(South Tipperary): I have described this measure as an enabling Bill because, with all due respect to the Minister, I do not think it is meant as a serious contribution to the life or the health of the people. It has in it the seeds of something for the future, but it has largely been produced as a matter of political expediency, and the history of this legislation will bear that out.
When I first entered the Dáil in 1961 a Select Committee was set up, and this Select Committee, like all other committees and commissions, was set up to put something on the long finger. At that time pressure was being brought to bear upon the Fianna Fáil Party and the Government to give the less well off section of our people free choice of doctor and to abolish the dispensary system, and in order to divert public attention from the matter this Select Committee on the Health Services was set up. None of us was aware at that time that it would eventually come to nothing, but after about a year it was obvious that Deputy MacEntee, who was a member of the committee, was determined not to allow it to bring out a report. Shortly thereafter the members of the Labour Party withdrew from the Select Committee and we in Fine Gael eventually withdrew from it.
We took an amount of evidence and when all our evidence was exhausted Deputy MacEntee set up steering committees; he was prepared to take evidence from any organisation under the sun, anything and everything in order to prolong the sittings of the health committee and prevent us from presenting a report. Ultimately no report was produced, but later on Deputy Lemass decided that he would provide a free choice of doctor and, at the same time, he told the country that Deputy MacEntee was not seeking the position of Minister for Health again. That was the first indication of a change of policy on the part of Fianna Fáil. Whether it was a change of heart or not I cannot say.
Since then this Bill could have been introduced. There is nothing in it that seems to me to merit delay from the time this Government were appointed after the last general election until now. It was produced, in 1961, but every effort has been made to put it on the long finger. It is only now, on the eve of an election, that the Minister for Health has decided to bring it in. It is a rather attenuated measure and gives, as I said, a limited choice of doctor to the dispensary patients, not a comprehensive choice such as we on this side of the House have advocated. There is no indication, either, of a change in the method of financing the scheme.
The Minister will have to agree with me that there is no specific virtue in saying we shall give free choice to 50, 60 or 75 per cent of the people. In general, if a free choice of hospital or free hospital treatment is given to a certain percentage of people while at the same time a percentage of the public are charged for domiciliary treatment, the tendency will be to drive patients unnecessarily into institutions. If the free domiciliary treatment is available to 800,000 people, as at present, and if there are double that number in the middle income group, 1,600,000 people, who have to pay for themselves outside and have to pay nothing but a few shillings in an institution, the tendency will be for those people to go into institutions.
I find nothing in this Bill which gives any indication that the Minister has any bed policy in mind. I presume the purpose of regionalisation of hospitals is to integrate and rationalise the service, but it is extraordinary in the face of that that there is not one comment from the Minister on bed policy. In this country we have more beds per 1,000 of the population than in any other country in the world, and we are a poor country. This situation arises for historical reasons, but there is no reason why it should be allowed to continue. A decision must be taken at some stage as to what would be a reasonable number of beds per 1,000 of the population and some effort should be made to adhere to that, but so far I have not heard one word from the Minister or any previous Minister as to what might be deemed a reasonable number of beds in proportion to the population.
Our hospitalisation policy has arisen for historical reasons. Possibly the earliest efforts to provide hospitals here on a modern scale were made by the Protestant minority. They built hospitals in different parts of the country, but principally in Dublin, Cork and Limerick. At a later stage the Catholic nursing orders provided hospitals, sometimes on a competitive basis. Then there was the money from the Hospitals' Trust which provided a third run of hospitals. Instead of integrating the earlier ones and producing a harmonious whole, a completely new run of hospitals was provided. The old district hospitals were allowed to continue. The result is that we now have more beds per 1,000 of the population than any other country in the world and that is the situation obtaining in a comparatively poor country.
