Committee on Finance. - Vote 48: Health (Resumed). – Dáil Éireann (18th Dáil) – Wednesday, 19 Mar 1969

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

Debate resumed on the following motion: "That the Vote be referred back for reconsideration."—(Deputy Ryan).

Mr. Crinion

The health of the nation is one of the most important matters we have to deal with. How many very wealthy people would give all the money they possess to have health? As a nation we must do our best to see that nobody is neglected for want of medical attention. We have a very good record as it is, but with modern achievements in the field of medicine more diseases can be diagnosed earlier on than was the case some years ago. We must make those achievements as widely known as possible so that people will know they can be treated and cured.

I should like to compliment the Minister on dealing with one matter which I brought to his notice during the year, that is, that the Dublin Health Authority were proposing to change over from turf heating to oil. I was glad he agreed that it would be definitely against Government policy to allow things like this to happen, particularly having regard to the amount of money that is being spent on the development of the bogs of Ireland. Such a change would have a great effect on my own constituency which supplies the turf for such purposes. I should also like to bring to the Minister's notice that quite recently in one of the daily newspapers it was reported that the Health Authority was once more thinking of changing to oil for the coming year. I should like him to take note of that and step in again before any harmful decision is taken.

My own constituency was one of those that fought particularly hard to have the wireless installed in ambulances so that they could be contacted at a moment's notice. It is heartening to see that so many of the local authorities have accepted the Minister's generous offer to provide wireless telephone communication for all the ambulances in each local authority area.

One disease which seems to be developing is multiple sclerosis, of which I come across more cases each year. I was informed recently that Northern Ireland and Sweden had the highest rates of this disease. Because of our proximity to Northern Ireland, I have seen quite a few cases of it. I grant that it would be quite a small percentage of the overall population. Nevertheless, there is still quite a number of them. It would be well if, for instance, a farmer or a selfemployed person suffering from this disease could benefit under some scheme for disabled persons so that assistance could be given to their family. Under the present scheme of disabled persons' allowances, there is an income limit and quite often people cannot benefit to the full extent. As this is rather a long illness, I feel that something should very readily be available to help such people. It is hard to describe the anxiety of their families and of their dependants when that happens. In a lot of cases, it takes the doctors quite a while to know exactly whether or not the patient has the disease. It can take more than a year between going to the doctor and the specialist and all the tests involved before they can really be certain what it is. I feel that some assistance should be given to those people of the kind given under the tuberculosis scheme a number of years ago to assist families and dependants. If they are employed, they have national health insurance, but, if they are not, they have nothing and, quite often, there is no money available for them for quite a long time. I have seen a few cases where the strain on them was so much that mental illness ensued and they had to be attended in a mental hospital for a period of time. When that happened, it drove home to me the anxieties that were placed on a person like that.

With regard to delay in the dental services, I am glad to note, as a result of the concessions the Minister gave last year to encourage recruitment to the dental service, there has been an improvement in the number of applicants. There is still a very long backlog. People who have their teeth extracted have to wait, sometimes, six months and very often longer, sometimes running into years. I suppose it will be quite a while before we shall be able to achieve something in that line in a matter of months.

It is well to note that a high proportion of the time available is being devoted to dental treatment for children. When a child reaches the teens he or she very often changes to secondary school or to some form of post-primary education and thus leaves the dental service. I consider that records should be kept so that children coming into that age bracket will be put on a priority list and called before they change their school.

I was pleased to know the amount of work being done for retarded children. In the past two years, about 800 extra children were taken into schools and the Minister hopes greatly to improve on this figure, as time goes by. Up to the present, the children taken were those for whom there was a chance that something could be done whereas children for whom there was very little hope of doing anything were left at home. From the point of view of achieving anything, this was the best policy but we must bear in mind the hardship that remained on the parents of children for whom very little could be done and who, as a result, were left at home because those are the very children who give the most trouble. I know of cases were the mother could not leave the house, unless somebody else was left in charge, because the child could not be left alone as it might harm itself in some way. In fact, I know of cases where the county medical officer of health took away a child for a month or so in order to give the parents a rest. The mental anxiety suffered by those people must be very grim indeed. A great deal needs to be done to help the really bad cases that are disturbed and that cannot stay quiet, and so on.

It is a big cross on the parents of such a child and I feel that a lot could be done to assist such families by accepting such children into schools where they can properly be looked after. It is hard on the other children in the family, especially where the children who are affected are sufficiently active to be in danger of doing harm to themselves and upsetting the household. It is well to see education being provided for some of these children so that they can earn their living or be of some benefit to themselves in later life. In most counties a school is provided and the Department of Education are providing transport for them to those schools. A good deal of thanks must go to the voluntary bodies engaged in raising funds to provide an educational system and also to organise the transport of those children to the schools.

As regards aid to those with eye trouble and so on, I think that in our hospitals here, particularly the Eye and Ear Hospital which specialises in such matters, not quite enough has been done or attempted in the case of eye grafts. It is hard to explain in words the tremendous benefit there is for a person who can avail of an eye graft. From what I gather very few cases, possibly some ten to 20, are dealt with here each year, a very small number considering the number who could benefit from eye grafts. Across the water, where there is a special hospital for graftings alone, operations are being carried out practically every day of the week, excluding the weekends. Some money could be devoted to the Eye and Ear Hospital here so that more eye grafts could be undertaken each year thus giving people who have been waiting an opportunity of regaining that wonderful gift of sight. Very often it is not disease that is responsible for loss of sight; it may be a small ulcer on the eye which branches out on to the cornea or seeing part of the eye, leaving a scar, and the only way of achieving sight in that eye again is by grafting. There are other diseases that affect the eye which would also be helped by grafting.

Grafts cannot be carried out without donors and very little has been done by way of requesting people to donate their eyes after death so that these eyes can be useful again. I should like to see the Department helping in this matter, giving people who have been waiting a number of years an opportunity of getting eye grafts. In other countries that have developed this service the delay is not very long, possibly only a couple of weeks. I should like to see much more done here to develop that aspect of our health services.

When the Minister was dealing with infectious diseases maintenance allowances and disabled persons' maintenance allowances he spoke of the increases that have been given but there is one aspect of both cases that I wish to bring to his notice. The people who get the five shillings and ten shillings a week increase in most counties are only those who were getting the full allowance at the time the increase was introduced. In quite a number of cases of people getting a partial allowance, getting £2 or £1 a week down to 10/-, the increase is only granted in part or not at all. It means their case has to be examined to see how much they will get. The Minister should grant these allowances right across the board, to everybody who is qualified, regardless of whether they are on 10/- a week or £2 17s 6d a week. This increase is intended in some measure to cover the increase in the cost of living and the cost to people with lower allowances is just as great as to those with full allowances.

Whether it is because of the higher pace of living or not, mental illness seems to be increasing but I was pleased to see that in quite a number of hospitals the actual number of inmates was going down and that, with modern treatment, they were able to discharge people much more quickly and deal with a number in out-patients' clinics.

With regard to out-patients' clinics —I came across this quite often in both Meath and Kildare—both St. Loman's and St. Dymphna's are remote from quite large areas of population and patients are naturally inclined to go to the hospitals nearest to them. Naturally, it would make it easier for their families to visit them if the patients were hospitalised because there would be a direct bus service. It would be much more convenient to allow patients to go into the hospitals or clinics nearest to them. I think I have covered all the points I wished to raise. I support the Supplementary Estimate.

Sir Anthony Esmonde

It is quite obvious from this Supplementary Estimate that the present system of financing health services is not satisfactory. Not only is it unsatisfactory but the financial situation itself is in a parlous state. I cast my mind back to 1953, when the Health Act under which we are operating was introduced here. The Minister at the time told us that the increase in the rates would be only 2/- in the £. At the moment expenditure is outrunning revenue. The projections in 1953, whoever was responsible for them, were entirely wrong and we find ourselves now in a position in which the impact of the cost of living, as a result of Government policy over the years, is hitting the health services harder than anything else. For some considerable time the Minister has been under pressure to change the system, to acknowledge its defects and accept that what was stated as health policy by successive Fianna Fáil Ministers is not in keeping with the facts now and that a change in the system of financing the services is necessary, not only in the long term but in the immediate future.

