Health Bill, 1969: Second Stage (Resumed).

Debate resumed on the following amendment:
To delete all words after "That" and substitute: "Dáil Éireann refuses to give a Second Reading to the Bill on the grounds that:
(a) it fails to provide a comprehensive health service available to everybody based upon insurance principles;
(b) it retains the injustice of financing half of the cost of health services out of local rates; and
(c) it gives at the expense of local authorities and hospital administrators excessive powers to central government."
—(Deputy Ryan).

(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.

At long last the Health Bill has appeared. Having regard to the delay, I anticipated a Bill that would spell out in detail what the Minister and his Department proposed to do for all the people. Instead, we have this insipid document which offers nothing. It merely proposes to abolish dispensaries. We were told that over three years ago. It is a shame and a disgrace that a Minister should take three years to prepare a Bill which could, with any degree of efficiency, have been produced for consideration by this House well over two years ago.

The Minister has made all sorts of promises to this House. He complained of the fact that negotiations were not completed with the medical profession. There were all sorts of amendments to come and this accounted for the protracted delay in publishing the Bill. I can only see it being produced at this time as an election gimmick by Fianna Fáil—a gimmick which they will use on their election platform to fool the people into thinking that a proper health service will be made available to all. I have no doubt whatever that this is what they have in mind. Deputy Lemass, as Taoiseach, realised at the last general election that a proper health service was what was foremost in the minds of the people. When he came back to the House after the election he told Fianna Fáil that the people would not tolerate the existing system and that they must have a proper health service. He realised that the people were not satisfied with the existing service but there was nothing to be gained politically by introducing a Bill sooner. The White Paper was produced to stave off public demand in the hope that the people would be satisfied, but the Minister is aware of the increased pressure by the people and they timed it nicely to come into the House with this Bill on the eve of a general election. The people know full well of the conservatism of Fianna Fáil and the conclusion of the Minister's speech states very clearly how Fianna Fáil feel about providing a proper health service in this country. He says:

...basically we are discussing on it what the public authorities should do for our people as a whole in the prevention and cure of disease and in caring for the ill, the infirm and the aged. I present the Bill to the House as offering what the Government considers the most rational solution to a number of the problems which arise. I put it to the House with no apology for its not being something else, such as a Bill for the introduction of a comprehensive national health service: we do not think that the people need that or want that.

I hope that in the very near future Fianna Fáil will put those words—"We do not think that the people need that or want that"—on their election manifesto. I should very much like to see these words on their election manifesto and I am sure that they will very readily get their answer from the people who have been overburdened during the past number of years because of demands in respect of medical and drug treatment.

The Minister has made the excuse that we cannot afford a proper health service but I have tried to explain time and again to him that the same administrative expense is involved in providing a health service for the lower income group. This is confining a health service to the lower income group. The figure admitted by the Minister is 30 per cent of the population.

Where there is a social need we should insist on the money being provided and health is something that should be provided as a matter of right for our people. Health is too important a subject to be treated lightly. It is more important than education and if we assume that education should be free for our people we must accept the fact that health should also be free for them.

Looking at it basically, in the context of economics, it should be possible to provide a comprehensive health service as economically from the administrative point of view as it should be to provide a health service for the lower income group. We, in the Labour Party, say that nothing less than a proper, free comprehensive health service should be made available for all our people. We have stated that the financing of this should be a combination of moneys from central taxation and the insurance principle.

Some years ago Fianna Fáil would not accept the demand for proper free education but they finally realised it was something that could and should be provided. We shall continue to press for a proper health service and we will finally convince this Government of the need to provide it.

This Bill, to use the Minister's words, is a "highly technical document". I cannot find anything in it that is of any use. The Minister mentions the fact that he has had protracted negotiations with the medical profession and I think it is important to read what he says. He has stated that agreement has been reached on most things in these discussions but he realises that the main subject of the negotiations was the method of payment to doctors. I do not know why he delayed so much with these negotiations. He should have known exactly what the medical profession were asking. He made it clear that he was surprised that the medical profession should reject his proposals. This, to me, would signify that the Minister has apparently no idea of what the medical profession are really asking. Those negotiations have been going on for at least eight months and I cannot see what has been achieved in those eight months. We are back to square one again, the Minister's proposals having been rejected and the profession categorically stating what they want. The Minister now says that a working party will be set up.

What I cannot understand is why this was not done eight months ago. He knew what the profession wanted. They made that clear at their first meeting. Why did he not establish the working party then? I believe the Minister himself might be agreeable to the request of the doctors on this fee-per-item-of-service but I think his advisers are opposing him. I cannot see why a fee-per-item-of-service should be rejected. It operates freely in New Zealand. It would ensure fewer admissions to the hospitals, which is a very big item in the present cost of the health services. The savings there could be tremendous. I cannot accept the Minister's statement that there would be a danger of it being abused. How could it be abused if it resulted in fewer people being admitted to hospital? The saving here would certainly be considerable.