In my opinion it is an unnecessary luxury. It is one we cannot afford. I would advocate fewer and better beds. That is the policy that should be pursued but, so far, there has been no indication from the Minister that he has formulated any particular level of beds. This is important because it is on the provision of hospital beds that nearly all the money goes. While it is very nice to be able to say we can always get a bed in a hospital that is not always the criterion of a good medical service. Indeed, a good medical service is one in which there will be difficulty in getting a bed because beds are strictly limited to demand. If beds are too readily available then some beds must not be utilised. I am not aware that the Minister has investigated in any comprehensive way the utilisation of beds. I have heard no inquiries as to how beds are utilised and what percentage is not in use. There must be some reason why it is necessary for us to have more beds per 1,000 of population than any other country in the world. This is an aspect of our health services to which it is desirable to advert.
When I say that it will be a long time before practical effect is given to the provisions of this Bill, I am conscious of the difficulty of introducing any proper rationalisation of hospitals because the moment one endeavours to rationalise one is up against local difficulties. No matter how small a hospital is there will inevitably be an outcry if the Minister decides the hospital no longer serves a really worthwhile purpose and spending money on it cannot be justified. Any Minister will have my sympathy when facing that situation because it will be a very difficult situation. Political capital will probably be made out of it. At the same time, it is the Minister's duty to evolve some rational policy in regard to the proportion of beds required in our society to meet our circumstances. I am not aware that any worthwhile investigation has taken place or any comparable figures produced to show that the situation can be brought under control.
Another defect in this Bill is the absence of any policy with regard to drugs. The Minister did say that henceforth drugs will be dispensed by chemists. It is hoped this will produce some saving and make for greater efficiency. It should make for greater efficiency because chemists are better geared to that type of work than the doctor could ever hope to be. Apart from that, there is no mention of a national formulary. This matter has been raised time and again with the Minister's Department. As everybody knows, a national formulary has been in operation in Britain for the last 30 years but no formulary has ever been introduced here. There should be no difficulty in introducing a national formulary. The Minister could take a few pages out of the one in Britain and that would cover a good many of the routine drugs. Some economies could be effected in that way. I do not understand the reason for the slowness in accepting anything in the way of a national formulary. Doctors should, of course, be allowed a reasonable latitude, but routine drugs can be bought much more cheaply on a national formulary than they can in chemists' shops. Anyone who examines into the expenses connected with our hospitals must realise that, next to maintenance, the biggest expenditure is on chemists' bills. Some of the modern drugs are beyond the purchasing power of the average citizen.
My next criticism is directed to the lack of financial policy. Presumably this scheme will cost more, but there seems to be no rethinking. With the outcry about rates all over the country one would have expected the Minister to say something about health charges and local authorities. Despite the fact that the Minister pays a little more than half, the health charges on local authorities are now very heavy. The Minister has made no reference to any change in financial policy, apart from a few pious platitudes asking people to economise and asking local authorities not to spend so much money. We have had reports from two or three committees set up to see if anything could be done to supplement health charges, but nothing seems to have come of these deliberations. The Minister has been no help to us with regard to the financing of this measure. Apparently the intention is to carry on as at present.
The Minister has sidestepped the issue with regard to the payment of doctors. He has adopted the old dodge of setting up a committee. That committee is actually sitting while we are here discussing this Bill. As Deputy Sir Anthony Esmonde says, it would be more appropriate if the Minister, first of all, sought agreement with those who will operate the scheme before he presents the scheme to us. I believe the Minister will have considerable difficulty; not alone will he have to face political and financial difficulties with regard to regionalisation of institutions but he will also have to face the considerable distaste on the part of the doctors in relation to the method of payment. As I understand the Medical Association, they are anxious to secure payment on an item-for-service basis: this type of payment is in operation in most Continental countries.
Considerable literature has been published on these varying methods of payment—all based on the same principle, namely, payment per item of service. It would more nearly approach private practice than any other method devised. This has been resisted by the Minister on the basis of administrative difficulties and I think possibly on the basis of expense. The administrative difficulties seem to have been overcome elsewhere and, as regards the question of expense, I appreciate that the present dispensary system is probably a fairly cheap method of payment—which may have been one of its attractions for Deputy MacEntee in his time. Certainly, looking at the expenses here for the year 1967-68, it is quite clear from these figures that our big difficulty here is the question of institutions.