There is an old dictum that one does not appreciate half as much that for which one does not have to pay. A system whereby it has to be established, either through a public or a local representative, that a person is or is not entitled to health services is not a good one. Medical treatment at any level, whether it be general practitioner or consultant, is a personal matter and should be maintained as a personal matter. While one is glad to see a certain amount of control held in the Custom House, I absolutely deplore basing our health services on dependence on Government action. I suggest, as I have suggested so often here, that the function of the State is to help as much as possible and encourage in every possible way the development of private practice, maintaining as far as possible the relationship that existed in the past between doctor and patient.

There are two salient features in this Estimate. One is the increase local authorities have to meet. A sum of £200,000 is required by local authorities and a sum of over £1 million is required by the voluntary hospitals. I take it this £200,000 is only for the remaining portion of this financial year; I do not know what element of retrospection enters into it. It will not make a very great impact on the rates. But, no matter what anyone may say, the rise in rates is due to the health services. Recently the chief administrator in my own constituency told me that the major cost putting up the rates was the health services, and nothing else. That proves that the present system is outmoded and the sooner this Fianna Fáil Government, for whatever period they remain in office, look for some other solution to this problem the better it will be.

As I understand the policy of the Labour Party—I am not very clear on it really—it appears to be one under which everybody, whether rich or poor, will be entitled to free health services. That does not seem to me to be the solution to the problem. It was tried by the first Socialist Government in Britain until they promptly found themselves in very serious difficulty after a short time; they had to take another look at the system and impose certain charges to try to offset the rising expenditure.

As I said, people who get something for nothing do not appreciate it. I am sure most of us accept that it is the responsibility of parents to pay for the medical care of their children, if it is possible for them to do so. I should like to see medicine taken away from the Custom House. I have a great admiration for the officials of the Department of Health but they are not qualified to assess properly the personal demands associated with the full and effective operation of medicine. At the same time, I accept the fact that, while there are substantial subventions coming from the Custom House, the Department of Health is entitled to some control but the Department is not entitled to lay down hard and fast rules and regulations, the sorts of rules and regulations which can, perhaps, be laid down in both commerce and agriculture. It does not make for effective and good medicine or medical services. Therefore, as I say, in so far as people are able to pay they should be asked to pay. I am expressing my own opinion and I have expressed it here before. I believe that a contributory scheme of some sort is necessary.

The county hospital in Wexford has been there for 100 years, efficiently and well run by up-to-date surgeons under the aegis of the Sisters of St. John of God. That is to be abolished and swept aside in spite of the fact that for the past 40 years we have been promised a new hospital in Wexford. Now we are told that there is a regional scheme. Does that not mean that the patients who were treated before in our own hospital will have to be sent elsewhere, and that someone has to pay for them? Hitherto the hospital dealt with all major problems. It was only the odd case that was sent to the voluntary aid hospitals in Dublin. Ordinary operative conditions such as strangulated hernia, perforated gastric ulcer, or appendicitis were dealt with in the local hospital at practically no cost whatsoever to the local authority.

The answer is that there will be regional hospitals under the control of the local authorities concerned. That is all fine, but once you cross a county boundary today you have got to pay— you have got to get the money. The Parliamentary Secretary will appreciate that if we send a patient from Wexford to Kilkenny, Kilkenny will have to be paid. I understand the Parliamentary Secretary is a member of the Kilkenny County Council. I am not a member of the Wexford County Council but as a public representative I have an interest in the matter of rates and I consider that the regional system may save money and that in the final analysis it may be beneficial from some angles. But it is a paper scheme which does not cover the immediate problems.

The suggested position at the moment is that anybody in Wexford who will require an operation from 1972 onwards will have to be transferred to Waterford for that purpose. That means that such people will have to travel from some areas in Wexford farther than if they were going to Dublin. It means also they will have to cross the bridge at New Ross and go through the town where traffic conditions are pretty bad and cause considerable delay. I ask in all reason if it is suggested here that a person suffering from an immediate surgical emergency, instead of being moved to the local hospital, should be asked to go 40, 50, 60 or sometimes 70 miles to be operated on in Waterford.

This is one of the beautiful dreams devised in the Custom House. These dreams have been dreamt there but the result does not always work according to plan. It is a matter the Minister for Health should consider seriously. He has informed me that he is not directly responsible for the suggestion —that it was apparently brought into being in the proposals of the FitzGerald committee. That may be, but the only chance a Deputy has of citing a case is on the floor of Dáil Éireann. Here, as public representatives, we can give our opinions as we see them from the facts we know. I have had letters about the transfer of the Wexford operating centre of Waterford from different organisations. Even the soroptomists wrote to me. The Irish Country-women's Association, the Association for the Blind, every philanthropic organisation in the country have written to me on this subject. I got a fresh letter this morning from another society.

I ask the Minister for Health and those who advise him to realise that this is a fatal mistake. In the final analysis you will have two hospitals. You will have one in Waterford which I have no doubt will be found to be a failure and you will have to have another in Wexford. Give us the hospital at Dunwoody which will save a lot of anxiety not only to patients but to relatives. There is the humanitarian problem that when people go to hospital their relatives like to visit them and to do so they may have to travel considerable distances. The sort of people who will be transferred to regional hospitals will have relatives who will not have the funds to travel to visit them. I ask the Minister to give this matter sympathetic consideration.

There is one other point I wish to make in relation to the regional system. I am glad to see that there is great knowledge now and appreciation of the need in this country to do something for severely handicapped children. This work is under the control of the Department of Health and I am happy that the Department are showing considerable sympathy towards it. Here, again, we propose a regional system, somebody having devised another beautiful dream in the Custom House. We have been told that in three or four years there will not be a severely handicapped child awaiting admission. At the moment there are 380 or 340 awaiting admission and in three years that situation will not exist. We are to have up-to-date fireproof structures for fear these children, who are not the same as others, might burn them down. It is far more likely that one of these children would fall into the open fire in his own cottage while he is waiting for admission.

That brings me to the point that the Minister for Health appears to be sympathetic to the idea that this is a problem we must deal with immediately. If we are to deal with it immediately, we cannot wait until this beautiful dream in the Custom House, or wherever it originated, is realised. We must institute temporary establishments. Such establishments would not be needed for only three or four years but for 20 years or more. These temporary establishments would be localised in the counties concerned, not regionalised. Anybody who has had experience as I have had, thank heavens not in my own family but through dealing with the problem in a period of four or five years, is aware that it is very difficult to get parents first of all to come forward and let you know they have handicapped children, and, secondly, to consent to have the child transferred to an institution. It is unsatisfactory to have these children kept in their homes because not alone do they wear out their parents but they are bad for the other children and the sooner they are domiciled elsewhere the better. When you come to a parent and tell him that he can get admission for the child after three years, if this beautiful dream works out, and that the child will be transferred to an institution 40 or 50 miles away, as likely as not you will get a refusal.

The Department of Health should consider seriously this problem of the licensing and the assistance they may give to the voluntary committees growing up all over the country. I have been particularly interested in the mental handicap committee in Wexford of which I am a member. I know of other committees in other counties who are equally anxious to get mentally handicapped children into institutions as soon as possible. The only thought is to get them into temporary institutions that will exist for 20 years, and it may well be that these temporary institutions will become permanent.

