improvements suggested in the White Paper.

The Minister saw fit in his speech on the Budget to refer to the absence of Labour Deputies when he was making his speech on the White Paper. If the Minister reflects, he will realise that there were more Labour Deputies present than the number he mentioned and that the Labour Party contribution to this White Paper has been quite good. If he wishes to reprimand any Party for their lack of attention to this White Paper, the reprimand should be given to the Deputies of his own Party. Last night there were only two Deputies of the Fianna Fáil Party in the House, the Minister and one other.

There are a few points I should like to make in connection with the White Paper. We welcome its introduction but it does not go far enough. I should like the Minister to indicate whether there is any truth in the allegations about a choice of patient for the medical profession. It is a matter that should be cleared up.

In his opening statement, the Minister says it is hoped to have a choice of chemist. Can he not be more definite and say that the people who come within the ambit of this scheme will have a choice of chemist, just the same as he intends, some time, to give them a choice of doctor?

The Minister indicated that plans have been in existence for about ten years for St. Laurence's Hospital in Cabra. Surely it is not impertinent at this stage to ask when we shall have the new hospital in Cabra?

I notice that there is to be a new general hospital and a new dental hospital in Cork. I was surprised to learn that an international architectural competition will take place for a suitable design. Surely an international architectural competition for a design for the hospital is not necessary? Surely we have a sufficient number of competent Irish architects who can provide us with a suitable design?

Everybody who knows or is interested in the operation of dispensaries will welcome the statement that it is intended to do away with them. The Minister did not indicate any positive change in the hospital dispensary system. In some hospitals, the dispensary position can be every bit as bad as in some local ramshackle dispensaries. He should take steps to ensure that people who are obligated to avail of the hospital dispensary should receive proper and courteous treatment. I have known of many cases and I have had experience myself. When they discovered that I was a member of the Dáil, they suddenly began to run around and look after me, but, before they found out, I had been there almost two hours awaiting treatment for a fractured ankle and, because it was a messy job, I had to wait. This happens daily in some of the hospitals in Dublin and something should be done about it.

On page 44 of the White Paper, the Minister deals with the situation with regard to the mentally handicapped. When does he consider he will be able to give effect to what is envisaged for these people?

I subscribe to the remarks by some other speakers in this debate that we should make every attempt to keep health administration out of the hands of politicians, irrespective of Party. I now ask the Minister to give consideration to representation on those boards to representatives of the trade union movement or the local members employed in the various areas. Such people are in very close contact with the community and could play a very useful part in ensuring that the boards could operate in the manner desired.

The Minister has indicated his concern, and rightly so, for the comfort and welfare of patients. On occasions outside this House, he has mentioned his concern for the welfare of the nursing profession. What does he propose to do about the comforts and welfare of the non-nursing personnel, this army of people who undoubtedly are the Cinderellas of the hospital services? In saying that, I am not suggesting for one moment that the situation as it applies to the nursing profession is anything but unsatisfactory.

I notice that the Minister talks about what will be done. For example, he mentions that in Sligo County Hospital, there will be a new major expansion of 100 beds. There is no mention of the other things that were promised to be done in this hospital that would affect the employees, such as the boilerhouse, a new chimney, a new kitchen and so on.

The Minister intends to do something about the Enniscorthy Mental Hospital. There is no mention of what will be done in the matter of accommodation for staff living in, which is so very necessary and about which the staff have made repeated complaints but without success.

In his reference to Portrane Mental Hospital, the Minister mentions that a new nurses' home will be provided there. Naturally, we should like to know when he envisages that the new nurses' home will be available for occupation. For many years past, having regard to the need for a new nurses' home, the suggestion was made that chalets for nurses and other staff be provided in St. Ita's Hospital. Some of the conditions under which the nurses have to operate in that hospital are archaic in the extreme. I entreat the Minister to arrange to have the matter of the observation rooms in this hospital looked into. It is vitally necessary because some of the conditions under which the hospital staff have to work there are beyond imagination. When people talk about the White Paper, or on the Estimates, they say that the welfare and comfort of the patients should be uppermost in mind, and while that is so, I submit we must not underrate the importance of looking after the staffs. A dissatisfied, badly-treated staff in any concern can result in the concern being completely unsuccessful.

A good number of statements have been made recently, coming from the Taoiseach down, in connection with lowly-paid workers. In this morning's papers, it is reported that a Fianna Fáil Deputy speaking on the Budget indicated that there were female workers in his constituency getting £2 and £3 a week in wages. This is not uncommon among hospital workers. I submit there is no use in talking about it. The people who are talking, the Taoiseach and Ministers, are in a position to do something about it. It is most frustrating to find that up to the present there is still passive resistance on the part of those controlling hospitals to any request to bring about a reasonable wage structure. We are told the wages and conditions of lowlypaid workers will be examined. It is true that a considerable number of married men working in hospitals are receiving £7 10s. 0d., £8 or £9 a week.

Deputy Lindsay last night in speaking of the administration of the health services indicated that because certain persons had the ear of the county manager, they succeeded in having a bill of over £100 paid, despite the fact that they had plenty of means and that when one patient died, he left thousands of pounds. I do not know whether this is correct or not but I am very conscious of the number of struggling families who have been denied benefits and if such a case has occurred, it should be exposed. I seriously suggest it is Deputy Lindsay's duty to submit such information to the Minister.

Going back to conditions of hospital workers, few people realise that among the non-nursing personnel, there is a system of payment which is sometimes fortnightly and in other cases twice monthly. There is a difference. This is not uncommon; indeed it is very prevalent among hospital workers, that they go on holidays and are not paid for the holidays until they come back. Surely this needs examination? In many hospitals also no pay slips are issued to the staff who get no account of deductions, despite the fact that with the pay-as-you-earn system in operation, this is surely possible. It is also true that a number of hospitals pay absolutely no overtime to any of their workers.

We seem to forget that hospital workers from the nurses down are working when most other people are enjoying themselves. They get no extra pay for working on Saturday afternoons and all day on Sundays. That being so, a case could be made for better treatment of them and in any case the least that should be given is due consideration on the part of the people responsible for the hospitals who should be prepared to sit down with representatives of the workers and try to reach an understanding with them.

I have had occasion to approach the Minister, and the Minister for Industry and Commerce and the Minister for Local Government, in regard to the attitude adopted by people in control of voluntary hospitals, the attitude of not being prepared to sit down with the workers' representatives and attempt to produce a reasonable charter prescribing minimum rates of pay and conditions for non-nursing personnel. Despite all our efforts, such an arrangement has not come about. Those who control voluntary hospitals are in a position to adopt a dictatorial attitude and when this White Paper is implemented, I hope they will not have any say in its administration. It is about time that they were obliged to sit down and discuss decent increases in pay for the people for whom they are responsible.

I note that the Minister said the coming years are bound to bring to light other needs. All this points to the necessity to establish priorities and concentrate available resources on the achievement of the more urgent objectives. Everybody agrees with that, but I thought it rather strange that the Minister did not set out his considered order of priorities in respect of this White Paper. If he had done so, it would be an indication that this is not only something on paper to be shelved for a long time. Many people have put material on paper but it is another thing to put it into operation. It is now 50 years since the 1916 Proclamation but it has yet to be put into operation. I earnestly hope it will not be 50 years before this White Paper is implemented so far as the Fianna Fáil Party are concerned. Certainly, if there is a change of Government and the Labour Party take over, they will give effect to proposals going beyond the White Paper, because, as I said earlier, the Labour Party advocated everything in this White Paper many years ago.

Seeing that everybody who spoke about the matter was of opinion that health should be taken out of the realm of politics, I hope the Minister will not wait for the next local elections to introduce a Bill giving effect to the White Paper and then allow another few years, perhaps five or even ten, to elapse before putting it into effect.

Mr. Healy

My contribution is more of an intervention than a speech. Much has been said about the White Paper and its proposals and it is generally recognised, I think, even by the Minister, that it will be some years before the intentions contained in it can be implemented. There is one thing we could do immediately and which would be necessary no matter how perfect a Health Bill may be, that is, we should appeal for more voluntary organisations and more voluntary help. Anybody with experience realises that in this country there is a tremendous fund of sympathy and goodwill towards those of the population who are either mentally or physically handicapped. The voluntary worker can do a tremendous amount to help that section of the community on which so much attention is now being focussed, the aged. The voluntary worker can go into the homes of aged persons, read to them, take them for walks, cook meals and help in various other ways, in a much more practical and better way than can be done by a State or local government service. There is a tremendous fund of goodwill and a great number of workers willing to help if they can be organised, as has been done in some parts of the country, and shown how they can help.

I am saying all this because I feel that, whatever delay there may be in the implementation of the services provided for in the White Paper, there should be no delay in carrying out my suggestions. I am perfectly certain, knowing the Minister as I do, that his heart is in the right place. I welcome his suggestions. I know he has the best intentions in the world. I am sure that eventually he will bring in a Bill which will be a credit to the country. In the meantime, he should appeal for help from those who are so willing to give it and who want nothing better than to feel that they are helping their less well-off brethren.

Minister for Health (Mr. O'Malley)

In the course of my reply, I shall try to deal as far as possible with most of the important points raised by the Deputies on different sides of the House.

Naturally, I suppose, little reference was made by the Fine Gael speakers to the considerable relief to the rates granted already and proposed in the White Paper. The Fine Gael Party, for reasons best known to themselves, have been very reticent as to how their proposals would alleviate the rates in any way. It now appears that they make no provision whatsoever in their proposals to take the ever-increasing burden of the health demand from local taxation and, as far as they are concerned, year in year out, local rates will rise according as the demand for services increases and/or as costs of wages and salaries increase.

I think I should draw attention to the fact that the White Paper states specifically that it is the Government's intention that no part of the cost of the extension of the services should fall on the rates and, further, that the Estimate before the House contains provision to ensure that in effect, subject to adjustment in respect of balances from previous years, the cost to the rates of the health services next year will not exceed the cost attributable to the present year.

Mr. T.J. Fitzpatrick

(Cavan): I have no intention of interrupting the Minister but I should like him to clarify that. Does that mean for this year or does it cover all future years?

Mr. O'Malley

The position, as I have said, is that the Government's decision was that the demand for health on local rates in the year 1966-67 will not exceed the actual cost incurred in 1965-66. In addition to that, the Government have decided that an extension of existing services or the coming into operation of new services will be borne by a source other than local taxation to the order of 100 per cent.

I do not know if Deputies generally appreciate the impact of this decision about the rates concession in their own areas. To take a few examples would not be out of place. There are 32 local authorities involved altogether and in the case of one of these, the relief will exceed 2/6d in the £; in the case of seven others, it will be between 2/-and 2/6d; in the case of five others, between 1/6d and 2/- and in the case of a further 14, it will be between 1/-and 1/6d.

Deputy O'Hara will appreciate more than many people the fact that there is this very important provision in the White Paper whereby I shall have discussions—indeed, they have started— with the Minister for Local Government in order to find some method whereby there might be an equitable distribution of the burden of health charges on various local authorities. As we know only too well, some counties down the years have been carrying a burden out of all proportion.

Mr. O'Hara

Hear, hear.

Mr. O'Malley

We hope to try to come up with a solution. It is not an easy thing. Therefore, I think the Government's decision is a tremendous step forward. People may say that it is all right to be preparing White Papers but when will these things come into operation. In actual fact, I think the provision in the Estimate for the concession towards the rate in this time of year alone is £330,000. Then, of course where the burden of local taxation is really intolerable in many instances, it is terribly important for people to know and to have some consolation in knowing, that the new services which will be proposed or extensions of existing services under the White Paper will not put another 10/-or 17/- on to the rates. Otherwise they might say that it is grand to have new services but where will it end as far as local taxation is concerned.

Mr. O'Hara

Mayo County Council have expressed their thanks to the Minister in that regard.

Mr. O'Malley

I should like to deal with points made by a number of Deputies in relation to the parentage of the White Paper. Practically every Fine Gael Deputy who spoke claimed that the White Paper policy is part of his Party policy for the health services. Deputy T.F. O'Higgins, in fact, went so far a few weeks ago as to claim that he wrote the White Paper. His comments in the present debate did not show that he had any great pride in its authorship. This does not worry me, of course. On the other hand, Deputy Kyne, speaking for the Labour Party, repeated a claim which Deputy Corish made at a Press conference shortly after the publication of the White Paper that it was based on a scheme issued by them in 1958. All this is rather like an inverted paternity suit. Generally, when the issue of paternity is being decided in the courts, the object of the contestant is to disclaim paternity but here we have the other two Parties vying for the credit of having fathered the scheme in the White Paper.