Our net health expenditure by health authorities in 1967-68 was £37 million and, of that, general medical services cost £3.3 million. Therefore, on these figures, this question of general medical services would seem to be a small proportion of the total medical expenditure. The headings include general hospitals including maternity hospitals, tuberculosis hospitals, mental hospitals, hospitals and homes for the chronic sick and mentally handicapped, mother-and-child services, maternity cash grants, infectious diseases, rehabilitation and other services. That is a comprehensive list of health expenditure and, as I say, it totals £37 million. The figure allocated to general medical services is £3.3 million so it does amount to only a relatively small proportion of the total expenditure.
Institutions seem to be our bug-bear and will continue to be so and, with the increased cost of living, they will become more and more of a burden upon our community. That is why,ab initio, I stressed the question with the Minister of a bed policy not in any sense to be hypocritical because I appreciate the difficulties he would be confronted with straight away—the local political difficulties, to start off with—the moment he approached that question. It would be hard to convince the average local representative or local individual—and some of them do not want to be convinced—that you cannot have a Mayo Clinic at every crossroads and any attempt made to produce a more comprehensive and a more rational system will meet, sometimes, with ignorant criticism and opposition and will create difficulties for any Minister.
I understand that, in the scheme as outlined here, there will be regional hospital boards the membership of which will be staffed as to one-half by the Minister and half of them will be nominated by health boards. I also understand that there will be local health boards as well as regional hospital boards. I should like the Minister to tell me—others may know it already— if these local health boards are designed to look after general medical services and if the regional hospital boards are designed for hospitals,per se. I think that is the practice in some countries: it is the practice in Britain. I wish to know if these local health boards will be, so to speak, general practitioner bodies dealing solely with general practice. If that is so, I think it is in line with what one might call insurance or general practice in Great Britain.
I was not present to hear the Minister make his opening speech and I did not see a copy of it but I read in the newspaper that he stated that last year the cost of our health services amounted to £51 million. Perhaps the Minister would be kind enough, when he comes to reply, to give us a breakdown of that £51 million?
A matter was raised here today concerning the appointment of a chief executive officer to these regional boards and the transfer of other officers from local authorities. I should like a statement from the Minister as to whether there is to be any interference, under this Bill, with the function of the Local Appointments Commission. In other words, are there any new appointments to be made by the Minister, or by a board set up by him, apart from the Local Appointments Commission which we have known traditionally here for a number of years? The general feeling here among some speakers was that the Minister would be in a position to take powers unto himself to make some appointments of the nature I have mentioned. I should like if he could tell us whether this Bill will lead to any interference with the traditional functions of the Local Appointments Commission as we have known them here.
Another criticism I have to make of this measure is that I think advantage could have been taken by the Minister when introducing this Bill to secure a greater integration between our university and teaching authorities and our voluntary hospitals. In this country, as distinct from other countries, there has been a lack of a working arrangement between our university authorities and our local institutions. I do not want to interfere with the autonomy of local hospitals but, in so far as the education of our medical personnel and doctors is concerned, it is desirable that a university, which is the ultimate authority leading to a degree, should have full rights to see that everything it requires for teaching should be forthcoming in any institution to which its pupils may go. I know from working in university hospitals in other countries that the research work and the teaching is very much dominated and controlled by the universities. Certainly in my time here that degree of liaison did not exist and it is highly desirable that it should. It would help the status of the graduates considerably and ultimately be to the good of the institutions concerned.
One other criticism which I should like to mention—the Minister mentioned the matter briefly—is that no effort is being made to secure better staff integration between our voluntary and State hospitals. I should like to see a situation develop whereby medical graduates, or specialists, if they happen to be in the service of a local authority hospital could transfer to a voluntary hospital, or from a voluntary hospital to a local authority hospital. At present there is difficulty securing staff and an effort should be made to secure a higher degree of integration.