It may be asked how are they to be financed. We must come to the Department of Health for some capital funds the same as is done in social services, the Department of Education, for instance, being asked to build schools. The Department of Health will have to assist local committees to do the same in the matter of the provision of local institutions, the Department going into co-operation with the various committees. This is something which the Department must consider actively as the answer to this problem. The continuing financing of these institutions, we hope, will be done by the local authorities and by voluntary contributions from different societies in different parts of the country. That is the right way. It is healthy co-operation between private enterprise and the State. That is where we will get results. When dealing with medical services, you will always get better results if you have co-operation between the philanthropic and humanitarian societies and private enterprise, plus the State. Private enterprise must reign supreme in the medical services.

Mrs. Desmond

I wish to make only a few brief remarks on this Vote which has been gone over very ably by our spokesman on Health, Deputy Kyne. I hope the few remarks I I have to make will be allowed and I make the case that they should be allowed because of the fact that a token sum of £10 was arranged for under this Estimate. Let me quote the Minister's own words at column 279 of the Dáil Debates of the 12th March, 1969:—

...a token sum of £10 under Subhead A to enable discussion to take place on the main Estimate which has already been agreed to.

Those of us who are members of health authorities are in constant touch with the sick at that level and also at personal level and, therefore, we realise that this must be the most important Estimate to come before the House. I say this while bearing in mind the enormous importance of other Estimates such as those for Education, Local Government and so on. However, I think that education, social services and housing only assume an importance for those who have their health because health is the most important possession we have as human beings and for that reason we should not count the cost as being of the greatest importance when dealing with the health of our people.

As the services are constituted at present there can be no doubt that considerable hardship exists for a large number of people and the Minister in the course of his address referred to the need to make the entitlement of such people better known. Until the present system is changed, there will always be great involvement in health matters for public representatives. Perhaps there is too much discretionary power at the moment. This, in effect, brings public representatives into the picture in trying to claim and to argue the entitlement of people to benefits which they should normally be entitled to.

A particularly sore point with us at the moment is the question of the cost of drugs. Drugs have now become the most costly element in an illness and their cost seems to increase all the time. I do not know if there is any control over the price of drugs; I expect there is but to the ordinary person it would appear that there is no way of anticipating what the price of any particular drug will be because of the fact that prices vary so much. This constitutes an enormous hardship to the medical card holder as well as to the person within the middle income group who is not a medical card holder. It can affect to a great degree the medical card holder who, for some personal or other reason, decides to seek the advice of a doctor outside his dispensary area. The cost of the visit to the dispensary will not prove very costly but the cost of the drugs prescribed by the doctor might well prove far beyond the reach of the person concerned and unless the dispensary doctor signs the prescription issued by another doctor or by a specialist to whom the patient has been referred there are no means by which we can induce our health authorities to bear the cost of these prescriptions.

The Minister in his speech referred to the amount of money being spent by authorities on medicines for those outside the lower income groups. I think it was the year 1967 to which he was referring when he said that the authorities spent £61,000 on such medicines. This might seem to be a fairly big sum but I know that if all those who were so entitled got their entitlement to medicines such as this the cost would be far greater and that a great deal of hardship would be alleviated.

There can be no doubt that while there is a barrier between those who pay for health services and those who do not pay and while those who do not pay receive a restricted service, there is an injustice being done to the dignity of the human being and particularly human beings who are ill.

I am greatly concerned personally with the care of the aged and I was glad to hear the Minister refer at length to this matter in the course of his introductory speech. I was glad, too, to hear him comment at one stage — I think it was in reply to a remark made by Deputy Ryan — that it would be much better to pay a certain sum every week to keep a patient in his own home than to pay a much greater sum to institutionalise the patient. The fact is that sons, daughters or relatives might well be prepared to look after the aged or the sick if only some compensation were available. If a person has stamps, compensation will be available from the Department of Social Welfare and if a person has not stamps there is home assistance available but I would appeal to the Minister for Health and to anybody in a position to control or influence the course of health services to try to get away from the idea of home assistance. The rigid means test and the whole concept of charity which surrounds this type of payment makes the system an outmoded and Victorian one.

The time has come when the payment of money to people in the lower income groups should be looked into. We have a most demoralising system in regard to payments of this kind. It is certainly no compensation to a son or more often a daughter who has to give up employment or, perhaps, who has never been able to take up employment because of the fact that he or she had an ailing or aged relative to look after. It should not be left to home assistance to compensate such a person but rather a system more in keeping with the dignity of the person should be devised — a system which would recognise the enormous contribution that person is making to the community.

Likewise, it is time that vouchers were done away with where at all possible. These vouchers are tags on a person's inability to pay and tags on a system which should not exist in 1969. Travel vouchers, perhaps, might be the exception but the idea of handing out vouchers for food and shoes, etc., has had its day. It should cease. In his speech the Minister referred to the question of patients in mental hospitals, to the enormous incidence of mental illness, and to overcrowding in mental hospitals throughout the country. Nowhere in Ireland is that realised as much as it is in Cork. We have an enormous mental hospital — Our Lady's Hospital —which is grossly overcrowded. We have taken fairly advanced steps to relieve the situation, and to start from scratch and make a completely new approach to the whole question of mental health services, by establishing an acute unit in the relatively empty St. Stephen's Hospital which was once a TB hospital and we are lucky to have available. There exists an enormous problem of overcrowding and a lot of improvement is necessary in Our Lady's Hospital. I would ask the Minister to accede to any demands from that hospital for funds or to any requests for improvements. The need is enormous. I have seen beds where patients could scarcely stretch out their hands without touching other beds. Such overcrowding would not be conducive to the speedy improvement and restoration to health of a mental patient.

There is also the question of the relegation of aged persons to mental hospitals. This is one of the reasons why so many hospitals are overcrowded. Many senile people, or people who have nothing wrong with them except their age, are being relegated to mental hospitals. We still have to have a new approach to this question. We are all conscious of the problem but I do not know whether our approach is impatient enough. We know the problem is there, but we do not know whether we are doing enough to see it properly solved. These aged people cannot apparently be kept at home but they do not deserve to end their days in mental hospitals.

The whole question of mental illness is receiving a great deal of attention now and I hope it will receive more attention in the immediate future. I can imagine in a very short number of years that people will raise their eyes in horror when they are told that aged people were put into hospital just because they were old and their illness was mental illness. We must get to the stage where mental illness is treated in the same way as other illness. I am sure that day is not far off when people who have no personal experience of the matter will be horrified when they hear that we shut people away in institutions. The day will shortly come when mental illness will be treated as TB is today. Not long ago it was something of a disgrace to have TB and we had an unenlightened attitude to TB that is laughable today. The same will apply to mental illness in a short number of years.

The Minister referred to another matter about which I am very concerned, and that is the question of dental health. At local level I have been concerned with the question of dentistry. I was disappointed at the Minister's remarks. He mentioned that dentists were scarce but there seemed to be no indication that he was beginning to grapple with the enormous shortage of dentists that exists. We all want to improve the dental service. We are all conscious of the need for dental care that exists in children. Modern foods and the modern approach to the treatment of children, and perhaps an overindulgence in sweets, means the children's teeth do need care. We had a situation obtaining in Cork Health Authority where we provided service in the City Hall at Cork. It was a voluntary service and one which parents were at liberty to avail of without being referred to it by a visiting dentist. It existed for a number of years, but the shortage of dentists was such that this service never really did what it set out to do. We had to confine its activities to children under the age of ten years. Any of us who have children know that children under the age of ten years have, with a reasonable degree of care, fairly good teeth. Their first teeth fall at six to eight years of age and they acquire a second set over the following couple of years and in that time their teeth are reasonabl ably good. Over the age of ten years children may have trouble with cavities and dental decay. We were confining our activities to children under that age and were not catering at all for the needs of those who perhaps needed even more dental treatment. Even with that curtailed service we found that we could not continue due to lack of dentists. The Health Authority advertised for dentists but were told that they could not be got.