The points we must consider in regard to our health services are (1) that doctors can provide proper services for their patients and (2) that patients can receive a proper service and be considered to be on a par with the people who will be paying out of their own pockets. The patients will have more dignity and they will not be called public health patients if the scheme can be operated on a fee-per-item-ofservice system. I honestly believe the Minister would be advised to give further consideration to this as being in the best interests of both the public and the doctors.

The Minister in his opening statement outlines how the system will work between doctors and patients in the lower income group. I cannot understand what he means when he says: "Patients could be assigned to a participating doctor where this is necessary". This is contrary to the principle of a free choice of doctor. This would mean that there would be control of the doctors entering the service. I do not agree with regulating what doctors can enter the service. The fact that doctors practise in this country should be sufficient to allow them to enter the service. I also cannot understand what the Minister means when he says that patients would normally be seen in the doctor's rooms where appropriate. I hope the Minister means that those will serve as doctors' practising premises and will not be health centres or dispensaries. The Minister should clarify this point. The Minister has stated that this Bill will come into effect in the middle of next year. A few weeks ago he said it would be the beginning of next year. I should like to know when this Bill will be brought into operation.

After the general election, which will be held on the longest day, which is of significance because the besieged on that day were routed and the citadel was captured. The general election will be on 21st June. Fianna Fáil will be defeated and Fine Gael will be in.

It is a great pity the Deputy will not be here.

In some senses I think it is but in others I think it is better for the younger ones to take over and face their responsibility.

Deputy Dillon cannot speak. Deputy O'Leary is speaking.

It is not Deputy O'Leary, it is Deputy O'Connell. The Deputy should get his facts right before he starts speaking.

Fine Gael are winning elections a long time by blathering.

The Minister should be more specific as to when this Bill will be implemented. A few weeks ago he said it would depend on improvement in the state of the economy. I wish he would spell out when it will be implemented. If he could say to us: "We will bring in those improvements in six months time if we are in power" then we would know where we stand. I do not like this vague, ambiguous statement "depending on improvement in the state of the economy" or words like "I expect it will not be implemented until about the middle of next year".

I would like the Minister to say when our lower income group people will have a free choice of doctor. When will dispensaries be abolished? This is the urgent question at the moment and I would like him to state exactly when this will happen.

I do not think the Minister has anything definite about how those patients will receive their drugs. In his speech he says something like: "I expect they will be able to receive their drugs from chemists' shops". There is something vague about that statement. The Minister has something else in mind. I hope the health authorities will be relieved of this function of providing the necessary drugs for people. People in the lower income group are being humiliated, especially in regard to the supply of drugs. They are told that no supplies are available and they have to go to the central depot which is not open when they call. I cannot see any reason for delay in reaching agreement with the chemists' shops about the supply of drugs for people. I did not think it would require legislation to bring this about. It could easily have been implemented and health authority pharmacies, especially in urban areas, could have been abolished.

Deputy Patrick Hogan referred to a national formulary. I agree we might see the need for this but it has not worked well in Britain where doctors still retain the right to prescribe drugs of their choice. I do not think coercion in this very important matter should exist. We are leaving this wide open to inferior quality drugs coming into the country and if you establish a national formulary you are resorting to the generic name alone. We found that this is no criterion as to the quality of the drugs. The saving would be negligible. The alleged high cost of drugs could very readily be related to the saving brought about by reduced admissions to hospitals as a result of the use of revolutionary new drugs. I do not think a national formulary will bring about the dramatic reduction in the cost of drugs to which the Deputy refers.

I asked the Minister a few weeks ago about the hardship clause. I brought to his attention the inconvenience suffered by people who must avail of this hardship clause and I did not get an answer. At present the hardship clause operates something like this: the health authority admits that hardship exists and agrees to provide the necessary drugs for approximately half the cost or less in some cases.

Before we consider that we must realise that the health authority purchases drugs at 50 per cent of the cost so that if a person, under the hardship clause, is granted the concession of getting his weekly drugs at half the cost I cannot see how the health authority, under the direction of the Minister, is providing any service at all. The Minister did not explain this when I asked him about it.

What is happening is that the person who must avail of this clause must travel up to the head office of the health authority and pay in the requisite amount decided upon by the health authority, obtain a receipt and bring it back to the local dispensary to receive the drugs. That may seem a very simple thing but only those who must avail of it know the inconvenience and indignity of having to avail of this service. One wonders what purpose is served by all this or would it not be possible to operate a much more simple and rational method which would allow these people to purchase their drugs through retail chemists and not subject them to the inconvenience and humiliation of obtaining drugs under the hardship clause?