I, of course, naturally, read several documents published by the other Parties in relation to health policy. I do not recognise any of them as being the father of my proposals, but, then, so much has been said by so many in this country about health policy in the past seven or eight years that it would be an ingenious person who could produce a health scheme which had no feature of any other Party's policy in it.

Some at least of the Fine Gael Deputies must be familiar with the 1958 Labour Plan for the health services and I would ask them to bear with me while I say a few words in relation to it for the benefit of the rest of the House. The main proposals in this plan, which was issued in September, 1958, are contained in paragraph (6) and I will quote it:

Briefly, we propose that a new health scheme should be introduced which would cover general practitioner service, hospital treatment, specialist services, dental services, ophthalmic services and pharmaceutical services. There will be no direct charge for general practitioner services, hospital treatment or specialist services. There would be partial charges to some persons for the remaining services (dental, eye and pharmaceutical) but these services would be without direct charges to certain categories of persons. The dispensary service in its present form would be abolished and all persons covered by the scheme would have a free choice of doctor. The present charges for hospital treatment would be abolished.

Paragraph (9) goes on to say:

There are administrative difficulties in bringing in literally everybody within an insurance scheme. The Labour scheme would, however, embrace the vast majority of the community. It would cover all employees irrespective of income, as well as farmers and certain other self-employed persons. Old age pensioners and others in receipt of social welfare benefits would be automatically regarded as insured persons for the purpose of the scheme. Insurance would be compulsory for all employees and for farmers with holdings having valuations below say £100. It would also be compulsory for other self-employed persons below a specified income limit, say, £1,000.

It was mentioned in the plan that the insurance would cover health services for dependants as well as the insured person. It was proposed that insurance contributions from employees would be collected by means of a weekly stamp, through a link with the existing social welfare scheme, and that farmers' contributions would be collected in conjunction with their rates payments and other self-employed persons would make contributions by means of stamps. The suggested rates for contributions were 1/3d a week from employees and a like amount from employers, 1/6d a week from farmers and 2/- a week from other self-employed persons. The plan stated that all persons covered by the scheme would be entitled to general practitioner service with choice of doctor, the remuneration of the doctor being on a capitation basis.

Deputies might wonder why I am going into great detail on the different plans of the political Parties. I think it is a good thing. We will see, particularly new members on both sides, where we differ, if we do differ, as far as health services are concerned. It will be brought up to date on the record of the House. Of course, if I have made any incorrect statements, and I do not think I have, I shall be quite willing to have them corrected. The scheme also proposed the abolition of charges for hospital services and the development of the dental services with priority for children and the provision of drugs and medicines free for the lower income group and with some charge to others covered by the insurance.

I would remind Deputies that the plan I have been quoting is that of the Labour Party which was published in 1958. However, how easy it would be to think that it was the Fine Gael scheme I am talking about. It will be clear to anyone who compares it with the scheme prepared by Deputy T.F. O'Higgins in 1961 that his is, in fact, a rehash of the Labour plan, heated up here and there and served with a lot of sauce, but it is a rehash of the Labour plan, and a direct "cog". Deputy T.F. O'Higgins snatched that and tried to pass it off as his own and as a new proposal of his own. I want to put that on the record and if Deputy Fitzpatrick, the Fine Gael spokesman, wishes to contradict me, I am inviting him to do so. He does not wish to do so?

Mr. T.J. Fitzpatrick

(Cavan): The Minister is too shrewd an operator. He knows perfectly well that if he tries to get me into an argument, I will be ruled out of order. Our programme on health is well known. The Labour Party's programme is for a free-for-all and ours is one based on social insurance. The Minister knows that perfectly well.

Mr. O'Malley

That is completely incorrect.

Mr. T.J. Fitzpatrick

(Cavan): I am telling the Minister what our programme is. Ask the Labour Party what theirs is.

Mr. O'Malley

The position is as I have said.

Mr. T.J. Fitzpatrick

(Cavan): The Minister cogged both of them and it took him five years to mess about and pick out a bit here and there, then dish it up as his own policy and promise that it would come into operation some time, when he gets the money.

Mr. O'Malley

Well, we have got Deputy Fitzpatrick to express himself and evidently the best he can suggest is that the difference is that his is a comprehensive scheme based on insurance——

Mr. T.J. Fitzpatrick

(Cavan): And the Labour Party's is a free-for-all.

Mr. O'Malley

The Labour Party's proposals as set out also depend on contributions from stamps.

Mr. T.J. Fitzpatrick

(Cavan): The Labour Party are well able to enunciate their own proposals.

Mr. Kyne

We do not mind the Minister quoting us.

Mr. Coughlan

We are pals, sometimes.

Mr. O'Malley

The scheme put out in 1961 by Deputy T.F. O'Higgins and subsequently repeated——

Mr. T.J. Fitzpatrick

(Cavan): Tell us about Deputy MacEntee's scheme.

Mr. O'Malley

——with some variations, in various policy statements by Fine Gael, and the submission which the Deputy made to the Select Committee, has all the features of the 1958 Labour plan. It is to be financed by insurance contributions; there is the limitation of the scheme to certain categories; and the provision of a choice of doctor, the capitation system for the remuneration of doctors and the subsidising of drugs for the middle-income group. There is even the idea of collecting insurance contributions from farmers in conjunction with their rates. Yet we have Deputy O'Higgins speaking on the White Paper and criticising us for, as he suggested, filching some part of his Party's policy and for having closed minds. Deputy O'Higgins last spoke his mind on health policy in 1961 when he swallowed the Labour scheme and then put it out as if it were his own.

Mr. T.J. Fitzpatrick

(Cavan): He last expressed his mind when he submitted a detailed memorandum to the Minister's Select Committee, which was ridiculed by the Minister's predecessor and which is now largely accepted by the Minister.

Mr. O'Malley

Did it never strike Deputy Fitzpatrick and the Fine Gael Party that Deputy O'Higgins was Minister for Health from 1954-1957?

Mr. T.J. Fitzpatrick

(Cavan): And the Fianna Fáil Party have been in power since 1957 and only now they produce a White Paper which they say will be in operation some time.

Mr. O'Malley

Deputy O'Higgins was Minister for Health from 1954-1957 and it is all right to say that in 1961 he produced certain proposals. Was there anything to prevent him bringing in these proposals in the three years in which he was Minister for Health?

Mr. O'Hara

Did your predecessor not say it would cost only 2/6d in the £ on the rates?

An Leas-Cheann Comhairle

The Minister should be allowed to speak.

Mr. T.J. Fitzpatrick

(Cavan): The Minister specifically invited any interruptions or criticism.

Mr. O'Malley

In the proper context when I come to it, if Deputy O'Hara is good enough to repeat the interruption, I should like to deal with that matter.

Mr. O'Hara

I do not want to interrupt the Minister. I appreciate he has done his best. In particular, my county appreciates it.

Mr. O'Malley

In regard to the point raised by Deputy O'Hara, when Dr. Ryan was going around telling the local authorities about the 1953 Act, he said the proposals would not cost more than 2/6d in the £, or words to that effect. He said that they might cost a little more in some instances but that, by and large, this was the expectation. He has not been very far out. You might be appalled at that and say: "But are some local authorities not paying 32/- in the £?" This is not the point. Even before the 1953 Act a considerable sum of money had to be obtained under the Health Vote from local authorities. Of course, the figure of 2/6d has been exceeded. It has been exceeded because down the year there have been increases in wages and salaries, extensions of existing services and very many new services. Provision has to be made in the Estimates to pay back moneys raised by way of loan. I went to the trouble of asking the city treasurer in one local authority and he bore out what I have just said.

Since 1961, Deputy T.F. O'Higgins's mind has been closed to any suggestion there is any fault in the basic reasoning behind the policy contained in what we will describe by courtesy of the Labour Party as the Fine Gael scheme. There is one basic issue which I think Deputy T.F. O'Higgins has not faced up to in connection with his Party's scheme, that is, whether the State is justified in stepping in to make compulsory arrangements for the provision of a service which can adequately be arranged privately. Of course, I am referring here to the general practitioner service. The Labour scheme and the Fine Gael scheme both jump to the conclusion that it is justifiable for the State to intervene financially between the doctor and the patient in arranging payment for these services for the entire population, or for the greater majority of it.

It is here that the essential difference lies between the other Parties and the Government. As I said in the White Paper, we base our health policy on the principle that the State should step in to organise services only where the need for them is clearly demonstrated. We are satisfied it is not demonstrated in the case of the general practitioner service for most of the population. This was the general tenor of evidence before the Select Committee. I think commonsense will tell any Deputy that the fees payable to family doctors are not an excessively large item in the household budgets of most middle-income group people. The big cost is not the cost of doctors' fees but the cost of drugs and medicines.

This conclusion is borne out by an inquiry carried out by the Voluntary Health Insurance Board in 1964 when they made a survey of the expenses of their members on various items of medical care. They have been kind enough to give me some information concerning it. The survey covered 16,419 persons. With regard to the general practitioner services, the average cost per year for each person covered by the survey amounted to 36/-. This, of course, was an average which covered those who did not find it necessary to attend the family doctor at all. The average cost per person for those who had to attend the family doctor was as low as £3 16s.

Mr. Kyne

What was it on a family basis? Was it not £7? I quoted from that document, too.

Mr. O'Malley

I said the average cost per year for each person covered by the survey was 36/-.

Mr. Coughlan

That is the easy way. You divide one into the other and get a common denominator.

Mr. O'Malley

Those big words will upset you. We will be talking about overflying Shannon next. The average cost for those who had to attend the family doctor was as low as £3.16 per year. These figures are related to contributors to the Voluntary Health Insurance Scheme who are mainly in the higher-income group. Accordingly, there can be no suggestion that expenditure on the family doctor was kept down through inability to pay. The result of this survey confirms the impression that any reasonable and sensible person has—that for a large percentage of the population, the State can well leave the financial arrangements for general practitioner services as an entirely private matter between doctor and patient.

Mr. T.J. Fitzpatrick

(Cavan): Is it not correct to say that the £3.16 covers children and old people, earners and non-earners?

Mr. O'Malley

It is the average cost per person.

Mr. Coughlan

The Minister has taken the Voluntary Health Scheme as a basis. Why did he not take as a basis the dispensary service, where he will find medicine is one of the lowest costs we have? The Minister said it was one of the highest.

Mr. O'Malley

The Deputy does not follow. I am on the cost——

Mr. Coughlan

Of medicines and GPs.

Mr. O'Malley

No.

Acting Chairman (Mr. P. O'Donnell)

The Minister must be permitted to make his speech.

Mr. O'Malley

I am on the cost of the family doctor to the middle-income group. Deputies in the Opposition Parties do not accept this principle. That is the essential difference between our scheme and their scheme, or the Labour scheme "cogged" by Fine Gael.

Mr. T.J. Fitzpatrick

(Cavan): All the Minister's nice remarks to Labour will not make up for the Government's recent Budget.

Acting Chairman

We are dealing with a motion on Health and Deputies must confine their remarks to that matter.

Mr. T.J. Fitzpatrick

(Cavan): Before you came in, Sir, the Minister provoked all this.

Acting Chairman

Deputies must confine themselves to this motion.

Mr. O'Malley

Any complimentary remarks I may have directed towards the Labour Party were directed, in the main, towards their chief spokesman, Deputy Kyne. I am very sorry that the Fine Gael spokesman did not take a headline from him, because I will say this, that down the years in this House, Deputy Kyne has shown a tremendous advancement in social thinking and has a social conscience. Deputy Fitzpatrick should read some of his speeches.

Mr. T.J. Fitzpatrick

(Cavan): Unlike the Minister for Finance in his recent Budget. Not much social conscience or social thinking was displayed in that.

Mr. O'Malley

Anyway Deputy O'Higgins claimed a short time ago that he was the author of the White Paper. The Labour Party fathered the 1961 Fine Gael scheme, but before leaving this question of paternity, perhaps we should bring it up to date. Whatever about the paternity, we have to rear it and pay for it. The Labour Party have now moved further to the left and in a statement of their policy issued early last year, proposed a free-for-all service on the lines of the British National Health Service. This statement of policy was the basis of a motion put down by Deputy Kyne which we discussed in this House last November. I quote the motion:

To call on the Government without further delay to establish a comprehensive no means test health service with a free choice of doctor for all sections of the community.

When the House came to vote on this motion, the Fine Gael Deputies went into the Division Lobbies to vote in favour of it.

Mr. T.J. Fitzpatrick

(Cavan): The Minister is being dishonest.

Acting Chairman

The Minister must be permitted to make his speech.

Mr. T.J. Fitzpatrick

(Cavan): The Minister is being dishonest.

Acting Chairman

Unless the Deputy wishes to raise a point of order, the Minister must be permitted to proceed.