We have now reverted to a schools service for the last 12 months. Parents in these areas are beginning to ask when is the schools service coming to their school as they do not get service at the City Hall. We do not know, but we do know that the service is inadequate. During the lifetime of the previous voluntary dental service we had cases where people needing extractions got teeth extracted immediately but if they had cavities they were referred back for six months. After that period the cavities, in some cases, had deteriorated to a stage where extraction was necessary. That was the situation operating then but the situation is worse now. In County Cork we are deeply conscious of the problem of the shortage of dentists. It is not enough to say we have not dentists and leave it at that. We must encourage dentists to come into the service and ensure that we have enough dentists to provide for the children of the nation proper dental services. Much depends on proper dentistry. We want our children to grow up strong and healthy and to do our best for the next generation. They will not grow up in such a manner if they are allowed to grow up without proper dental treatment and care. Such a lack definitely interferes with their future health.

The approach to dental health is appalling. I was disappointed that the Minister was so brief in his remarks on the question of the improvement of the dental service. He referred very briefly to arrangements being made for fluoridation in those areas which will not have fluoridated water supplies. This is another example of the lack of a link between the Department of Health and other Departments. I have mentioned over and over again that we have a situation sometimes where one Department is completely out of touch with another. We have a Minister talking about areas without fluoridated water. The fact is that the majority of those areas have no water at all. Vast areas in this country have no water at all. There are areas where water has to be conserved and as much use as possible made of it because of the hardship of bringing it to the house. This is really a health problem and one on which there should be some link between the Department of Health and the Department of Local Government, which is responsible for the bringing of water supplies to rural Ireland. There is very little talk about it.

We have another problem in Cork Health Authority. We have the problem of the payment of disabled persons' maintenance allowances. In the Cork Health Authority we were conscious of the need to provide more comfort for aged people. Many of these people find their way into hospital for no reason other than destitution and because they are not able to provide the extra money required to provide the extra nourishment which a disabled person needs as well as the extra money required to provide heat. Conscious of these aspects we unanimously decided to pay disabled persons' maintenance allowances to people over 70 as well as to people under 70. There appears to be no legal difficulty in doing this but our manager thought otherwise. I still contend that he was wrong in thinking otherwise. However, he refused to do this. I know that the Minister is concerned with the plight of old people, particularly those in our institutions, and I would ask him to impresss on people like the manager of the Cork Health Authority the need and the desirability of making payments from any source open to us to elderly people, particularly disabled elderly people. Such a small payment might perhaps enable the person to provide more comfort for himself or herself or enable small jobs, perhaps strenuous ones, to be done for that person which the person could not do himself. If such payments are not made many of these people will find their way into hospitals, where they will be unhappy and will, through no fault of their own, be clogging up our health system. On the other hand, if they are at home and are treated properly, having proper social assistance, social workers to attend to them and a proper domiciliary service it will mean that the turn-over in our hospitals will be far greater and the system will operate more efficiently and competently than it can do at present.

I could not leave this Estimate without referring to the problem of mentally handicapped children. This is a problem about which we are all concerned and I am glad to see that so much is being done for these children by voluntary organisations and by the Department. However, a great deal more needs to be done. The Minister in his introductory speech said that over the past few years 880 additional places had been provided for mentally handicapped children. We are all in agreement with the efforts being made in this direction but it is not enough to say that we can tackle the problem bit by bit and that finally it will be solved. The whole future of these children is at stake. Some of them are suffering from mild handicap, some from moderate handicap and some from severe handicap, and in the case of the first two categories a great deal can be done to turn these children into useful citizens who can cope for themselves in the future. There is a time when these things can be done but if we allow it to pass we can never catch up on it again. It is like providing an educational system for ordinary, healthy schoolchildren. If we leave the problem for another four or five years then we will have missed the opportunity of developing the capacities which these children have and which can be developed if they are properly trained. These children are our first responsibility and we should give them first priority. Everything we can do to help them should be done this year and not next year.

We do not hear so much about our physically handicapped children, our blind children and our deaf children, who can become useful citizens with proper training arising from the proper approach. For these children, too, we should do all we can. There is a research unit in Dublin which has done a great deal in regard to the problem of mental illness. This is a very formidable problem but anything that we do in this regard will bring a hundredfold reward in the future.

We have, too, the old question of the financing of the health services. While we are conscious all the time of the cost of these services we should still aim to provide the best we can in the knowledge that this must be done. The question of financing the services is a very thorny one. The collection of the necessary money by taxation or by rates is really a case of "six of one and half a dozen of another." The rating system, of course, is completely inequitable and rates are being extracted from people who have nothing but the homes in which they live. On the other hand, taxes are being extracted from people with only £6 5s or £6 10s a week. However, this is not the occasion on which to debate the means of collecting revenue and all I am saying is that both systems are inequitable. The ratepayers are up in arms in regard to the imposition of health service charges and each year they say that a good deal more of the cost should be borne by the Exchequer and by the people generally through taxation. This is quite true, this should be done, but again we have the problem of evolving a more equitable system of taxation. I will conclude by saying that we should address ourselves to that problem but, above all, we should bear in mind that the health service is the most important service we can provide and that it is not a question of whether or not we can afford it; we must provide the best possible service and find ways and means of financing it and distributing the cost as equitably as possible on our people.

Mr. P.J. Burke

This is a very important Estimate dealing with the health of our people, their very lives, and with the cost of providing these services. The financing of the health services is the most hotly debated subject at all local authority and health authority meetings. As the last Deputy said, no matter how we manage it, somebody must pay. The unfortunate thing is that the rates are increasing year after year and they are imposing a very real burden on all sections of the community. Indeed, there are many small business people in the towns who are not able to carry on because of the increased costs. It is a problem about which the Minister has received various deputations. In Dublin 95 per cent of our charges are statutory and we cannot do anything about them.

A number of our people are members of the Voluntary Health Insurance. If we could get more people to join, it might relieve a lot of the charges we have to meet. The Minister for Health received the members of the Dublin County Council in a most courteous, kindly way. I have no doubt that, if he could get the money, he would relieve the rates not alone in Dublin but all over the country, but we have many demands on the Central Exchequer and you cannot take the trousers off a Highlander. I understand an inter-departmental committee has been set up to deal with the problem of rates and the rating system. At the moment people on static incomes, especially people on small pensions from the Civil Service, local authorities and so on, are asked to pay. We have a system in the Dublin Health Authority whereby we help the old age pensioners, the poor widow and people like that, but it is taking it out of one pocket and putting it into the other. At least we are trying to eliminate hardship. We are concerned with individuals. We are concerned to see that they do not suffer. We know we have the sympathy of the Minister and the Government. We are all concerned about the increase in rates.

With regard to home assistance, we have set up a very efficient social welfare department under the auspices of the Dublin Health Authority. We are concerned to see that no individual in our society is hungry or in want. If we must err on this side of generosity in regard to home assistance and home help, I feel we should do it. I have agitated for this for many years. I have been a member of that authority for nine years and I happened to be chairman of it for one year. I am concerned with individuals. I am concerned to see that nobody is hungry or in want. I feel we have the backing of the Minister and his Departmental officers in this.

If we err at all let us err on the side of generosity. Home assistance does not apply only to old age pensioners and widows. It applies to anybody from any walk of life who may, through no fault of his own, find himself in want. You may have the case of a father dying and leaving five or six children. I dealt with a case this morning where a father died and left five or six young chlidren, the oldest nine years of age. They have not a penny. The rent of their house is £4 a week. We had to go to their aid. Otherwise, we would have them in St. Kevin's Hospital or some other institution.