I realise that this brings up the difficulty that the person was originally appointed to an institution which belonged to the State and the other institution belongs to a private body. I am sure that difficulty could be ironed out as it has been ironed out elsewhere. However, there is no attempt being made in this Bill to move in that direction. In years to come we will have increasing difficulty securing staff for our provincial institutions whether they be house officers or county surgeons or physicians.
I should like to see the position whereby a junior member of the staff of a voluntary hospital could be seconded to a county hospital if they had difficulty getting staff and that he would not lose his status but if necessary would be able to return to his previous hospital after two or three years in the provincial hospital. By that means you would be pretty secure in regard to having continuing service. At the moment there is difficulty not alone in getting dispensary doctors but in getting doctors for our institutions.
There are many smaller points in the Bill with which one must agree entirely and one is in regard to the extension of the services in respect of defects discovered at school health examinations to defects discovered at examinations of pre-school children. That is a desirable addition. I could never understand why that gap existed. I think the position was that if a defect was discovered in the first six weeks after birth the child was entitled to free treatment and not after that until the child went to school. If a defect was discovered then he was again entitled to free treatment. Certain defects do arise in between. For example, if a child gets a congenital hip it may require treatment for a couple of years and it is desirable it should be diagnosed and treated before the child goes to school. Under the present system if the child is going to school he gets free treatment, but if he is not he may not come within that category. Similarly, if a child gets aphasia the parents may not realise at first that the child is not talking properly. Eventually they may decide something is wrong and the child, who has not yet gone to school, may need speech therapy which may last for a couple of years. Yet he is not eligible for free treatment. If the parents are not too well off they are going to suffer financial hardship. Similarly, if a child gets congenital heart disease he is unable to go to school and does not qualify and I need not tell the Minister that anyone who has to pay six or seven surgeons for a heart operation nowadays would want to be in the Ministerial income bracket.
I welcome these changes. As far as I understand the Bill, these sections are calculated to cover these gaps in our previous legislation and, as such, they are very welcome. I also understand that the Minister is taking unto himself the function of determining eligibility for health cards. Heretofore the distribution of cards was a managerial function and, if there was an appeal, the appeal had to go back to the manager. The Minister was out of it. It was thought that the county manager would be the best judge of the circumstances in his area, but in the event it led to the most extraordinary percentages of people drawing health cards in different areas. You had some poor counties like Longford having a much lower percentage of cards compared to Limerick which would be considered a much wealthier county. Nobody has ever been able to give a reasonable explanation why there was such a disparity between one county and another. Perhaps, now that the matter is being dealt with on a more centralised basis and under the Minister's administration, there may be more uniformity. It certainly did seem very odd that some of the lower percentages came from the poorer western counties and the higher percentages from the richer eastern counties.
I do not quite understand the statement that something new is being given here in the form of help to the middle income group for drugs. As we all know, the middle income group under this Bill are getting nothing extra but the Minister does mention, under section 57, that he proposes to introduce a new scheme for persons with limited eligibility. I do not know precisely what he means by that except perhaps that it is getting legal backing. In effect this is not new as most local authorities, certainly my own, have been giving some help in the past few years to those in the middle income group who had to meet heavy chemist's bills or were using very expensive drugs for a long period. Each case was judged individually and a subvention of some sort was made available to help the people concerned. As I say, I do not know what the Minister means by saying that he is introducing something new unless he means that he is giving legal backing to something which has already been in practice for a considerable period.
I appreciate that the Minister could not give us more details as to the number of boards to be set up and the number of persons on these boards. In a complex matter like this it is hard to expect him to be able to give us the complete pattern of things to come but I should like to know if it is intended to set up these boards forthwith and put them into operation. When the Bill is passed how long will it take to establish at least the boards in this regionalisation system? I appreciate that any question of dealing with the number of institutions we have or interfering with existing institutions is something that must be done slowly over the years. Whatever decision may be taken as regards any rationalisation of local institutions must be spread over a number of years because it is certain to meet considerable resistance and the Minister, before he is finished with it, will have to receive many deputations and many protests. Could he say when he is likely to set up these boards?