Mr. T.J. Fitzpatrick

(Cavan): The Minister has invited me to tell him where he was wrong. The Minister knows that that motion was discussed with another motion which deplored the existing health services, and surely we all agree on that?

Mr. O'Malley

Deputy Fitzpatrick is confusing the issue. He should look at the relevant Dáil Debates in November.

Mr. T.J. Fitzpatrick

(Cavan): That motion deplored the existing health services.

Mr. O'Malley

I deplore the lack of knowledge and information of Deputy Fitzpatrick.

Acting Chairman

While the Minister should be permitted to continue his speech, he should not provoke interruptions.

Mr. O'Malley

I bow to your ruling, Sir. I repeat that the Labour motion called on the Government——

Mr. T.J. Fitzpatrick

(Cavan): Will the Minister read the motion?

Mr. O'Malley

I am talking about the Labour motion.

Mr. T.J. Fitzpatrick

(Cavan): Will the Minister read the Labour motion?

Mr. O'Malley

The motion reads:

To call on the Government without further delay to establish a comprehensive no means test health service with a free choice of doctor for all sections of the community.

Mr. T.J. Fitzpatrick

(Cavan): That is not the entire motion, and it was taken with the Fine Gael motion.

Mr. O'Malley

No.

Mr. T.J. Fitzpatrick

(Cavan): It was.

Mr. O'Malley

This is a very important matter. I shall sit down if the Deputy wants to——

Acting Chairman

The Chair cannot permit the Deputy to continue interrupting.

Mr. O'Malley

Fine Gael Deputies trooped in with the Labour Party and supported them on this motion.

Mr. T.J. Fitzpatrick

(Cavan): They deplored the present health services.

Mr. O'Malley

I have all the information here. I quote from the Dáil Debates of Tuesday, 23rd November, 1965: "The Dáil divided. Tá: 35; Níl: 51." Looking at those who voted "Tá", I see the names of Deputies Thomas A. Kyne and Thomas J. Fitzpatrick (Cavan). The question was declared lost. It looked from this as though the Labour Party were going to father another health scheme for Fine Gael, but this was abortive. In the present debate, we find Fine Gael are back again to the scheme which they advocated in 1961 and which they advocated at the last general election in their “Towards a Just Society”. There are several means tests in this document “Towards a Just Society”. They pieced it together just before the last general election, as Deputies will remember; then they had a press conference and had only one copy available for everyone, a well-thumbed copy.

Mr. T.J. Fitzpatrick

(Cavan): And the Taoiseach accepted most of it as the campaign went on.

Mr. O'Hara

The Government have got the makings of many Health Bills from this side of the House over the past 30 years.

Mr. O'Malley

We have given the House lots of Health measures: the Health Act of 1947, and the Health Act of 1953. I hope to introduce into this House in November next another Health Bill proposing improvements. This will not be the be-all and end-all of health legislation. It will be another advance, and further progress will be made in the future in line with modern medical developments and the capacity of the country to pay.

Deputy Hogan (South Tipperary) said during the debate that he saw no reason for providing 100 per cent coverage in respect of general medical services, and I quote what he said at column 679, volume 221 of the Dáil Debates of 1st March, 1966:

I see no reason for providing 100 per cent coverage in respect of general medical services unless one is a doctrinaire socialist, and if one is a doctrinaire socialist, one must socialise everything to the limit.

Presumably the Deputy views those of his colleagues, including Deputy Fitzpatrick, who voted for the Labour motion in November, as doctrinaire socialists.

Mr. T.J. Fitzpatrick

(Cavan): The Minister knows perfectly well the spirit in which we voted on that motion. It was to get the Minister to do something.

Mr. O'Malley

Deputy Hogan did not vote with Deputy Fitzpatrick.

I should like now to refer to the Fine Gael arguments on the means test. The criticism levelled by Fine Gael speakers at the proposals in the White Paper is that they retain a form of means test. I never thought I should see the day when Fine Gael would be appalled at the idea of a means test. I suppose there is no means test where social welfare benefits are concerned, and no means test for old age pensions? I did not hear Fine Gael advocate anything about that but they object to my including in the White Paper a form of means test. Deputy Dr. Gibbons in a very able and constructive speech—we have had constructive speeches from both sides of the House—pointed out that the Fine Gael scheme had at least two means tests implicit in it, in that it would be necessary to test means in order to find who was over the income and the valuation fixed.

Mr. T.J. Fitzpatrick

(Cavan): There were no inquisitions because it was £15 valuation and the social welfare classes.

Mr. O'Malley

I am not talking about inquisitions; I am talking about means tests. Deputy Fitzpatrick is talking about a comprehensive-no-means-test. That does not exist. It would be necessary to have a means test in the Fine Gael scheme to find out who was over the income and valuation limits mentioned. It would be necessary to have a means test to decide who would be exempt from paying the proposed insurance contribution.

Mr. T.J. Fitzpatrick

(Cavan): That is quite clear. There is no means test there at all. Groups of people are absolved from paying the contribution —farmers under £15 valuation, those in receipt of unemployment benefit, or social welfare benefit.

Mr. O'Malley

But there will have to be a calculation. The statement was that 85 per cent would benefit. Under the regulations which will come into force tomorrow, over 90 per cent will be entitled to some benefits under the Health Act. Surely, in order to arrive at the 85 per cent under the Fine Gael scheme there must be a means test? Surely there must be an upper income limit? The Fine Gael Party are obviously confused. The trouble is they do not know what they want and, when they are in doubt, they run along and have another "cog" at someone else's policy.

Mr. Coughlan

Now, listen. If the Minister does not leave Fine Gael alone, I shall complain him to Ted Russell.

Mr. O'Hara

Good man.

Mr. O'Malley

Deputy Clinton was very naïve. On the question of who would be exempt from paying insurance contributions, he said the 15 per cent included themselves because they were not obliged to make a contribution and they were people who were so obviously in the upper income group that it was easy enough to recognise them. That statement will be found in the Official Report of 3rd March at column 983. Was there ever a more stupid statement made in this House? In the ordinary course of events, Deputy Clinton is a most conscientious Deputy. He has put forward here on occasion very constructive proposals. How he could suggest there is no means test in the Fine Gael scheme passes my comprehension. Presumably some official sits down in a front room and watches the people passing up and down the street and picks out those who are eligible and those who are not.

Mr. O'Hara

An identification parade.

Mr. O'Malley

The 15 per cent exclude themselves, and they were the people who were so obviously in the upper income group that it was easy to recognise them. That will go down in history as one of the best examples we have ever had of double thinking.

Mr. O'Hara

Down in history with Deputy Burke's "tanner".

Mr. O'Malley

We are facing up to the issues. With regard to insurance contributions, I do not agree with Deputy T.F. O'Higgins, Deputy M.J. O'Higgins and the others who spoke in the general tenor that financing on a social insurance basis was fundamental to the development of our health services. As I said in my opening statement, the Government are prepared to examine the question of introducing such types of contribution as an aid to general taxation in financing the services. Insurance contributions could be no more than an aid. No one has suggested that the entire cost of the health services could be met from insurance contributions.

I do not intend to approach this issue of insurance contributions with the same mystical fervour as Deputy O'Higgins. When I consider it, I will be mainly concerned with any practical advantages it may have as against any other source of income because, when the State compels a person to make a payment to meet the cost of a public service, it matters little to that person whether the cost is described as an insurance contribution or a tax and, therefore, it is as a form of taxation that we must consider these contributions.

Deputy T.F. O'Higgins referred to his proposed weekly contributions as the equivalent of the price of ten cigarettes. If I thought a man would save the money to pay his insurance contributions by cutting down on his smoking, that would be a big factor in helping me to appreciate the merits of such contributions. Deputies know well that 2/- a week, or whatever larger sum may be required, would not always come through cutting down on luxuries. It would be a weekly tax on each worker and each farmer within the prescribed limits, payable, generally speaking, at a flat rate, irrespective of income. This is the kind of insurance contribution they have for the British health services. There it is at the rate of 3/4 per week and as a form of taxation, it does not seem to be very well liked.

On 7th February, 1961, and I think I mentioned this quotation before, the then Minister—he was a Conservative —speaking on a proposal to increase the rates by 1/- per week, said that this contribution, like any other flat rate contribution, was in the nature of a poll tax, irrespective of the earnings of the person by whom it is paid. The Labour Party in Britain did not think much of this contribution. I am quoting Miss Jenny Lee who spoke on 18th May, 1963, and said that there was no justification whatever for imposing a poll tax of 3/4d per week on every man and woman who happened to be an insured person. She said:

We want it to be well known that a future Labour Government will end this totally unfair practice.

Mr. O'Hara

From what is the Minister quoting?

Mr. O'Malley

I am quoting from Hansard, volume 677, column 467. An Irish Labour Party speaker said, and I quote:

The health services are available free to every one in Britain. They are paid for by the Exchequer. The more you have the more you pay. That is the way it should be. That is what we mean by a comprehensive health service. We do not think insurance contributions could pay for it. The Labour Party would never agree that insurance contribution should pay for such a service. We believe it should be a charge on the Exchequer.

That was Deputy Dr. O'Connell speaking here on 24th November last on the Health and Mental Treatment (Amendment) Bill and it is to be found in column 320 of the Dáil Debates of that day. The House will also note that on 17th November last I quoted the views of the two major Parties in Britain as I have quoted them above. In doing this, I seemed to be able to influence the policy of our Labour Party here in Ireland to some extent, whatever about them influencing our policy.

I have dwelt on this matter at some length and my purpose in doing so is to convince the House that in considering insurance contributions as a source of revenue, we must not take a completely one-sided view. These insurance contributions have their disadvantages as well as their advantages. Perhaps when I have completed my technical examination of them as a source of finance, we could approach a further consideration of this issue. My purpose and intention is to implement everything in this White Paper as speedily as possible. It is my intention to bring into the House next November a Health Bill whereby the proposals in the White Paper can be implemented.

If, at the time, it is necessary to make the financial arrangements whereby some contributions will be necessary, then I think I would be quite agreeable to recommend to the Government that such contributions should be utilised. There is no point in approaching this question of these contributions in a one-sided manner. The whole question is a problem. I have discussed this with my colleague, Deputy Boland, the Minister for Social Welfare, and I can see that I could not be cluttering up his social service stamps and the contributions from the workers. He has his priorities. The old age pensioners, the widows, the blind and other social service classes are low enough as it is.

We have to be realistic about this. Do not be under any illusions about this. The proposals in this White Paper are going to cost the country a lot of money and might cost a lot more than I have set down here. In May I am bringing out a White Paper on mental handicap. This is a tremendous problem and I have not yet got the report of the Commission on Mental Illness. The care of the aged, the care of the mentally ill—all this is going to cost an awful lot of money, capital expenditure, the funding of that, the provision of accommodation and the finding and maintenance of staff.

Mr. O'Hara

When does the Minister expect the report on mental illness?

Mr. O'Malley

About June. I believe we should not be clashing on the question of insurance contributions. I want to get this thing off the ground and I am going to see it gets off the ground. If I find difficulty and if I have to do certain things, I will do them, but insurance contributions are not the answer to the problem. I cannot be cluttering up the impositions on the insured workers. It could become an intolerable burden. If it seems to the Government that it would be advantageous to introduce such contributions, then we will not hesitate to propose them to this House.

In the meantime, I want to make the point that I do not think the solution of this issue is fundamental to the further development of our health services as proposed in the White Paper. The discussion as to the method of financing it is, to a great extent, academic. My main anxiety at the moment is to get the document into the form of legislative proposals and bring it in here so that proposals for remedying all the anomalies and shortcomings will be brought before the House for discussion.

I should just like to say this about insurance contributions, too. It will be very tough if a person relying on medical attention and medical services has to worry about how many stamps he or she has. The Fine Gael Party will exempt certain categories. They say that the old age pensioner will not have to pay any contribution, that he will automatically be free, that he will not be required to make any contribution whatsoever, and likewise categories of £15 valuation and under. This is totally unrealistic. I have not brought out my scales of eligibility so far but my personal opinion is this. Why should a man with £8, £9 or £10 a week and three or four children pay a contribution, pay anything, for drugs and medicines or for hospital services? I would charge him nothing—nothing —not the old age pensioner alone, not the widow alone, not the unemployed alone. I could not consider that a man with a wage of that amount, £8 or £9 a week, and three or four children, and paying rent for a house, could make any contribution whatsoever towards drugs and medicines or towards his hospital charges.

Mr. T.J. Fitzpatrick

(Cavan): That man you are talking about is not entitled to a health card at the moment.