Under the auspices of the Dublin Health Authority we also have the "Meals on Wheels" scheme. I want to take this opportunity of thanking the voluntary organisations and the religious organisations, the St. Vincent de Paul Society and other charitable organisations for their work in this line. We are dealing with about 2,000 old age pensioners in the Dublin Health Authority area. It is a good investment to help these people because we have too many aged people in our hospitals and homes and we have not room for them all. It is very costly on the Exchequer to keep them in hospital. We should be a little more generous with old age pensioners and look after them better. I am concerned with people who are living alone. I want to say that sons and daughters should have regard for their fathers and mothers. In other countries in which I have travelled on deputations I have found them doing that. I have found them doing it in Ireland, too. There are thousands of children in Ireland looking after their fathers and mothers reasonably well, but you also find that section who are living alone and are nobody's children. I feel that, if we are generous to them and help them, we will save them from coming into hospital suffering from malnutrition. I know the Minister is very concerned about the old age pensioners.

There are also people who are prematurely old and dejected even at 60 and are not entitled to any benefit except home assistance. We are concerned about these people. It is the concern of our society to help them. The voluntary organisations have been doing their best. They cannot do much because they have only a certain amount of money which they get in voluntary contributions. Things have improved a good deal. The contributory old age pensioners have succeeded in becoming reasonably well off as far as the resources of the State can afford. However, this is another day's work. This is for the Department of Social Welfare.

In County Dublin we have seven per cent or eight per cent of the population with medical cards. I feel that an old age pensioner who is not working should have a medical card automatically. This would be an encouragement for the sons and daughters to keep them. I have known cases where old age pensioners have gone to hospital and the son or daughter has been billed with the expense for the time they were in hospital. I am not dealing specifically with the contributory old age pensioner. If he works for a few years after getting the contributory pension he is better off than he was at 60 because he has his pension as well as his pay but I am dealing with the person who is not working.

I believe home help is very essential. I believe it would stop people from going to hospital. If a daughter is working and has to stay at home to look after her mother, I believe it is the concern of the Minister to see that she gets something. By giving that girl something to support herself while she is not working she will be able to look after the old person at home. If that old person has to go into hospital it costs the Dublin Health Authority £15 or £20 a week, so by giving £4 or £5 a week to the person who is staying at home from work we shall save public money and relieve a lot of congestion in our hospitals.

Many of these charges should be subsidised by the Department of Health. While the Department of Health gives a direct subvention to the hospitals, home assistance, home help and things like that are the responsibility of the local authority. It is time that the State gave a 50 per cent or some substantial contribution towards these costs to which I have referred, because it is one of the biggest jobs we have.

There are a number of geriatric patients who are in mental hospitals because we have no suitable place to put them. We want our psychiatric hospitals to be acute hospitals as far as possible, but they are cluttered up with these old patients. Due to modern treatment some of these people are living to 100 years of age. During the year I was chairman of St. Kevin's Hospital, and there were three people who had attained the age of 100. People are living longer nowadays and naturally we do not want to see anyone die even for economic reasons.

Great strides are being made in psychiatric treatment compared to years ago. In the central psychiatric hospital in Dublin, St. Brendan's, and the two subsidiaries, there can be 100 or 200 patients admitted and a similar number discharged per month. Even in the small hospital, St. Loman's, there are about 50 admissions and 50 discharges every month. This shows what modern treatment and a more enlightened outlook can achieve. A great deal is also being done by way of finding employment for these people and rehabilitating them. They can go to work and come back to the hospital while they are undergoing treatment. I wish to thank the Minister, the Secretary of his Department and the officers for the co-operation they have given in this excellent work. There are a number of old hospitals, including St. Kevin's and other geriatric hospitals, that need to be replaced. While great advances have been made, there is room for further improvement.

Since 1953 there has been a big fall in the number of TB cases. A number of factors contributed to that reduction: first, modern drugs and, secondly, the building of up-to-date hospitals for TB patients. However, one of the most important contributing factors in reducing the incidence of TB was the psychological factor that, under the 1947 Act, a TB allowance was given to the patient. Heretofore a person suffering from TB would say: "What is the use of my going to hospital? I have a wife and family to support and I have to keep working. If I go to hospital I shall only be worrying." When the TB allowance came such people could be a little happier going to hospital and getting treatment. The tragedy today is that TB is being contracted by older people. In my younger days the trend was for people of 16, 18 and up to 30 years to contract it. Now the trend is the other way, at least under the Dublin Health Authority.

As regards the co-ordinating of various hospitals for more specialised treatment, I am a member of the co-ordinating committee on the north and south sides of the Liffey. On the federated hospitals side there are seven hospitals plus the Dublin Health Authority, and we have had quite a few meetings with them under the auspices of the Minister for Health. Some progress has been made, but it will take some time to get the most modern hospitals and the best equipment available to treat our people who are ill. The discussions are only at a preliminary stage. One such hospital is to be built at St. Kevin's under the auspices of the federated hospitals and the Dublin Health Authority and the other at Elm Park. By getting the most modern equipment for specialised treatment in a co-ordinated hospital we shall avoid overlapping in the smaller hospitals.

In the United States they have gone into this problem in a big way, because the charges for medical treatment there have become prohibitive. I have been reading reports of commissions to see what they are trying to do. If we succeed with the idea the Minister for Health and His Department have at the moment we shall be doing something very sound for which posterity will be thankful to us. There are a number of small obstacles. The boards that have been associated with various hospitals for years are naturally conservative and do not want to give up what they have, but in the interests of the well-being of our people, there should be a sane approach to matters of this kind. The best possible equipment for the treatment of any disease should be available in a particular centre. In that way the little frustrations experienced by small hospitals would be avoided and the intelligent policy of the Minister and the Department could be implemented.

On the north side there are three hospitals under the Dublin Health Authority. Dublin Health Authority are trying to have part of the James Connolly Memorial Hospital utilised as a general hospital.

An Leas-Cheann Comhairle

I do not wish to interrupt the Deputy but I feel that his remarks would be more appropriate to the Health Bill, which the Minister has promised to introduce and which will be before the House shortly. At present the debate is confined to the Estimate before the House.

Mr. P.J. Burke

I bow to your ruling, Sir, and apologise if I have transgressed the laws of courtesy. Great progress has been made in the matter of dental treatment. I want to take this opportunity of thanking the dentists employed by the Dublin Health Authority for the wonderful work they are doing. The lectures given to school children on the care of teeth are very useful. There is, unfortunately, a shortage of dentists. Dublin Health Authority are trying to overcome that difficulty and a big improvement has taken place.

There is the problem of mentally-handicapped children. There is a huge waiting list for admission to institutions. Great advances have been made during the last few years. I know the deep interest the Minister has in this matter and I would ask him to continue the good work he has been doing. Everything possible should be done to help families who have the problem of a mentally-handicapped child. The care of such a child imposes a great strain on a mother. I know of one case in Dublin where there are three mentally-handicapped children in one family. This strain on the mother is very severe. Some parents do not want to have such children admitted to psychiatric hospitals. A child may be taken into a home and may be transferred after some time to a public hospital. I have great sympathy with parents who have a mentally-handicapped child. This is a problem which concerns us very deeply. We have received wonderful co-operation from the Minister and his Department in this matter. All possible help should be given to parents of mentally-handicapped children.

There are many other matters that I could deal with but I shall conclude by saying that voluntary organisations should co-operate to a greater extent with the Department of Social Welfare and the health authorities. They are co-operating fairly well. If at all possible, aged persons should be kept at home in their own surroundings. Dublin Corporation have made an effort in their housing programme to house aged persons with younger families. We have had the experience that where elderly persons are housed with younger people the younger people have looked after them and have been helpful to them, especially in the case of elderly people who live alone.

I wish the Minister and the Department well. They have a big job to do.

Mr. Reynolds

When the Health Act was introduced I was a very young member of a local authority and I remember travelling to the town of Sligo to hear the then Minister for Health tell us that when the Bill was passed everything would be well and that the cost to the ratepayers of the three or four counties represented at that meeting would be not more than 2/- to 2/6d in the £. One can judge how far out the estimation was and how misleading a statement it was to the members of county councils present when one looks at the estimates for the current year of most county councils and finds that some of them are seeking an increase in rates under the health heading alone of from 4/- to 6/- in the £ in one year. It is not now but many years ago that the Government Party should have introduced a health scheme.