Our hospital system is very badly designed for the historical reasons I mentioned. As a people, in recent years, we have not helped the situation. Deputy O'Malley mentioned Limerick. There is an example of a completely ridiculous situation made more ridiculous by the system of planning evolved there. Originally, there were two hospitals in Limerick, Barringtons and St. John's. The State then moved in to establish a further hospital, a regional hospital. I do not know if in future it will be called a regional hospital but up to now it is so called. There was no attempt to build one central hospital for Limerick. The regional hospital was built a couple of miles outside the city. The corridors were wide enough to play an All-Ireland final in. It was provided with everything a hospital needs. Later, it was decided to build a maternity hospital and instead of building an annex to the existing hospital which was already serviced at considerable expense with water, sewerage, electricity, nursing staff, lay staff, laboratory, X-ray, ambulance and telephones, we built another new hospital in Limerick city thereby duplicating all these services, and providing such auxiliary services as an ophthalmic surgeon, a physician, a radiologist, and we had the whole story all over again, a couple of miles away.
What man, for example, who had a hotel and needed extra beds would move down the street and build a new hotel to provide them when he already had an institution fully serviced? We have done that, unfortunately. Similarly we made mistakes in Waterford. At a time when we already had drugs that largely controlled tuberculosis we built a number of hospitals on a villa basis. They now have to be serviced by cars driving food from one institution to another. This means a permanent increase in the maintenance cost of these institutions. Similarly, we built a hospital at Kilcreene, in Kilkenny, an orthopaedic hospital, out in the wilds. We could equally well have built an accident block or wing on to an existing hospital. Cashel lies roughly half-way between Dublin and Cork on a main highway. Here is a centre where you would probably continue to have a fair number of road accidents. It would surely have been more rational to get an orthopaedic surgeon and give him an annex there with everything already laid on, rather than build a hospital at Kilcreene and now have us leaning over backwards trying to keep these beds filled. There has been considerable lack of forethought in our planning in regard to hospitalisation. No particular individual is completely to blame but there was a lack of foresight.
If this Bill does any good it directs our attention along those lines so that we will not make the same mistakes as were made in the past. It is clear that with increasing specialisation in medicine as in all other disciplines there must be increasing integration of services. There must be larger institutions. We must accept that as inevitable if we are to provide a comprehensive service. The days are gone when one or two people could provide the kind of service and the range of services which the public now demand and are entitled to. All these things mean change and difficulty for the administration and for the Minister for the time being who is trying to handle the changes. All change is resisted everywhere. There are always vested interests. The difficulty about the mistakes we made in the past in trying to establish a comprehensive service on a county basis and in matters like that is that in each case we have created vested interests. Now we have the task of trying to undo these vested interests.
The criticism I made about our efforts at hospitalisation could be applied equally well, though less forcefully, to Dublin. When things were less foreseeable in the past we had evolved in this city a number of small hospitals. Now, we are in the process of trying to integrate them and form a federation of Dublin hospitals in order to provide a service conforming to modern needs. That is understandable because in those days we did not foresee the development which subsequently took place. I remember—to give one small example—that when I was doing radiology we covered the entire field of radiology, diagnostic and therapeutic. Nowadays we have one man doing the diagnostic-radiologist, another X-Ray hytherapy, another radium, another electronics and we have the physicist. In a few years we had various specialities arising. Similarly, in pathology. At one time you had at Trinity College one professor of pathology who covered the entire field; you cannot get such a man now. He must be either a pathologist, a bacteriologist, a virus specialist, or a micrologist; all working into specialities. You find it impossible to get anything but specialist training. That has affected us and is one of the reasons why we must move away from the concept we have been pursuing of relatively small units. Inevitably, we must accept more integrated units in this age of specialisation.