Mr. O'Malley

Correct—and, even if he were, he might be entitled to it in one county and not entitled to it in another. I want to make it very clear that it is my ambition not to have the absolutely free confined to the social welfare beneficiaries alone. If Deputy Fitzpatrick tells me that a man with £9 a week, three or four children, and paying rent for his house, who goes into hospital, can contribute to his hospital charges or, if he does not go into hospital, gets a prescription and has to go to the chemist, could pay for those drugs and medicines, my belief is that he just could not do that.

Mr. T.J. Fitzpatrick

(Cavan): Nobody ever said such a thing.

Mr. O'Malley

I think I have made myself clear on my philosophy.

Mr. T.J. Fitzpatrick

(Cavan): Would the Minister tell the House, in plain language, how he proposes to finance his White Paper on Health?

Mr. O'Malley

The Deputy may not have been listening to me.

Mr. T.J. Fitzpatrick

(Cavan): I was listening to the Minister talking in riddles and avoiding the issue very cleverly. I should like him to tell us now, in plain language, how he proposes to finance his White Paper, if he knows. If he does not know, we shall accept the fact that he does not.

Mr. O'Malley

If the Deputy studies the White Paper he will see that the estimated cost, in round figures, is £4¼ million. If the Deputy will look at the Order Paper and at the proposals, he will see that the alleviation of rates alone—the bearing of the cost in the manner sent out to the different local authorities—due to Government decision, is costing £330,000 in this financial year.

Mr. T.J. Fitzpatrick

(Cavan): That is the present grossly inadequate, miserable health service the Minister is talking about. I am talking about the White Paper.

Mr. O'Malley

I want to give a breakdown of the £4¼ million the White Paper will cost. I have mentioned £330,000 already incurred. My Health and Mental Treatment Act comes into operation tomorrow, 1st April; that is costing £650,000. There is £1 million of the £4¼ million in actual fact already being expended. That leaves approximately £3¼ million for the White Paper. Under the new arrangement, the Department of Health will take over certain liabilities for ophthalmic and dental health benefits which were hitherto borne on the Vote for the Department of Social Welfare: that is £500,000. That amounts, now, to about £1,500,000 out of a £4¼ million. Supposing that leaves £2½ million or £2¾ million. The Deputy asks me where I am to get the money. I will tell him this. I do not think it will be too difficult to do so.

I discussed this the other night with the Taoiseach. Now, we are not like Fine Gael. I do not mind saying that I discussed a matter with the Minister for Social Welfare or with the Taoiseach. All right; I discussed this. We do not think it will be that tremendously difficult to provide the money. You see, this is a thing we have to do. It is all right to talk about a shortage of money for expenditure here or capital expenditure there. We are going through a temporary period of shortage. We all know that. We hope that, towards the end of this year, about November or December, it will be all right again.

Apart from that, Deputy Fitzpatrick does not realise that this is not an "if" or a "but": this is a priority. It is the method whereby we have to provide money for this purpose that is in question. I know that if there should be financial stringencies of a very serious nature at the time, that we cannot anticipate now, we should have to accept that fact: God knows what might happen. But, taking things by and large, we should be faced with the problem of finding, say, £3 million. I still think that, when we get this White Paper working, it will cost a lot of money—more than that.

To answer the Deputy's question finally, therefore, I am saying that if the Exchequer, so to speak, could pay for these extensions in toto, this would appeal to me far more than putting an insurance contribution on the worker, the same insurance contribution on the man earning £7 a week as on the person with £15 a week. However, I do think that we shall have to get some contribution from the stamp. I think this is what I shall have to recommend to the Government. I shall have to be realistic in this.

Mr. T.J. Fitzpatrick

(Cavan): You will soon have accepted it all.

Mr. O'Malley

All what?

Mr. T.J. Fitzpatrick

(Cavan): The Fine Gael policy on health.

Acting Chairman (Mr. P. O'Donnell)

The Minister must be permitted to speak.

Mr. T.J. Fitzpatrick

(Cavan): I am sorry, Sir.

Mr. O'Malley

Deputy Fitzpatrick referred to 85 per cent of the people as being eligible for health services under their scheme. I would remind him that, as and from tomorrow, 1st April, 1966, over 90 per cent of the population of this country will be eligible for hospital and specialist services and the valuation for farmers is raised to £60 and the income limit for self-employed persons to £1,200—from tomorrow on.

Mr. T.J. Fitzpatrick

(Cavan): Is there any truth in the rumour that the 10/- per day contribution for hospital maintenance for the middle-income group may be increased soon?

Mr. O'Malley

No.

Mr. T.J. Fitzpatrick

(Cavan): Is there no foundation at all for that?

Mr. O'Malley

No.

Mr. T.J. Fitzpatrick

(Cavan): That means no?

Mr. O'Malley

No; I am on the record. I do not know if it is a Fine Gael election rumour which was discussed at an afternoon tea-party which they arranged——

Acting Chairman

That may be beneficial to health but it does not seem appropriate to the debate.

Mr. T.J. Fitzpatrick

(Cavan):

The Minister attended a few parties.

Mr. O'Malley

I did, indeed, but they were not tea-parties. I should have put on record that all insured persons qualify for the services since September 6th last when the limit for non-manual workers went up to £1,200 a year. I would ask Deputy Fitzpatrick: does he propose that these limits should be reduced so as to cut the eligible percentage back to 85 per cent?

Mr. T.J. Fitzpatrick

(Cavan): Do not be funny.

Mr. O'Malley

I should like to talk about the Common Market.

Acting Chairman

If it is appropriate to the Estimate.

Mr. Coughlan

Do you not know there is economic stringency?

Mr. O'Malley

There are none so blind as those who will not see.

Mr. Coughlan

There are. They are seeing their way from Shannon to Dublin.

Mr. O'Malley

Deputy T.F. O'Higgins and other speakers suggested that if we were to enter the Common Market, it would be necessary to develop our health services on similar lines to the health services of the Common Market countries. I am not aware of any requirements in the Treaty of Rome whereby Ireland would, on entry to the Common Market, have to model her health services on those of other Member States. The relevant position of the Treaty referred to is "Close collaboration between Member States in the social field..." It seems clear to me both from the text of this part of the Treaty and from policy statements from the European Economic Community that uniformity in social services is not aimed at or required. For example, the EEC Commission in its "Exposé sur l'Evolution de la Situation Sociale dans la Communauté en 1961" said:

The Commission view this harmonisation of social systems not as an effort towards uniformity nor as an alignment pure and simple of the different laws and practices towards those of such one of of the Six as may as may appear to be the best developed...

When the White Paper is implemented, we should have a health service meeting in the main the needs of this country and we need not be ashamed of comparison between it and that of other countries. It is a wise thing for EEC to agree that there would not be common policy for all member countries because each country has problems peculiar to itself. We even differ greatly from Great Britain in regard to the requirements of our people. Certainly, there would be certain basic differences between ourselves and, say, Italy or France. I should not like the House to think that I was of opinion, however, that we cannot learn anything from other countries or profit from their experience. This does not mean that in developing our health policy, we should uncritically adopt health concepts formed in an entirely different background.

Deputy Kyne, comparing the cost of our services with those in Northern Ireland, seemed to envisage that if his Party's policy were adopted, we would be spending about £50 million on health services.

Mr. Kyne

It is £25 million in Northern Ireland and we are roughly double in population.

Mr. O'Malley

That matter is gone into in more detail in the debate of 1st March. The Deputy conceded that was a pretty big figure but it seems the Labour Party would be willing to face up to spending it and, more important, to raising it. He says this would mean increased taxation in some cases but he thinks a considerable part, from £5 million to £10 million, could be met by insurance contributions. Even if this could be arranged, the Labour Party's scheme would still involve a big increase in taxation, and I find it very difficult to reconcile what Deputy Kyne said with what the Leader of the Labour Party said at the news conference on 26th January last in connection with the White Paper. Deputy Corish then said:

The Labour Party was opposed to any type of extra taxation including turnover tax being imposed on people who were supposed to benefit by the proposals in the White Paper.

Several Deputies, including Deputies Fitzpatrick, Mrs. Desmond and O'Hara, referred to the question of district medical officers and suggested it was time to make it clear to the holders of existing dispensary posts that they would not suffer any loss of income as a result of the introduction of the revised scheme. I should like to remind Deputies that in my opening speech I said:

These radical changes in this service will pose a number of problems. The most outstanding of these is, of course, the fact that at present we have permanent salaried district medical officers in about 550 dispensary districts throughout the country. One of the big problems in bringing in this scheme for choice of doctors will arise from the arrangements which will have to be made to fit these into it——

In other words the existing men——

In some areas, particularly in the West, the dispensary doctors will have to be retained on a salaried basis because, in practice, there will be no choice of doctor. However, in most of the country, we must look forward to the eventual abolition of the post of dispensary doctor, and existing holders must be fitted into the new scheme with due regard to their present position and pension rights. I cannot say now what the exact answer to this problem will be and indeed there may be a number of answers varying from area to area. I have, however, promised the Irish Medical Association, when they sought clarification of my intentions in this regard, that I will attempt to ensure that permanent and pensionable district medical officers who continue to provide, in their present areas, services on the scale on which they provide them at present will not suffer any decrease in remuneration from public funds as a result of the change in the service...

The end of my remarks on that occasion was:

and I expect that, in the event, the present dispensary doctors will be satisfactorily fitted into the new service.

Deputy Fitzpatrick said, in effect, that there was no problem involved. The doctors, he said, had a contract with their health authorities and they must receive a guarantee that they will not suffer any loss of income. I cannot go further than what I said in my opening statement which I have just quoted but the Deputy would hardly expect that the governing authority, whatever it will be in future, would continue to pay to the age of 70 the full salary of a dispensary doctor who decides himself when the new scheme comes in that he will accept only private patients and so would give no service for his salary.

Mr. T.J. Fitzpatrick

(Cavan): In my opinion, these doctors have a binding contract of service and if they are to release their employers from that binding contract, it can be done only on payment of reasonable and adequate compensation to the doctors concerned, by agreement, I would say, with the medical profession.

Mr. O'Malley

In any event, the Deputies can take it that the organisations representing the doctors, the IMA and the IMU, can be relied upon to protect the interests of their members and I am in fact meeting 35 representatives of the dispensary doctors with the IMA and the IMU in the Custom House today at 5 p.m.

Mr. T.J. Fitzpatrick

(Cavan): I am very glad to hear it. That is a big improvement on the performance of the Minister's predecessor.

Mr. O'Malley

I am afraid Deputy Fitzpatrick is not conversant with that problem. It is a very long story and we do not want to go over it. My predecessor, Deputy MacEntee, is a man of great principle and in this instance, against very adverse criticism, he stuck to those principles.

Deputy Hogan of Tipperary spoke about the method of payment of doctors. He devoted most of his speech to a jet propelled tour of western Europe and the Antipodes. He described the way in which doctors are paid under health services in the various countries. I know the book he read to describe these payments. That book is not very reliable, I am advised. I know there is a great number of variations in the basic ways of paying doctors under health services. The ways of paying doctors and, indeed, of paying for the services as a whole, have evolved in each case in the circumstances peculiar to the country concerned, and we in this country would be very slow to reach a conclusion that because a particular country favours a particular way of paying its doctors, this is what should be adopted here. We are always hearing experts in medicine saying that this is what they do in Australia or Norway or Sweden, and why we cannot do it here.

Deputy Hogan, in the end, seemed to come down in favour of the fee per service item method of paying the doctors. I do not know that this method of paying the doctors seems to work in many countries. However, the capitation system also works in other countries. There is no black and white comparison between the two methods. Deputy Esmonde made a reference to this matter also.

When we consider the type of service which is proposed by the White Paper, a general medical service limited to that proportion of the population which cannot afford to arrange it privately, there are certain features of the fee for service system which we have to look at specially. I think I am right in saying that whereever this system of payment is used, there is always a requirement on the patient to pay some fee to the doctor, the object being, of course, to prevent abuse of the service.

New Zealand was referred to on several occasions. Let us be clear as to what happens there instead of trotting out suggestions without giving the facts. In New Zealand the doctor charges the patient 5/- or 7/6d for a visit, in addition to the benefit of 7/6d per visit which he receives from public funds. In Norway, the patient pays at least one-fourth of the doctor's fee from his own pocket, and in some cases more. We could not have that here in our conditions. A man with a wife and a large family might not have the money. We must remember that a high proportion of the people who will be eligible in this country for general medical services will not be able to make any payment to the doctor and, in any event, I do not think this House would favour the introduction of charges on eligible persons for these services.

In a fee for service system for which the public authorities pay the full charge to the doctor, it would be necessary to have very stringent controls to prevent abuse. This might involve interference with professional freedom and it is one of the reasons I am not inclined to regard this as the best system of payment in our circumstances.