Deputy Burke referred to the allowance being paid to TB patients in 1947. In case Deputy Burke may have forgotten, I am bound to remind him that in 1947 a brother of mine had TB and we tried to get him into an institution. There was absolutely no chance of getting him into any institution in this country. Fortunately, a sister of mine, who was nursing in England, came home to care for him. Were it not for the care that my sister gave my brother I doubt if he would be alive today. Perhaps, as Deputy Burke says, the Government did pay an allowance at that time; I do not know; but I certainly want to put it on the record of this House that after 1948, when the inter-Party Government had been a very short period in office, nobody had to take his place on a waiting list in order to get into a sanatorium. The inter-Party Government built sufficient sanatoria to isolate TB patients. The Members of this House should never forget that, no matter on what side of the House they are. Certainly the members of my family will never forget it. It is only right to mention that in passing.

With regard to the care of the aged, as some speakers have said, a very big percentage of the people of this country are very kind to their parents and look after them in their old age but there is a very limited number of cases where children neglect their elderly parents. There is also the case of elderly persons who have no children to look after them. In the West of Ireland — I am sure nobody knows this better than the Minister for Health— in the part of the country he represents, no more than in the part of the country I represent, we have a very big number of old people. There is a waiting list in most county councils for the admittance of old people into some institution or other — county homes, and so on. In one county in the West of Ireland, there is a waiting list of 25 aged people who are living alone and who are trying to get into a home. Some type of institution will have to be built to provide for the accommodation of these people and it must be provided immediately in view of the present desperate situation.

It might be a considerable help if an allowance were paid to the young people in a house to look after the old people there. An allowance as high even as £4 a week in respect of mobile aged persons would help to leave accommodation in some institution for aged people who are not mobile. We must be more than thankful for the work which any society or voluntary organisation is doing for our aged citizens. If it were possible for some of these people to have a prefabricated unit erected which would be equipped with television, washing-up places, and so on, so that some of our public health nurses could look after the people there, I am sure it would be a great benefit to mobile aged citizens. Something like that, or both of these efforts together, would certainly give relief in a very short space of time.

The term "home assistance" is outmoded and outdated. We have inherited it from the British regime in this country. Probably it was then called "outdoor relief". It means the same thing. It is a dirty word and the way it is administered is even dirtier. Very often, the people concerned are poor and, like most of us, are too proud to admit it. Some neighbour or a local councillor might mention the matter to the home assistance officer. An application form has to be filled up and an investigation must be made and then the application must go before the superintendent and up to the county manager for the miserable amount of money which is given to a person under this heading. In these days, there should be an easier and a better way of doing this. It is not difficult for a home assistance officer, particularly in the rural parts of our country, to find out the circumstances of a person, thus avoiding the tremendous amount of probing that goes on at present.

The Minister said that over the past four years, 880 extra beds have been provided for mentally-handicapped children. That means that 220 beds were provided, on average, in each of the past four years. I am sure that every county council in Ireland has a waiting list for the admittance of such unfortunate children into some type of institution. Certainly, that is the situation in the counties I am most familiar with. The number of beds under this heading must be increased substantially. When the parents of such a child decide to apply for some type of institutional treatment for the child, its name is put on a waiting list. Somebody with more influence, although the application may be made later, is able to have his child taken first. That is most unfair.

Every mentally-handicapped child should be cared for free in an institution, irrespective of the means of the parents who, undoubtedly, have suffered enough as it is. We have voluntary organisations all over the country which are doing a tremendous amount of work for these unfortunate children. In the town of Mohill, County Leitrim, a number of people set up a type of school there to give some education to these children who could not get into any boarding institution. The organisation sought an allowance from the Minister's Department and from the Department of Education in respect of the transport of the children to school but, because a sufficient number of children was not involved, the allowance could not be given. Surely that is not fair? An allowance should be made available wherever local people are making an effort such as this. Were is not for the generosity of the county councils concerned, it would indeed be a sad situation. The financial help an organisation would get directly from the Department would be very small. Much more help should be given to them.

We all know that some counties, particularly in the West of Ireland, have advertised for dentists on numerous occasions and are failing to secure them. Something must be done about this service. Schoolchildren need dental treatment and that aspect of our health services is very much neglected. I discovered recently that, in one county, the dentist calls to the national school once a year. Nobody could call that a service. If the Department of Health is to protect the teeth of our children it will certainly have to increase the number of inspections in our national schools. An inspection once or twice a year is not sufficient. It will have to be increased to three or four times a year.

The hospital rationalisation committee reported recently to the Minister. I take exception to the downgrading in that report of the surgical hospital in County Roscommon. This hospital has given a tremendous service down through the years to the people of that county and to the people of South Leitrim. I trust the Minister will see to it that the surgical hospital in County Roscommon is not down-graded. We had surgeons there like Mr. O'Hanrahan, who gave a tremendous service at a very cheap price to the people of South Leitrim and North Roscommon. It would be most unfair to have this hospital down-graded in any way.

I was glad to read last week that the Minister said we would have the new Health Bill this week, I think. It is long overdue. We have only to consider the issue of medical cards and the percentage issued in some counties as against others. On 26th February I put down a question to the Minister, as reported at column 1729, Volume 238 of the Official Report, asking the Minister for Health the number of applications for medical cards in each year since 1954 for each health authority giving (a) the number of applications received and (b) the number rejected to the latest convenient date. The Minister replied that the information sought was not available.

My reason for that question was the disparity in the percentage of medical cards issued in one county compared with another. On the same day, I think, I had a question asking the Minister the percentage of population covered by medical cards to the latest available date and the Minister gave that information to 31st December. On going through the percentages we find that County Carlow has 47.2 per cent of its population covered by medical cards. That figure may be reasonable; I do not know anything about Carlow, but here is something worth looking into.

Leitrim has 34.7 per cent, Sligo 35.4 per cent and Roscommon 50.1 per cent of the population covered. When I discuss this and ask the county manager or the people in the health section in County Leitrim or in County Sligo about this they will tell me it is because the people did not apply. I know well that the people applied, but County Leitrim and County Sligo have the one county manager who decides who is and who is not entitled to medical cards.

The net result of this silly way of issuing medical cards is that we have a county manager in Roscommon giving over 50 per cent of his population medical cards — and if you were to compare any counties in Ireland you would certainly compare Leitrim and Sligo and Roscommon — while we have a county manager in Leitrim and Sligo who is prepared to give only 34 per cent of the population medical cards. The sooner this method of issuing medical cards is changed, the better and the more satisfactory for all of us. That was why I put down this question. The Minister may be right; the information may not be available, but I do not think it would be very difficult to get it. If the Minister gives me any encouragement, I will repeat the question. Probably he did not know what was in my mind in asking the question; it was exactly what I have now explained.

We have a number of dispensary doctors operating in a temporary capacity in some counties. In County Roscommon we have them in the following districts: Ballinlough, Lough Glynn, Ballinameen, Athlone No. 2 and Athleague. I think the Department wrote to Roscommon County Council saying that any vacancies should be filled only in a temporary capacity. That is not the right procedure. If the county council can get people to occupy the dispensaries permanently, the Department should sanction that.

As regards disabled persons' allowances, we have the case of the person who is ill or not physically fit and who applies to the local authority for this allowance. He must get a certificate from the local dispensary doctor saying he is not physically fit. He is then examined by the local MOH who sometimes cannot make up his mind whether or not the person is disabled. I remember that once we had a MOH in my county and an unfortunate man who grew up to only about four feet and was 28 years of age and had a hunchback applied for an allowance. The MOH could not make up his mind whether or not he was disabled and decided to send him to an orthopaedic surgeon. How daft can these people be with this sort of carry-on, or where will it end if it is allowed to go on? If you take it up with the Department they will say they have no control over it. One day, while this procedure was going on, I suggested to the MOH that I would take this boy into a county council meeting. Then he decided he was disabled. It is terrible that a county MOH cannot make up his mind whether a person in these circumstances is disabled or not.