However, I would stress that all we said in the White Paper was that the capitation system seems the most practicable. These are the words used there. I have not nailed my colours to the mast on this and I am quite willing to listen to any arguments put forward by the medical profession in favour of any other system of payment. However, I hope the profession on their part will appreciate that I am prima facie inclined to favour capitation because I think it would suit their interests as much as that of the administrators.

The capitation system is, of course used now under the National Health Service in Great Britain and the Six Counties and I have heard criticisms from some of our doctors of its operation there. I should point out to the House that in the last year or so there has been a very detailed review of the whole system of paying general practitioners in Great Britain and the Six Counties under the service and I should like to have on record for the benefit of Deputies some of the conclusions which have been reached.

Every Deputy is going to have to listen to arguments on television, radio, from doctor friends and at official level as to the method of payment when the dispensary system goes. In the supplement to the British Medical Journal of 13th January last year, there was published a report of a working party set up by the British Medical Association on general practice under the National Health Service. This report is based on opinions which were sought from all the various regions in Great Britain and, in brief, its conclusions on the method of remuneration of doctors under the service were in favour of the capitation system. The report states that most of the regions consulted stated that:

if the capitation fee were sufficient, much of the present discontent with the method of payment would disappear.

And then:

A careful study of the reports of the regional meetings indicates that the capitation system is still preferred by the majority of family doctors.

On the fee for service system, the report states: "There was some but not much support for such a scheme".

This is important because from documents I have seen from the medical representative bodies, they are evidently going all out and mounting a campaign for a fee for service payment and I am going to come under heavy fire. Obviously all the Deputies have been lobbied and have got documents in the post from bodies representing, to some extent, the medical profession and they are going all out for this fee for service system. This could become very serious. I know what I am saying when I say this. This could snowball. All I can say is that before people get hot and bothered, they should study the implications. There are hotheads in every organisation. There are hotheads in the IMA and in the IMU. This is not all confined to the "wildcatters" who it is suggested from time to time are responsible for industrial disturbances. They are in the professional bodies as well. Do not have any doubt about that.

However, I am satisfied that when dealing with reasonable men, a solution can be worked out in regard to the method of paying doctors. But I am a layman as are most people in the House. When a reasonable body like the British Medical Association sets up working parties and goes to the different regions in Great Britain and then comes up with this report —well, I do not know. As I said before, the report says that "there was some but not much support for such a scheme." Careful study of the reports from these regions shows that the capitation system is still preferred by the majority of family doctors. I should say that when this report was prepared, there were negotiations between the British Ministry of Health and the doctors on a new contract for general practitioners. A variation of the capitation system of payment was negotiated and seems acceptable to the profession in Britain. This variation caters for special payments for duties outside normal working hours and a few other improvements like that.

It was suggested to me that a fee per item of service method of payment would help to keep patients out of hospital by encouraging doctors to look after the patients at home. If this were to be the case, it would be a strong point in favour of the system because the more people we can keep out of hospital, even though we have to pay for medical attention for them in their homes—and this is a good deal, particularly when one considers that some of the weekly charges in hospital are up to £30 a week—the better. This country which the medical profession are citing, New Zealand, does not confirm this. It has a comprehensive general practitioner service for the entire population, the doctors generally being paid on a fee for service system. The patients pay so much, as set out earlier, but their hospital admission rate is higher than ours.

My natural reaction when I heard people quoting these different health services was to get a report on them for the Members of the House and for my own benefit. According to the report which we got from the New Zealand Department of Health for the year ending 31st March, 1963, the latest available report, the hospital admission rate for 1961-62 was 10.81 per 100 of the population and our figure at the same time was 9.42 per 100.

Mr. Dillon

Per 100?

Mr. O'Malley

Yes.

Mr. Dillon

Nine per cent of the population goes to hospital every year? That is a remarkable figure.

Mr. O'Malley

The New Zealand figure was nearly 11 per cent and in our case it is 9.4 per cent.

Mr. Kyne

Does that include maternity cases?

Mr. O'Malley

Yes.

Mr. Dillon

Does the Minister not agree that it seems a strange figure that one-tenth of our population are patients in hospital?

Mr. O'Malley

It is a strange figure.

Mr. Dillon

Does that include out-patients?

Mr. O'Malley

It includes, to use the awful word they use in America, all hospitalisation, but not out-patients. Deputy Kyne suggested that we have a high hospitalisation rate because our general medical services are not comprehensive. Deputy Fitzpatrick stated that at the moment nobody qualified for a medical card unless he or she was in dire need. The eligibility for general medical services is defined in section 14 of the 1953 Act—persons unable to provide by their own industry or other lawful means the necessary services for themselves or their dependants. There is no provision whereby a person must be in dire need and no rigid standards are laid down. Without going over it again, we know that there are variations from county to county in the manner and method in which different county managers or the delegated officers interpret "lawful means". However, we are agreed that the method is unjust, subject to harsh interpretation and that there is a lack of uniformity. The percentage of the population in hospital which is confusing Deputy Dillon would include people who went in for a day or a day and a half.

Mr. Dillon

I think the Minister will agree it is remarkable that 1,000 people per day are admitted to beds in hospitals?

Mr. O'Malley

Or are in beds in hospitals.

Mr. Dillon

Admitted daily.

Mr. O'Malley

I would not describe it as that, but that is more or less the position. The phraseology would suggest that 1,000 come in every day but there might be a variation in the stay. Since this is a very interesting figure. I propose in due course to have it broken down and to inform the House.

Mr. Dillon

I would be glad to have that.

Mr. O'Malley

Before Deputy Dillon came in, I was saying that the emphasis must be on preventive medicine, to keep people out of hospital. Apart altogether from the humanitarian aspect, if we can keep people, particularly old people, in their own homes, I think it is a good deal because at present it costs up to £30 to keep them in hospital. This is a personal opinion of mine which I am trying to plug. I do not know whether I will succeed or not. Take the case of an old age pensioner who is kept out of the county home and treated in her own home. It is not drugs or medicines that poor woman needs but attention such as nourishment and chiropody.

Mr. Dillon

Hear, hear.

Mr. O'Malley

Very often such people suffer from loneliness and lack of nourishment. On one occasion, seeing £75 worth of medicines, I said to a public health nurse: "What are all those bottles for?" and she replied "It is me this woman wants." Our aim should be to try to get these people treated and looked after at home with the assistance of the public health nurse and to provide such things as extra nourishment and chiropody. In addition, while most of these people would be in receipt of the old age pension, I would be most anxious to try to channel through the appropriate doctor or nurse some little cash payment for them so they may have extras such as food and even books. After all, magazines and books are just as much medicine and an aid to recovery, I suppose, as tablets and medicines.

Mr. Dillon

The county library service would be most eager to cooperate with the Minister.

Mr. O'Malley

That is so. I think the House is unanimous that one of our priorities should be the care of the aged.

Mr. Dillon

The dispensary nurse is the solution to your problem.

Mr. O'Malley

I see in the statistics that 29 per cent of the population had medical cards on 31st January, and in seven health authority areas 40 per cent were covered. I do not think anyone could suggest that all these people were in dire need.

Mr. T.J. Fitzpatrick

(Cavan): It was pointed out to the Minister that in Cavan, for example, 29 per cent had medical cards while in Carlow over 40 per cent had them. That is hard to understand. In Leitrim, one of the poorest counties, it is only a little over 20 per cent.

Mr. O'Malley

That is low. I am inquiring into this. I already have one explanation. However, we are all agreed it is unsatisfactory. That is why we hope to get into every ordinary household a booklet setting out in ordinary parlance the health services each individual is entitled to without having to make representations to a TD, local councillor or anyone else.

Deputy Tully referred to the undesirable procedure followed by some health authorities in checking on the incomes of applicants for medical cards. I agree with him fully. As he knows, on 28th January I sent a circular to the health authorities drawing attention to this matter. I stated that I considered the certificate forms issued by health authorities to applicants or employers to be completed by the employers should not bear the name of the health authority or indicate that the person concerned was an applicant for health services.

Deputy Kyne referred to the discrepancies which exist at present between decisions in relation to eligibility for medical cards. He suggested I should issue a direction to county managers to indicate some limit of eligibility so that the people would know where they stood. The only means of achieving basic improvements is an amendment of the law, which is what is proposed in the White Paper. This will take time. In the meantime, I have urged health authorities to examine critically their methods of assessment for eligibility.

It is only fair to point out that in accordance with the White Paper the future law will make it clear that only a person's means and that of his wife will be taken into account when assessing eligibility for the general medical services. The means of other members of the family will be ignored. This will follow the precedent recently set by the Health and Mental Treatment Act, 1966, which comes into operation tomorrow for hospital and specialist services and maternity services.

Deputy Esmonde asked if in advance of the implementation of the proposals in the White Paper, steps would be taken to give medical cards automatically to old age pensioners.

Mr. T.J. Fitzpatrick

(Cavan): That has been done.

Mr. O'Malley

Yes. We have been acutely conscious of the needs of those people and the question of medical cards for old people has been discussed in this House on more than one occasion. During the passage of the Health and Mental Treatment Bill, I informed the House I had sent a circular about this matter to every health authority. This circular is quoted in columns 967 and 968 of the Official Report of 14th December last. It points out that my Department advises that non-contributory old age pensioners or wives and widows with non-contributory pensions should automatically be regarded as eligible for section 14 services. That had been endorsed in the House during the Committee Stage of the Bill.

The circular states that at a meeting in my Department on 20th October last managers of health authorities had agreed that applications for medical cards from such people should receive special and sympathetic consideration, and that particulars of any case in which it was felt that the circumstances did not warrant the issue of a card would be reported to my Department. Returns since received show that in 22 health authority areas all applications received from 20th October last to the date of the returns were granted. In the remaining five areas, seven individual applications in all were refused; two in one area are being reviewed. This is a considerable improvement on the period before the meeting with the managers of 20th October and I am keeping the position under continual review. Someone might say it is surprising to see that even one case of an old age pensioner would be held in doubt by the county manager. I asked my officials why there was doubt about some cases. I came across the case of an old age pensioner whose son, with whom he was living alone, had a very high income and was in very good circumstances. I presume he had this old age pension due to his entitlement on the stamps to which he was contributing.

Mr. T.J. Fitzpatrick

(Cavan): I do not think the Minister's direction applied to contributory pensioners, only to non-contributory.

Mr. O'Malley

Yes. I used the words "old age pensioner".

Mr. T.J. Fitzpatrick

(Cavan): The Minister is aware that before he was kind enough to send out that direction, these people were being refused wholesale all over the country?

Mr. O'Malley

That was unfortunately true.

Mr. T.J. Fitzpatrick

(Cavan): Until it was raised in this House.

Mr. O'Malley

I would not say "wholesale".

Mr. T.J. Fitzpatrick

(Cavan): A very considerable number.

Mr. O'Malley

It was very hard to understand the mentality of a manager of a health authority or the person in charge who would do that. I did indicate in paragraph 51 of the White Paper that under the legislation which I propose to introduce providing for regulations specifying the classes of persons entitled to participate in the general medical service, recipients of non-contributory old age pensions, blind pensions and widows' pensions would be specified as eligible. The position in regard to the eligibility of these pensioners for medical cards has much improved. I do not think that special amending legislation is called for to cover their eligibility in advance of the general legislation proposed in the White Paper. If it had been brought to my attention, with the response to the Department's circular, that these recipients already mentioned should automatically get the medical card, I would have recommended to the Government that I be given permission to introduce an amending section in this House to compel them to do this, but the returns, as Deputy Fitzpatrick said, show a very great improvement in the position which had existed before the 20th October.

Deputy Burke said that in the determination of eligibility the discretionary clause of the 1953 Act should be retained. It will, both for hospital service and general medical service. Paragraph 52 of the White Paper says that persons within the prescribed limits would automatically be eligible but that it would be necessary to leave a discretion to the authorities operating the service to admit other cases experiencing undue hardship at any time because of special circumstances, in meeting privately the cost of medical care.

On paper, a person might seem to have a very good income, £1,800, £2,000 or £2,500 a year, but that person might be crippled with medical expenses. In fact, it might be a greater hardship for that man if his wife or children were ill to meet the expense involved than for a man with £10 a week who would have to pay for tablets or something like that. I have come across cases of people with large incomes who were facing bankruptcy or very great worry.

Mr. Dillon

Is this in respect of expensive drugs or hospitalisation?

Mr. O'Malley

Hospitalisation.

Mr. Dillon

They ought to be in the Voluntary Health Insurance Scheme.

Mr. O'Malley

I thoroughly approve of the conception of the Voluntary Health Insurance Scheme and I want to ensure that my phraseology is such that it will not be interpreted that I am picking out any defects. Let me put it this way: I come across people who may not be in the Voluntary Health Insurance Scheme due to the fact that at a certain time of their lives everything is going right, their prospects are good and their income high.

Mr. Dillon

Is that not the very time they ought to join?

Mr. O'Malley

I agree, but they would deem that their income is such that should such a contingency arise, they would be able to meet the expenditure on hospitalisation from their income.

Mr. Dillon

They are daft. I am in it since the day it was set up.

Mr. O'Malley

That has happened, unfortunately.

Mr. Dillon

They are daft and they should be told so.

Mr. O'Malley

There are certain categories which the Voluntary Health Insurance Scheme does not cover, and were it to cover these, it would be tremendously difficult to make it economically viable. By and large, I endorse what Deputy Dillon says, that such people should be in it. Nevertheless for various reasons which we have to accept, without asking the reasons —there is no point in locking the stable door when the horse has bolted —there are cases of people who were at one time wealthy but have carried a burden of excessive medical expense for a number of years until they have got to the end of the road and face this crisis. It is possible to get assistance under the discretionary clause, and a very good thing I think it is. When people become ill and have illness diagnosed, it is not very fair then at that stage to go to the Voluntary Health Insurance Board and say: "I am sick. You take over. Here is the premium."

Mr. Dillon

They cannot. They must do it at the time the Minister says, when the future is looking rosy and their income appears to be superfluous. That is the time to go to it, and they ought to be told so.

Mr. O'Malley

Deputy O'Connell referred to the desirability of group practice in the general medical service. Surely this is a matter for the doctors to arrange and not for the Minister or a health authority? Any merger of doctors by direction of a Minister for Health would be doomed to failure, To be successful, group practice should be a completely voluntary effort on the part of the doctors concerned. I cannot see any objection for my part, when a choice of doctor comes, to considering an application for a group of doctors. After all, a doctor must have time off as well as everyone else. He must have his holidays. He cannot continue working all the time. It appears to me group practice would be reasonable and would make for healthier and better tempered doctors, thereby benefiting the patients in the long run.

Deputy Fitzpatrick made the point that hospital charges of up to 10/- a day to the middle-income group should be eliminated. I trust the Deputy will appreciate that I am not now being disparaging, but I think he overstated his case. This charge is not an onerous charge. I have criticised officers of health authorities for somewhat rigid and unsympathetic consideration but the information I have indicates that, on the whole, their approach has been very reasonable. The charge was originally fixed at 6/- a day under the 1953 Act. It was changed to 10/- back in 1957 and it has remainied at that level ever since, despite the change in the value of money. While we might like to see free hospitals, free this and free that, I must cut my cloth according to my measure and adopt certain priorities and work within those priorities.

If a person carries his wage or salary into the hospital with him—a man earning £1,000 or £1,200 a year, married with perhaps one child, or no children at all—it is not unreasonable to charge him 10/- a day, £3 10s. per week for his week or fortnight in hospital. He could not live on that sum outside. Of course, if income ceases, that is a different thing altogether. Hospitals have very heavy commitments to meet and this cost of up to 10/- a day covers food, light, heating, bed and bedclothes, service, and so on. It may not be popular to say it but I do not believe this charge is a burden. It is a reasonable charge.

Mr. T.J. Fitzpatrick

(Cavan): If the Minister asks the members of his own Party, he will find that a great deal of their time is taken up in trying to get hospital bills reduced.

Mr. O'Malley

That is one of the difficulties in relation to the existing Health Act; members of my Party, or any other Party, should not be in a position that they have to use their good offices to get such bills reduced.

Mr. T.J. Fitzpatrick

(Cavan): Then get rid of the means test

Mr. O'Malley

No; we will not go over all that again. I am talking about this 10/- a day and I am pointing out that it has been at that figure now since 1957.

Mr. Dillon

Would the Minister agree it is a heavy burden in the case of chronic mental illness?

Mr. O'Malley

Yes, I agree with the Deputy. I see from the statistics that, in the case of a person confined to a mental hospital, the charge is very seldom levied. Deputy Fitzpatrick raised this matter earlier and he ultimately agreed with me, I think, that only a very small percentage of long-staying patients in mental hospitals are charged.

Deputy Fitzpatrick made the point, too, that it is unfair for a health authority to move against the estate when such a patient dies. I get representations—everyone does—from the families of such people. Relatives have been inmates in mental hospitals who, knowingly or unknowingly, had money to their credit. When they die, probate has to be taken out. It has often transpired that substantial sums have been lying in a bank or elsewhere. It is only right that the estate should contribute to what the patient cost the taxpayer and the ratepayer over the years.

Mr. Dillon

Surely the Minister knows that, if a person is mentally ill, and he is the owner of substantial property, he is made a ward of court and his property administered by the court?

Mr. O'Malley

I am not talking about that type of case; I am talking about the type of case in which a patient is maintained in a mental hospital at the expense of the taxpayer and the ratepayer. On his death it is found that he has a considerable sum of money to his credit—perhaps £5,000 or £6,000. Now the taxpayer and the ratepayer contributed to that patient's maintenance. On his death his estate may pass to a grandnephew or a grandniece. Why should the ratepayer and the taxpayer not be recouped out of that estate, not directly, of course, but by recouping the mental hospital? If the charge were a particularly high one, I should be the first to insist that it should go. However, the emphasis now is on preventive medicine to keep people out of hospital. I do not think abolishing the hospital charge will encourage people to stay out of hospital.

We have to be realistic about this. The cost of hospital treatment has increased dramatically. We must face that fact. In a county hospital the cost has increased from £8 to something over £19 per week. In the Dublin teaching hospitals, costs have increased from £10 to £30 per week. That is the cost of maintaining a patient in a public ward. Of those in the middle-income group, only about 12 per cent have been asked to pay the maximum charge of 10/- per day. I agree that 12 per cent is too small and I agree that there are people who have got away with it. The figure of 12 per cent is far two small and should be larger. The higher the contribution we can get from the people who can afford to pay, the more we can do for the less well off.

Mr. T.J. Fitzpatrick

(Cavan): In rural Ireland this charge of 10/-per day is a source of considerable worry and anxiety to people of the farming community entering hospital.

Mr. O'Malley

I represent a constituency which is half a city and half a town, and on Saturdays I get 30 or 40 people from the country into me and I hear no great complaints from them. If there is any county in which the charge is automatically made without inquiry into the circumstances of the patient, I should like to hear about it. The only time that it really becomes a burden and source of anxiety is when a patient has to pay the full 10/- per day over a period of long duration, say from 40 to 50 days.

Taking into consideration the average stay in medical and surgical wards, the average cost of treating a medical patient in a county hospital would be £41 and the cost of treating a surgical patient would be £25. The average term of stay in the medical ward is about 18 days and in the surgical ward, about 21 days. The middle-income group patient called on to pay 10/- a day would contribute £9 and £5 10s respectively in these instances and the balances of £32 and £19 10s respectively would be shared by the health authority and the Exchequer.

The contribution by the better off middle-income group patients can hardly be held to be penal. The average rate is under 6/- per day for those who are charged. I said in my opening statement that the limits of eligibility will bring in a number of those who are to be classified as members of the higher-income group. In the past they had to face the hazard of having to meet the full amount of hospital charges before I raised the limit of income from £800 to £1,200.

Deputy Fitzpatrick asked if it was worthwhile collecting these charges and Deputy Carty, who was Chairman of the Committee on Health Services at the time, mentioned that the cost of collection was £60,000. That leaves a big credit balance to the public funds and I would not ask the Minister for Finance to dispense with it.

Mr. T.J. Fitzpatrick

(Cavan): Does that take into account the travelling expenses of the social welfare officers who investigate these claims? Are they paid out of the health charges?

Mr. O'Malley

No. That is a separate charge.

Mr. T.J. Fitzpatrick

(Cavan): Are travelling expenses and portion of their salaries taken into account?

Mr. O'Malley

Yes. Deputy Kyne, when speaking of hospital charges, said that the income derived from these charges could be got just as well by adding a small amount to social welfare contributions. That is an idea that could be considered in my examination of alternative means of finance but I will point out that at the moment many insured people do not have to pay hospital charges. What Deputy Kyne suggests would mean that all workers, lowly paid, and highly paid, would have an addition to their contributions and that contribution would increase if the charges for the better off workers are abolished.

Deputy Harte referred to the fact that in the case of school children, the cost of treatment is paid by the health authority where the treatment is found to be necessary after the children have entered a school, but that if the ailment is found in pre-school days, the cost has to be borne by the parents. I have this matter under consideration and I indicated in reply to a Parliamentary Question last December that a comprehensive review of the child health scheme is being carried out by a committee of members of the staffs of my Department and of certain health authorities and I will deal with the matter in the light of their report. I will bear the Deputy's representations in mind.

Deputy Esmonde, in dealing with geriatric treatment, asked that local voluntary committees be aided by giving subventions to them. Assistance is already being given by health authorities to bodies dealing with the care of the aged under section 65 of the Health Act of 1953. Health authorities may give assistance to any organisation which is providing a service similar or ancillary to the service which the health authority itself can provide. This can be done either by contributing to the expenses, by supplying fuel, light or food or by the provision of premises. Health authorities have given substantial assistance to organisations dealing with the care of the aged. In most cases this has been done by way of financial contributions to the running cost of the institution run by these voluntary bodies. In some cases authorities have provided assistance by the way of capital expenditure. The Dublin Health Authority made a substantial contribution to the provision of a new voluntary institution for the care of the aged.

Grants have also been provided to assist centres such as the Mary Aikenhead Social Centres in Waterford, Dublin and Kilkenny, and the Little Sisters of the Assumption in Limerick, which provide domiciliary and other assistance to old people such as meals on wheels. The total number of institutions and charities which have benefited under the provisions of section 65 of the Health Act, 1953, is 27.

Deputy Crinion stressed the importance of keeping old people at home whenever possible. I fully agree with his point of view. I was not aware of this myself, until it was brought to my attention. I should like to stress, particularly for those who are members of local authorities, local bodies, that the Minister for Local Government may, under the Housing (Loans and Grants) Act, 1962, make a grant to an approved body, providing, on a philanthropic basis, one or more than one house for the accommodation of elderly persons. The amount of the grant will not exceed £300 in respect of each house or each separate dwelling forming part of a house. A grant may be given in respect of the erection, reconstruction, conversion or purchase of a house. The local authority may make a supplemental grant not exceeding the amount of the State grant.

The new Housing Bill which is being discussed at present by the Seanad and which was passed by this House, reenacts these provisions and provides for their expansion by enabling the Minister for Local Government to pay subsidy to housing authorities, in respect of housing for the elderly, at the rate of 66-2/3rds of loan charges. This new Housing Bill also includes provisions to enable the Minister for Local Government to pay grants for accommodation for caretakers in the precincts of elderly persons' accommodation—I think this is important—and to enable housing authorities to help, by loan, guarantee or periodic contribution, bodies whose objects include the provision of dwellings for old people, and to empower housing authorities to give technical assistance to persons, including housing associations or societies, providing houses.

As I have already mentioned, an inter-departmental committee is already considering the question of the co-ordination of the various public and voluntary services for the aged.

Deputy Dowling has mentioned interesting developments in regard to the care of the aged at St. Mary's in Dublin—a system whereby patients are taken into the hospital for six weeks, then returned to their homes for six weeks and brought back again to the hospital for another six weeks, thus relieving relatives of the problem of providing continuous care for them. I sanctioned proposals in this matter last November. We are all watching the progress of the experiment with great interest. For the success of a procedure of this nature, it is probably necessary to develop community services as well as hospital services. Deputy Dowling also mentioned the need for making old people aware of the services available. I have already stressed to health authorities the need for the development of information centres and the publicising of the services available through suitable media.

A number of Deputies referred to the inadequacy of the dental, ophthalmic and aural services and particularly to the fact that in some areas denture services are not available for lower-income group adults following extraction of their teeth. I am sorry to say that this is only too true. All members of the House must know that the poor standard of the public dental services has been with us for many years and that successive Governments have, understandably, given priority to other needs in the sphere of health. Leaving aside any question of who can claim the credit—my Party or Fine Gael or Labour or the Coalition Government—I hope the House will agree with me that this country has succeeded in making impressive strides in tackling the serious problems in health in the past two decades. We have reached the stage when we can now contemplate dealing with certain problems which have not been tackled as vigorously as we all would wish. The dental services, in particular, are an example. They are admittedly bad and must be remedied.

Not only are the treatment and denture services for adults in the lower-income group inadequate in general, but the arrangements for treating school-children, to put it mildly, fall short of the desired standard in many areas—even though they are accorded priority of treatment. Surveys carried out by the Medical Research Council in connection with the fluoridation of public water supplies revealed an extremely high incidence of dental decay in children in this country. The position is that the number of dental officers employed by health authorities would need to be very substantially increased before anything approaching an effective treatment and follow-up service for children alone could be provided by health authorities.