After going through all this we then have the home assistance officer waiting to investigate means and going to the person's parents or brother or whoever lives with him to see what land they have and what stock is on it. Ultimately, the poor fellow ends up by getting 50 per cent of the disabled person's allowance. That is a desperate situation. In this particular case I think the man should have got the maximum allowance, that there should be no doubt about it. He lived with his mother who was a very old woman. The means test is too rigid and I think 90 per cent of such people should get the maximum allowance.

We come now to the burning question of rates which is troubling all of us. We find that last year 35 per cent of the rate collection was for health. At present we have 87 rating authorities, 27 county councils, 49 urban authorities, seven boroughs and corporations and four county boroughs. In 1968/69 a total of £37,660,000 was collected, of which 35 per cent was for health services. That was an increase over the previous year of £2,950,000. One would be inclined to ask at this stage what will be the increase in the current year if it was over £2 million last year. It will certainly be much greater. We are all prepared to admit, although the Government do not seem to be doing anything about it, that this rating system is out of date and outmoded.

These words were used by the Leader of the Fianna Fáil Party in my constituency in the last general election. He said they would revise the system, that they would make some change. However, nothing has happened and, each time one looks into the matter, it becomes just a little bit more ridiculous because some county councils get only £150 if they increase the rates by one penny while others will get an income of £2,500; and, coupled with that, there is recoupment to the tune of 50 per cent. The system is outmoded and out-dated. It is a most unfair system in present circumstances. I trust the Minister will introduce the new Bill very soon and that this problem in connection with the rates will be solved. The Government have on numerous occasions accepted most Fine Gael policy. If there is one particular Fine Gael policy they should accept it is Fine Gael policy in relation to health services. The Minister for Finance referred to it in the last Budget. There will be no comfort until all are on the one level. The Voluntary Health Insurance Scheme has proved that. The only solution is a contributory scheme and the Minister has his opportunity now.

Mr. Cosgrave

A number of matters falling to be dealt with on this Supplementary Estimate will fall to be dealt with again on the promised health legislation but, since it is likely to be some time before that Bill comes before the House, there are some aspects of the present health services to which I think it is appropriate to refer. The fact that so much money is spent on health services indicates the extent to which the community and this House are concerned with the need to provide the best possible health services for all our people and, in particular, for those of our community who are not able to look after their own health needs out of their own resources or the resources of their families.

Our present health services grew up in a patchwork sort of way. Many of the defects inherent in them are a legacy from another era from an alien Administration. That does not absolve us from trying to provide health services not merely catering for those who require them but also financed and paid for on an equitable basis. Many of the services at the moment do not provide either the benefits or the financial assistance we would like them to provide. The real area of disagreement arises out of the method of payment for the services. I agree with the Minister that, no matter how the services are provided, and trusting that the services provided in the future will be higher than those provided at the moment, it is inevitable that they will cost money. It is equally inevitable that the more the services are improved the greater will be the cost. Agreement is fairly general on this and I should like now to quote from the White Paper issued by the Government some years ago in which it was stated at paragraph 116:

The Government, having studied this issue, are satisfied that the local rates are not a form of taxation suitable for collecting additional money on this scale. It is therefore proposed that the cost of further extensions of the services could not be met in any proportion by the local rates. Following this decision, other possible sources of revenue to meet the additional cost are being considered. It seems likely that the general body of central taxation must bear the major part of the burden. Pending further consideration of the methods by which extensions of the health service will be financed in future years the Government have decided to make arrangements which will ensure that the local cost of the service falling on the rates for 1966-67 will not exceed the cost for the year 1965-66.

At that time there was specific relief for that year. Whether the health services are paid for out of rates or out of central taxation, the obvious fact is that they must be paid for, but there is one very clear difference and distinction. As I understand it, approximately one-seventh of the population are liable in respect of rates. If the burden of cost were spread over the community as a whole it would be much more widely spread. Most of us are naturally concerned with the impact in our own particular area. In respect of the Dún Laoghaire Borough the proportion of the rate required for health is the largest single item in the rates estimate. It is over 34 per cent of the total rate. The estimated increase this year is 1/- in the £. Out of a total rate last year of 67/- in the £ no less than 24/4d was in respect of health services. Most people feel that the burden of expenditure falling on ratepayers is excessive because of the manner in which liability falls to be met. In respect of most other forms of raising public funds—in respect of a certain proportion at any rate of expenditure and thereby a certain proportion of the money raised from taxation — people have a choice, but, when it comes to rates, people have absolutely no choice, irrespective of their capacity to meet them.

The rate is fixed on the basis of the valuation. While older buildings are based on old-time valuations, nevertheless in many cases the valuations bear no relation to the actual capacity of the person to pay. Therefore, I want to urge the Minister on these Estimates to consult with his colleagues in the Government in order to try to meet the very serious problem which health authorities face this year.

It is reasonable to assume that the whole question of the health services will be discussed on the Bill which is to be introduced, and which it is proposed to circulate shortly. The fact is that by the time that piece of legislation is enacted into law, most of this financial year will probably have elapsed, and the problems which the rating authorities are faced with will not be eased by the proposals for the health services included in the Bill.

The position in relation to the Dún Laoghaire and the Dublin Health Authority is particularly acute. Statistics have been published, not merely the figure which I have quoted. It is a fact that, although the present health services are based on a 50-50 contribution from the State and the local authorities, the urban ratepayers pay a higher proportion than the rural ratepayers in respect of health services.

It was intimated in the Budget last year, and I understand it has since been confirmed, that an investigation is being undertaken of a proposed method of financing the health services on an insurance basis. We have argued for many years that this is the proper way to finance the health services. As Deputy Reynolds said a few minutes ago, the success of the Voluntary Health Insurance Scheme confirms that. Undoubtedly, it is confined at the present stage to a relatively limited section of the community as a whole, but the fact that it has worked so satisfactorily on a limited scale justifies its extension to the general body of persons covered by the health services.

It is only right that in considering this Estimate tribute should be paid to the voluntary organisations. The Minister and other speakers have adverted to the great work which is being done. This applies particularly to the groups catering for the aged. Undoubtedly, because of their activities, the proportion of elderly people in the Dublin Health Authority area admitted to institutions under the control of the authority has dropped. Unfortunately, many of these organisations are formed on an ad hoc basis and, in many cases, operate without any great help except what they can organise locally. The help and assistance provided by them and the comfort and consideration they extend to aged persons living in their localities are a very real and considerable benefit to the persons concerned. It is paradoxical that, for many reasons, very often elderly people living in urban areas are more lonely than people living in the country. In many cases they have no relatives living near them and consequently they depend to a considerable extent on the help of bodies of this sort.

The Minister referred to the proposals in regard to retarded children. I am glad to see that progress has been made towards providing a unit at Stillorgan in my constituency. Those of us who have been approached by constituents are concerned at the lack of adequate accommodation for retarded children. This is one area in which there has never been a satisfactory solution in respect of education and training for some of these cases. For too long the matter has been passed between the Department of Health and the Department of Education, with neither accepting responsibility for what each Department claimed was the duty and area of operation of the other. That was particularly unsatisfactory in these cases, because the unfortunate children and their parents or their families are the direct sufferers. I believe that the need for much greater facilities for retarded and autistic children is very considerable. Up to now I think the unit at St. Loman's was virtually the only one available. In my constituency at Stillorgan there is a special school for deaf children. The work which is carried out there by the Sisters, the application of modern teaching methods, and the use of technical and other modern facilities and equipment, make an enormous difference, and make it possible for those children to get the benefit of training which would not otherwise be available to them.