The fundamental difficulty in the way of a speedy improvement in this situation is that, coupled with the very big problem of widespread dental decay, there is a national shortage of dentists, which has created difficulties for health authorities in recruitment. That difficulty is not peculiar to this country. It is experienced in Britain and in other countries as well. We shall have to face up to the fact that if, to raise our public dental service to the required standard, we are to secure the return of Irish dentists from abroad, and to retain those newly-qualified from our dental schools each year, we shall have to compete with other countries for their services. There is no point in beating about the bush.

While we should have this tremendous drive for dental services, it appears to me, as a layman, that decaying and decayed teeth, or lack of dental care, must be the cause of a lot of poison in the system or illness at some period. Therefore, we shall just have to face up to this fact of supply and demand. We shall have to compete —and to do so quickly. I think I mentioned some time ago, in a speech somewhere, that we had calculated that we are short 275 dentists in Ireland. I should mention, too, that the services of dental officers employed by the health authorities have been and are being, supplemented by private dentists employed on a sessional basis by health authorities to provide services for the present eligible classes either in health authority clinics or in their own surgeries. I intend to take all possible steps to clear up this very serious position and I hope to arrange discussions with the Irish Dental Association to see what can be done about clearing it up.

Deputy Fitzpatrick also referred, at column 624 of the debates of 1st March, to the delay which will be involved in extending the dental, ophthalmic and aural services to the middle-income group. In the light of the inadequacy of dental services for the classes at present entitled to them, it would be impracticable at the moment to bring the middle-income group within the scope of these services. I think it reasonable that an effective service should be provided for those classes of the community, that is, children and persons in the lower-income group, who are to a greater degree dependent for treatment on public dental services, before any extension of the services to the middle-income group is undertaken. That is proposed in the White Paper. It is proposed that as a first step the staffs and facilities of the health authorities will be expanded so that satisfactory treatment and follow-up service for children and others now entitled to priority will be provided, together with a satisfactory service for adults in the lower-income group. When this has been done, the problem of extending services to the middle-income group will be tackled through wholetime pupils of vocational schools and secondary at first, and then the middle-income groups generally.

Although this is the scheme in the White Paper, I personally, as Minister for Health, am urging my officials to come up with some proposals whereby we could take in all schools because I think the whole basis of success is in the schools.

Mr. T.J. Fitzpatrick

(Cavan): Would the Minister like to give us an approximate date for the application of the scheme to the lower-income group?

Mr. O'Malley

It is not a question of the application of the scheme. The provision is there on paper but the people are not getting the service they are entitled to. All I can say is that I cannot answer that. There is a shortage of dentists and that is really the problem. It boils down to this: they say they are not being offered enough and if their services are required, they must be paid for.

Mr. T.J. Fitzpatrick

(Cavan): Does it look as if we will not have these services in the foreseeable future?

Mr. O'Malley

I could not say, but I shall be amazed if, before the end of the year, we cannot come up with some concrete proposals because it is far too serious a matter to be allowed to drift. I cannot, however, tie myself.

Mr. T.J. Fitzpatrick

(Cavan): I do not wish to argue or appear to be interrupting but I think there are a number of counties in which there seems to be an adequate number of dentists. In the small town in which I live, there are at least four dentists in private practice.

Mr. O'Malley

We are looking at the whole country. What the Deputy states may well be true and if so, he is lucky. Again the dentists may be there but there might be no deal made between them and the health authority. They might not be doing any sessional patients and just working for people paying fees.

Mr. T.J. Fitzpatrick

(Cavan): They are therefore private patients at any rate and I am sure they could cater for public patients.

Mr. O'Malley

I do not consider that ophthalmic services for the middle-income group is a matter of such urgency. In the lower-income group, children attending child welfare clinics and national schools are already covered and inexpensive services are already available to insured persons under the Department of Social Welfare benefit schemes, but it is intended, under the White Paper proposals, as Deputies will see, to make this service generally available to the middle-income group, including insured persons and their dependants, on a contributory basis as soon as the health authority services are sufficiently developed to cater for them.

As regards the aural service, I intend that the middle-income group who may at present avail of ear, nose and throat specialist services provided by health authorities shall be able to use the services of the National Organisation for Rehabilitation. We have already had discussions with that body. The existing hearing-aid service is operating satisfactorily but there is room for some improvements in the procedure for ascertainment of hearing defects, particularly in children. With that in view, I have asked health authorities to ensure that an adequate number of public health nurses in their areas are trained in audiometry and, equally important that their services are fully utilised. Moreover a training course in audiometry for public health nurses, followed by a refresher course for those nurses who have been already trained, was held recently. That, and the field work of these nurses should considerably improve this service.

In regard to the existing ophthalmic service, I think it is reasonably satisfactory. In some areas there is room for improvement in the quality of spectacles. The spectacle frames supplied have evoked criticism and I have asked health authorities to provide a better variety of spectacles.

Mr. T.J. Fitzpatrick

(Cavan): Would the Minister do that in such a way that the present position will be improved? If you meet a man in the street now, you know from 100 yards away that he is wearing social welfare spectacles. It should not cost very much to change that.

Mr. O'Malley

I agree. I also agree that the present system of contracting for the supply and repair of spectacles could be improved. It is a matter that will be specially considered in the overhaul of the ophthalmic services.

There is some delay in securing treatment for cataract and squint under hospital conditions. We are specially examining this. I said in reply to a Parliamentary Question some months ago that there is quite a waiting list.

Mr. T.J. Fitzpatrick

(Cavan): How many hospitals in the country cater for that sort of thing at the moment?

Mr. O'Malley

Not many cater for squint—six altogether.

I gather from Deputy Kyne's remarks on the dental services that he would be in favour of solving dental problems by amending the law to permit of the supply and fitting of dentures by dental technicians. There are only two areas in Europe where this practice is permitted, in Denmark and the Canton of Zurich, and before promoting new legislation for this purpose, I should have to be satisfied that a practice which has been apparently rejected by the authorities in the majority of European countries could be accepted in Ireland without danger to the health of the people. At present the weight of professional opinion and advice is against it and I do not consider that I should be justified in promoting legislation to permit of a practice that might involve a health hazard merely because of the difficulties health authorities are at present experiencing in their recruitment of dentists. I intend to take all possible steps to improve the public dental service so that there can be fully effective treatment and follow-up service for the classes at present entitled to it.

The Deputy might have seen in the public Press criticism of the White Paper by the Irish Dental Association. I have now been furnished by the Association with the text of a statement which was dated 1st March on the development of community dental services which was adopted by the Council of the Association and which formed the basis of the Press publicity. I have not yet studied the document in detail but there are a few comments that it would be appropriate to make at this stage.

The first point the Association made is that the public dental services should be run by a central organisation on a national basis. I would not agree with this suggestion for a central organisation on a national basis. There seems to be no compelling reason to single out one particular service to be administered in this manner. Up to now the policy has been to integrate health services, for example, as happened in the integration of the mental and other general health services and the placing of the services in Dublin, Cork, Limerick and Waterford under unified administration and the further step now proposed of setting up regional health boards.

Mr. T.J. Fitzpatrick

(Cavan): Westmeath and Longford.

Mr. O'Malley

All this will, of course, come in due course for discussion—the scheduling of the areas. I do not want to bring in any proposals that are not in the main acceptable to everyone here. I think it would be retrograde to do what the Association suggests.

The services for school children will continue to be regarded as the priority in the organisation of the public dental services. I consider that such a service can best be provided by wholetime staff employed by the health authority. That policy was endorsed by the Irish Dental Association as recently as its last conference in April, 1965 and I am at a loss to understand why in the short interval since then the Association has changed its views; and now considers that private practitioners should be used to the greatest extent possible in the provision of services for school children.

I agree that some emphasis on dental health education is desirable but not, as the Association suggests, that every area should have a nucleus of dental officers employed in educating children and parents in this matter. Up to the present, our efforts have been concentrated on the treatment of dental decay and little, unfortunately, has been done to prevent its occurrence. Some thought will have to be given to spreading the doctrine of proper care of teeth, particularly among children and parents. In view of the national shortage of dentists, however, which is likely to persist for some time, it would hardly be practicable in present circumstances to think in terms of employing dentists wholetime on such a service. I intend to examine the possibility of organising this educational preventive work on the basis of dental ancillary staff specially trained for it.

The provision of adequate services, particularly denture services, for the lower-income group, presents a special problem in view of the shortage of dentists, the need to concentrate available staff resources mainly on the services for children and the very great backlog of work for adults which has to be overtaken.

The Association's statement went on to discuss services for the lower-income groups, to mention a new basis on which they might be concluded in future. These services are being fully considered and in due course I will arrange discussions with the Association to see what best can be done to give a better service for that group.

I appreciate the point made in the Association's statement with regard to the considerable cost involved in the extension of the dental services provided for in the Health Act to the middle income group generally but, as our economy expands and more funds become available for health services, we can face up then to meeting this cost.

While on the school health services, I should like to refer to the excellent health education work done through the film shows organised by the National Film Institute for my Department. It is important that the rising generation should be conscious of health problems. I should like very much to see local health authorities extend their work in the schools through lectures arranged in co-operation with the school authorities.

I think I should make some reference to the timetable of the changes proposed in the White Paper. I should like to repeat that any Deputy who has had the experience of the responsibility of ministerial office will appreciate only too well that changes such as are contemplated just cannot be made overnight. Deputies who spoke on behalf of the Labour Party assured me that if I brought in a Bill tomorrow to give effect to the White Paper proposals, they would be willing to facilitate me in arranging for its immediate passage. This is just being unrealistic. We cannot have a complicated Bill of this nature prepared in a short time and I do not think it would be proper for the House to pass such a Bill without full consideration, nor do I think it would be proper for me to come to decisions without having the necessary discussions with the parties who can be of assistance to me in the advice they will tender and also from the point of view of ascertaining the problems of the various bodies, associations and organisations who will be affected by certain decisions which might be taken in this House.

If I can have a Bill brought before this House in the autumn and in force before the end of next year, I do not think that I will have anything to reproach myself about, nor do I think anyone will have anything to reproach me about if I can stick to that timetable. I can assure the House that I will do all I can to do so.

Reference was made to the mentally handicapped and it was suggested that not sufficient appreciation of the problem of mental handicap has been shown in the White Paper. I do not think that is a reasonable or fair interpretation. It was clear from what I said in introducing the Estimate and the motion in connection with the White Paper that the reason I did not propose to refer at length to the many problems of providing adequate services for the mentally handicapped was, not that I lacked appreciation of the problems and their pressing urgency, but that I proposed soon to issue a separate White Paper which would set out proposals arising from a very thorough examination of the commission's detailed and comprehensive report. Until that is available, I do not propose to go into it in more detail.

Deputy Ryan criticised arrangements for hospital outpatient services. I am aware that in some outpatient departments, patients have to wait a considerable time before they receive attention. This is not the fault of the medical or nursing staff who behind the scenes are working conscientiously and energetically to deal with all patients as quickly as possible. Unfortunately, the patients are not always aware of this and sometimes they get the impression that there is an attitude of indifference towards them. For that reason I feel that some hospitals might give a little more consideration to the matter of public relations. A helpful explanation to a waiting patient, or a sympathetic word, is never out of place.

Some months ago in the course of a public address, I urged hospital authorities to give this aspect of their service closer attention and I hope that my appeal has had some effect. I have heard it said that delays in outpatients' departments are unavoidable and that a scheme of appointments or prearranged times would be impracticable. I understand, however, that an investigation conducted in Great Britain last year led to the conclusion that it should be possible to devise a reasonably effective appointments system. I would urge that our hospital consultants and hospital administrators cooperate in an effort to devise a suitable appointments system. The benefits to all concerned of an effective system of this sort would make the effort worthwhile.

Deputy Coogan referred to overcrowding in the Galway Regional Hospital. My Department at present is considering the possibility of closer co-operation between that hospital and Merlin Park so that the accommodation in both can be used to the best advantage. We all know that the Galway Regional Hospital is completely overcrowded and that there are some unused but usable units in Merlin Park. A senior medical inspector from the Department recently discussed the matter locally with the officers of the health authority and we are examining his report at present.

Mr. Coogan

It is a very urgent matter.

Mr. O'Malley

It is. Deputy McLaughlin was worried about the difficulty of referring people from County Leitrim for specialist care. I understand that any doctor who wishes to refer patients for specialist, surgical or other treatment is not restricted to Manorhamilton. If the doctor considers the particular requirements of a patient make it necessary to refer him to a hospital outside the county, he may get the health authority's agreement to do so or, in case of emergency, may refer the patient without such agreement.