The need for further facilities for retarded children is very considerable. Deputy Reynolds also referred to the suffering and anxiety, and the sense of sorrow and tragedy, which prevail in a household where there is a retarded child. There is an obligation on all of us to try to provide a much better health service than that with which we were satisfied up to the present.

In advocating a proper health service, referred to by Deputy Ryan and others, we have proposed a service based on insurance in order to do away with some of the objectionable features of the present service. Most people find that the officials of local authorities, in investigating individual cases, operate in as reasonable and fair a manner as possible, but the very nature of the system is defective and, from any point of view, is objectionable. Many of us are familiar with cases of people in receipt of old age pensions, contributory or non-contri-butory, who find that in respect of some health service they require, perhaps, medicine prescribed, they are obliged to look for a medical card. They then have to submit themselves to an inquiry or inquisition under the present system. A great many of them resent it for many reasons, some of them because they feel that once they are entitled to pensions they should also be entitled to the consequential services which follow.

Our proposal to establish a health service based on insurance seems now to be generally accepted as a practical proposal. What the Government announced in the course of the Budget—this has since been said to be the subject of investigation—justifies us in expressing our conviction that this is the only method whereby a proper, adequate health service, which will provide benefits to the standards required, can be financed. Undoubtedly, it must, as any service will, cost money. It will involve contributions from the persons insured, from the employers and from the State.

The defect in the present system is that a great many people are obliged to pay an ever rising charge by way of rates irrespective of their capacity to pay, of their economic and financial circumstances. At the same time, their neighbours as well as themselves find objectionable the health service now in existence which is not merely inadequate but incapable of providing the standards they require. Our proposals provide that apart from persons now covered, such as old age pensioners and those in receipt of widows' and orphans' pensions, unemployment assistance and home assistance, farmers with low poor law valuations would be given these services and with medicines. We also propose that such a service would be based on a choice of family doctor and that hospital and specialist services would be available.

One of the special problems which most persons have is the cost of drugs and medicines. Despite all the modern developments both in the production and sale of drugs and medicines, it is characteristic of modern medicine that drugs and other medicines become ever more costly and an increasingly greater burden on those obliged to pay. Those of us with experience of the work of the Dublin Health Authority have found that people have been shown to need a contribution in respect of the cost of expensive drugs. In many cases persons who apply for medical cards to the Dublin Health Authority are not deemed to be entitled to cards because of their incomes, but cases occur where either the wage-earner or his wife or family have prescribed for them expensive drugs and medicine, and in these cases the authority make contributions. All these cases require examination and investigation as to means, and it is probably this aspect of the health service provided by statutory authorities that evoked the recent comment by the Bishop of Killaloe.

Many people who approach public representatives do so because they find either they are not able to state adequately their cases or are unaware of the help and relief which will be provided. Those of us who have had occasion to deal with the Dublin Health Authority are familiar with the large number of cases where the applicants are not considered to be entitled to medical cards but where, because of the high cost of medicines, they are deemed eligible for contributions for whichever period prescriptions are regarded as necessary.

The proposals which we make include the provision of community welfare centres. It is completely in line with the experience, on a limited scale, of voluntary bodies. We are familiar with voluntary institutions and committees who operated in the past, including nursing organisations which no longer exist and which did great work. At present there are many voluntary groups in different areas. They provide for the needs of old folks and others. Their work has provided an immense service in Dublin in respect of the voluntary hospital. The contribution which the voluntary hospitals have made to medicine in Dublin for generations has won for these hospitals and their staffs a high reputation not only in this city and in the country but abroad. I was glad to understand that no proposals are in contemplation which would in any way weaken the area of responsibility of the voluntary hospitals or lessen the contribution which the voluntary hospitals are making to medicine and the care of sick persons.

The demands this year for health services by the Dublin Health Authority on Dublin Corporation, the Dublin County Council and Dún Laoghaire Borough Corporation have already been referred to. The increase is quite staggering. As I mentioned, in the case of Dún Laoghaire the proportion taken by the health services in the estimates for the current year was over 34 per cent. The increase in respect of health services this year in Dún Laoghaire is another 1/- in the £ or slightly more. The increases are very considerable and I want to endorse what has been said, that there is an urgent problem which must be faced and which must be faced before any consideration is given to the Health Bill which is to be circulated shortly, irrespective of what health scheme emerges after the passage of that Bill into law. Obviously it cannot take effect in the current year, or certainly for the greater portion of it, so that the estimates being considered now by the local authorities make it imperative that the Government should, through the Minister, indicate a decision to these authorities.

Some weeks ago I asked the Minister for Health if in view of the substantial increase in the rates due to the health services he was in a position to say what contribution would be made by the Government from the Central Fund to ease the burden and he replied that he had communicated with the health authorities and had asked them to re-examine their estimates. Deputies who are members of health authorities or local authorities, or those of us who have been in contact with either the officials or the members of the authorities, are aware that not only are reductions unlikely but that in most cases they are barely providing, from the projected rate which it is intended to be struck, for the existing service. The authorities themselves at preliminary meetings examined the estimates submitted and certainly so far as Dublin Health Authority is concerned and the various authorities responsible for providing the rate in respect of health services the position would indicate that the prospects of any reductions are negligible.

If the rate element in respect of health was extracted then in a number of cases the increase, which as I have said is very considerable, would be very much less. The present position, therefore, is one which calls for an immediate decision in line with the paragraph in the White Paper published over three years ago in which it was stated that the Government, having studied the issue, were satisfied that the local rates were not suitable for collecting additional money on the present scale and proposed that the costs of further extensions should not be met by the local rates. That decision was announced over three years ago and the position has deteriorated further since then. The delay in introducing the Health Bill, the fact that no alternative satisfactory scheme has been produced, has meant further additional burdens being imposed on the ratepayers and on persons already taxed, has imposed demands on them which in many cases they are unable to meet without hardship. The only way in which this service can properly and satisfactorily be provided is on the basis of a contributory insurance scheme. Until this is done then the ratepayers, the various local authorities and the health authorities expect that the Government will come to the ease of their problem by making additional funds available to offset the increase for the current financial year.

Mr. Foley

There are a few aspects of this Estimate to which I should like to refer. One problem to which I should like to refer is that of phenylketonuria babies, commonly known as PKU babies. A PKU baby is an infant who may become severely mentally handicapped if the condition is not diagnosed at a very early age. In order to diagnose this ailment the common practice is to take a blood sample from the baby and have it tested and then the decision is arrived at, whether or not the baby is a PKU baby. This test has been carried out very successfully and the response from people has been reasonably good but not 100 per cent. However, that is not my complaint. My complaint is that in regard to these children who could become mentally retarded—and some have failed to respond to the test and have become mentally retarded—the Department are not aware of the difficulties, the hardship and financial expense involved for those who have to rear these children. There is a particular type of diet known as Lofenalac which costs £6 a tin. The parents are told by the Department and by the Dublin Health Authority that when acquiring this food they should get in a month's supply. The parents say: "Very well, we will do that," but some children require two tins a week and you can just imagine the cost involved —£48 a month. These parents go to the dispensary and are told there that the food is not available, that they can get it for them but only in a week's supply. We have one section of the health authority telling them they should have a month's supply and when they go seeking it from another branch of the same authority they can only get it in weekly supplies. One can see the difficulty involved for these people. They may have to queue up at the dispensary for two to three hours and, when their turn comes, they may find that the dispensary has not got the particular food they require. This is a serious problem, which will eventually cost the State a considerable amount of money, and should be taken in hand immediately.

Progress reported; Committee to sit again.

Dáil Éireann díospóireacht - Wednesday, 19 Mar 1969

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

Dáil Éireann díospóireacht -
Wednesday, 19 Mar 1969