Mr. T.J. Fitzpatrick

(Cavan): He must send him to Manorhamilton first.

Mr. O'Malley

No.

Mr. T.J. Fitzpatrick

(Cavan): Perhaps there is a special arrangement.

Mr. O'Malley

Patients are told things by officials which are not correct. They are told things as being so to facilitate an official but these are the facts.

Mr. Dillon

Nobody knows these facts. It is a universal practice in the country that if a patient wants to go to a particular hospital, he must first go to the county hospital and be referred from there or he will find himself being called upon to pay.

Mr. T.J. Fitzpatrick

(Cavan): The Minister may take it that if a middle-income group patient is referred to a Dublin hospital by a private doctor without first going through the county hospital, he is at the mercy of the county manager in regard to payment.

Mr. Dillon

That is certainly the practice.

Mr. O'Malley

Deputy McLaughlin raised this point and I will have it on the record what the position is. If a doctor considers that the particular requirements of a patient make it necessary to refer him to a hospital outside the county, he may get the health authority's agreement to do so, or, in case of emergency, he may refer the patient without such agreement and the health authority will accept responsibility for the cost.

Deputy McLaughlin also referred to the delays in securing X-ray examination and again I assume he is referring to Manorhamilton Hospital. I am told that normally there is no delay there for X-rays except in regard to this barium meal test for which there is a delay. There is an average of three weeks' delay in waiting for this test which is a fairly time-consuming one. I have no information that suggests there is any delay in providing a patient with X-ray examination where medical opinion regards it as urgently desirable.

In the course of the debate we had a number of references to nurses' pay. I should say that as far as nurses in the local authority hospitals are concerned, the present scales, which represent a considerable advance on the previous rates, were fixed recently following arbitration. The new rates applied in the voluntary hospitals from the same date as they applied in the local authority service. I am afraid Deputy Kyne is under a misapprehension in stating otherwise. I do not think that pay constitutes a major grievance. The major complaint as far as I can gather relates to accommodation and working conditions of nurses. There are different opinions expressed on this question of accommodation and as to whether nurses should live in or outside the hospital. I would have thought that most nurses would have preferred to live outside but evidently there are quite a number who prefer to live in.

Not all the hospitals have nurses' homes of which we can be proud, I am sorry to say. A good deal has been done, and is being done, to bring the homes up to acceptable standards or to replace unsatisfactory homes by new homes. The table of work in progress which I circulated contains particulars of these and I do not want to go into detail now. In regard to working conditions, I am in entire agreement with Deputies who suggest that it is inappropriate that nurses should be employed on non-nursing duties. I have referred to this myself in the past and I have been engaged in seeing how we can get away from this practice where it exists.

When I spoke last October to a meeting of nurses. I directed attention to a number of improvements I should like to see being introduced. I had in mind particularly the situation in regard to student nurses whose hours are long, who have to attend lectures in their free time and who in some hospitals are required to be in at night at a particular hour which many of us would consider unreasonable.

Mr. L'Estrange

We would, in our young days.

Mr. O'Malley

A girl of 18, 19 or 20 training as a nurse is entitled, for instance, when she is off duty, to go to the pictures, sit out the programme and maybe go for a cup of coffee afterwards with a friend.

Mr. L'Estrange

Hear, hear.

Mr. O'Malley

She is entitled to go to an occasional late dance and, what is more, she is entitled to be in a position some time ahead to tell her boy-friend she is able to go with him to a particular dance on a particular night. These are all human factors——

Mr. L'Estrange

Very human.

Mr. O'Malley

——which keep girls happy and keep them here in Ireland. Girls going to dances have to get——

Mr. Allen

Their hair done.

Mr. O'Malley

Yes, and all that. She is entitled to a comfortable, elegant uniform. She is entitled to have a means of putting her case in regard to any of these matters to higher authorities in the hospital. However, I realise there is another side to the story. Of course, parents whose daughters leave home—student nurses in their first year—are naturally anxious that supervision is exercised so far as their children are concerned. I am talking about those who have become acclimatised—girls of 18, 19 and 20. In my part of the country, I have come across girls having to be in at 8 o'clock or 9 o'clock at night.

Mr. Dillon

I never heard of that.

Mr. O'Malley

I received a deputation in Limerick from nurses complaining of the hour at which they have to be in. This is not peculiar to Limerick. However, there is a body charged under the law with the responsibility of the training of nurses. Before I took any action to forward to the hospitals any of the recommendations I consider to be desirable, I felt I should consult An Bord Altranais and I put to them certain questions to which recently I have received their observations. When I consider these, I propose to communicate with each training hospital, telling them what I think could and should be done.

Mr. Dillon

You would not like to take a Gallup poll of the parents?

Mr. O'Malley

As I said, we are bearing in mind very much the natural anxiety of parents, particularly in respect of first-year students. Take the university halls. The supervision there is realistic. In Dublin and Cork, students in their first year have to be in at a certain hour, but as time goes on, they can get late night passes, subject to the person in charge being satisfied as to where they are.

Mr. L'Estrange

They even let them stay up for the "Late, Late Show".

Mr. O'Malley

This is as far as I can go in relation to the voluntary hospitals, which are autonomous in matters of internal administration such as this. I am not without hope, however, that they will make such immediate changes as are feasible in each case. Other changes may take longer because they might involve considerable rearrangement of procedure and also additional staff, with possible consequent accommodation problems. In every hospital, the paramount consideration must be the well-being of the patient. I would be surprised if there is any hospital in which the administration is such that you can get a good service for the patient from discontented staff. Consequently, I look forward to the utmost co-operation from all hospital authorities in bringing in reforms such as I have mentioned. There are also in these hospitals a high percentage of non-nursing staff, a very fine type of young girl employed in the domestic staff. We want to give them the same fair-mannered treatment as the nurses so that they, too, can have their nights off, subject to what I have said about supervision.

Deputy Kyne referred to the refusal of permission to nurses employed by the Dublin Health Authority to attend an international health conference in Germany. I think he was referring to the International Council of Nurses Congress held in Frankfurt last June. I told the Deputy in reply to his Parliamentary Question that the Dublin Health Authority did not receive any prior application from their nursing staff for the granting of facilities.

Mr. Dillon

In fact, the voluntary hospitals were represented at that conference.

Mr. O'Malley

Yes. There was no prior application from the nursing staff for the granting of facilities to enable them attend that congress. Therefore, the health authority could not refuse any nurses permission to go. I agree with Deputy Kyne's view as to the need for nurses to keep up to date in regard to professional developments. Ample facilities for refresher courses for nurses are made available on an organised basis by An Bord Altranais and the Irish Nurses Organisation, with the co-operation of the Department and the teaching hospitals. The primary purpose of these courses is educational. Nurses are encouraged to attend such courses at regular intervals. Their attendance is rewarded by facilities such as leave with pay, travel and subsistence expenses and the fee for the courses.

Deputy Dowling asked that old age pensioners should have a leaflet issued with their pension books indicating the health services to which they are entitled. This seems a good idea and I am going to see what I can do to implement it. Deputy Dowling also mentioned special hospitals for care of the aged. I welcome his interest in this. I assure the House that I intend to take very seriously my responsibilities in improving and co-ordinating services for the aged. The Deputy referred to vacant beds in some hospitals and overcrowding in others. The cases in which there are vacancies are the infectious diseases hospitals, particularly tuberculosis sanatoria. As far as possible, vacant accommodation is changed over to meet some current health need and the possibility of releasing institutions for other health purposes is kept under constant review.

Deputy Moore suggested an accident hospital should be established in Dublin. While he pointed out there would be some advantages in this approach to the hospital care of accidents, medical opinion in general is against him and the advice I have received is against him. This was also considered by the World Health Organisation and the view taken was that by reason of the variety of services available in general hospitals, it would be desirable to provide for accident cases at such hospitals rather than in isolated units. There is a problem in Dublin arising from the large number of hospitals, most of them dealing with relatively few serious accident cases. The question of how to rationalise and improve the service has been under examination for some time by the Medical Association, and they are very kindly going to submit their views to me very shortly. As Deputy Moore will appreciate, the Dublin voluntary hospitals are mainly concerned in this matter and their agreement would be necessary to any changes which may be needed.

Deputy Clinton referred to the need for a service for the early detection of cervical cancer. I am fully conscious of the need to make such a vital service available as soon as possible to women in the vulnerable groups. Experience elsewhere suggests that this type of service can be effectively provided on a centralised basis. Nearly two years ago a decision was taken at the instance of the then Minister to appoint a cytologist to the Dublin Health Authority and to provide him with the necessary laboratory facilities and equipment at St. Kevin's hospital for the provision of a cytological investigation service for hospitals and medical practitioners referring tests to him. I am sorry to say that so far it has not been possible to recruit a suitable cytologist.

Mr. Clinton

Is it because of the salary?

Mr. O'Malley

I do not think so. Competitions held by the Local Appointments Commission in July, 1964, and in June last year failed to secure an adequately qualified candidate. In recent months the post was advertised for the third time, and we expect to know within about three weeks whether the Commission will be in a position to recommend a candidate on this occasion. In the meantime we have got the necessary technical staff required at St. Kevin's. Two posts as senior laboratory technician have been created, and the persons appointed to these posts have completed training posts abroad in cytological techniques. I should mention that the Regional Hospital in Galway is developing a cervical cytology service for the western counties, and I consider that the consultants concerned have shown commendable initiative in doing this. However, all the Dublin maternity hospitals are also providing a limited service of this sort for their patients.

Deputy Clinton referred to a reply to a question by Deputy O'Connell on 23rd February. I think he implied that I had on that occasion criticised two identifiable senior officials of Dublin Health authority. I should like to correct the Deputy. At no time did I say or imply that either of the two officials in question was personally at fault or had personal knowledge of the matters with which I had to find fault. Because of the offices which they hold, however, they are answerable for the executive functions of the authority, and it is proper that they, and not junior officers, should have been asked to come to the Custom House to discuss the matter in question.

It is quite true, as Deputy Clinton stated, that certain proposals in relation to the pharmacy service which were submitted to Dublin Health Authority in recent years were not sanctioned by my Department, but these were not connected with the specific inadequacies of the pharmacy service which occasioned my remarks relating to the purchase of medicines and to arrangements for the supply of medicines from the Central Pharmacy to local dispensaries. I am now assured that the pharmacy arrangements in Dublin are working reasonably satisfactorily, and I intend to keep the matter under review.

Deputy O'Connell referred to the possibility that doctors in the health service would be limited in their choice of drugs, and expressed fears as regards the danger of the use of inferior drugs. No doctor in the health service is now or will be prevented from prescribing any drug which he considers to be specially necessary for a particular patient. It is accepted, however, that there is often a choice of drugs of the same ingredients and equal quality and effectiveness but differing in price. It is only reasonable, in the interest of economy, that this information should be readily available to the doctors. The formulary for use in the health services and which is mentioned in the White Paper will endeavour to convey this and other appropriate information.

In the main, the purpose of the formulary will be to act as a guide to the doctors in the choice of drugs with a view to fostering efficient and economic prescribing. As regards the preparation of this formulary, it is clearly set out in the White Paper that the medical and pharmaceutical professions will be consulted. It can, therefore, be accepted that the formulary will not be open to objection so far as these professions are concerned. Should there be any objection to any matters contained in it, the organised medical and pharmaceutical professions can be relied on to bring any such objections to notice.

It is my concern to ensure that drugs and medicines provided for the health services are and will continue to be of satisfactory quality. The existing arrangements for the supply of drugs and medicines are made under the provisions of the Local Government (Combined Purchasing) Act, 1939. While the Department of Local Government is responsible for the detailed arrangements as regards the invitation of tenders and the making of contracts, my Department is always consulted before any contracts for the supply of drugs and medicines are entered into by the Combined Purchasing Section of the Department of Local Government. The House may rest assured that every precaution will continue to be taken to ensure that drugs and medicines supplied under such arrangements are of satisfactory quality. As regards the purchase of the drugs by Dublin Health Authority referred to by the Deputy, I am not in a position to make further comment on this at the moment as my inquiries in the matter are not yet complete.

Mr. Dillon

Has the Minister received complaints from the IMA in regard to the lack of a standard of quality for certain drugs?

Mr. O'Malley

No, not recently.

Mr. Dillon

Would he ask them if there are any complaints as to the lack of standard in regard to certain items?

Mr. O'Malley

I can assure the Deputy that if the IMA had such complaints, they would be submitted immediately.

Mr. Dillon

There would be no harm in asking because certainly such complaints are in circulation.

Progress reported; Committee to sit again.