I wonder whether this Bill will make it easier for people to claim their rightful due under these services. What officers will establish who is entitled to the medical card because that is what it will be? It will entitle the person to avail of a free practitioner service and a free drug service. I feel we are complicating matters. The Minister must receive an average of 20 letters a week from me concerning people who have been denied medical cards. I constantly write to him and show him the injustice of this and make representations to him on behalf of these people. I have done this deliberately to show the Minister how people who are entitled to medical cards or are borderline cases, under the present unjust system are deprived of medical cards and their rights to a free medical service. The humiliation they suffer in establishing their rights is deplorable. I wonder how this Bill corrects that. I cannot see what it does to improve the situation. They will still have to establish their rights, they will still have to take forms for completion by their employers and be branded as paupers unable to provide a health service for themselves and their families. This is exactly what we are asking them to do in this Bill. Surely it should not have been beyond the powers of this Department to come up with some other solution?

I do not believe people should have to establish their rights. I have emphasised this because it is very important. We have Departments which are trying to deprive people of their rights. We have not tried to solve that in this Bill. We are creating the same problems. The new Health Bill does not change it. Surely it should be possible to set some kind of standard and say: "We know you are entitled to it. You do not have to establish this. You do not have to get these forms completed"? There should be some means of deciding immediately that people are entitled to medical cards. We would have achieved something really constructive in this Bill, which would save these people humiliation, if in future we could say: "You are earning so much, there is no delay, you can have that medical card immediately." If we had something in this Bill which would ensure the provision of a medical card immediately pending investigation, we would have achieved something worthwhile. Under the present system temporary medical cards are rejected time and again by the dispensaries and the Minister knows this. Cases have been brought to his attention by councillors and members of health authorities on both sides of the House where these temporary cards are rejected. We must include something in this Bill which will ensure the continuity of these cards and give them the full authority of permanent medical cards.

Whatever system is introduced I would like to see a minimum of delay in establishing a person's rights to a medical card. Where it is incumbent on the person to seek renewal of the card we must establish some means of ensuring its continued operation. We should stop asking these people to justify their entitlement. Very often they are told they can have a medical card and after three months it must be renewed. We must stop this and produce a better system which will permit them to obtain a medical card and have it renewed without trouble. We are not dealing with cards for employment exchanges or anything like that. We are dealing with people who must have medical care and treatment and interrupted treatment can be disastrous in many cases.

I am glad to see in this Bill an arrangement for the payment of disablement allowances to people which does not take into account the income or earnings of other members of the family. This is important. I have seen so many disabled or mentally handicapped people deprived of disablement allowance by virtue of the fact that their brothers or sisters were working. They were deprived of any means of independence due to this fact. I thought it was a most unjust system and I am glad to see that it is being abolished. If a person is disabled in any way there should be an allowance for him and regard should not be had to the income or earnings of any other member of the family. If it achieves that alone I suppose it is well worth while.

To get back to the general purposes of the Bill, I am wondering if the Minister's Department have costed a general medical service free of charge for the entire country. The Minister mentioned figures like £80 million, and I am wondering if this is not a slight exaggeration, and if a basic medical service, a family doctor medical service, free of charge, could be provided for the population at large for a sum far below the amount stated by the Minister. I am wondering if the Government of the day intend to abide by their decision not to provide medical services for the entire population. They have not indicated, by any means, that they will extend the free health service. They are stating categorically that they will not. I am asking them now if it is their intention to extend this service. I should like the Minister to answer that point.

I am not pleased with the section in the Bill—and I think it is important to look at this — which deals with the hospital in-patient charges. I see something sinister here. The section provides that the Minister may make regulations providing for "the imposition of charges for in-patient services in specified circumstances on persons who are not persons with full eligibility..." He may also make regulations "specifying the amounts of the charges or the limits to the amounts of the charges to be so made". I must accept this fact. We cannot maintain the charges if we are not going to accept the principle of a free for all medical service. I realise that if we do not provide that we must accept that we can change the 10s per day maximum. This gives the Minister power to change at will the cost of the hospital services for the middle income group. It is very vague to my way of thinking.

I come now to section 57. The Minister referred to it as an important provision to safeguard the middle income group against having to meet, unaided, high expenditure on drugs and medicines. I cannot see how it offers anything better. It is too vague. There is nothing in it. The Minister said:

It will be clearly spelled out that expenditure by a person with limited eligibility over a specified amount in a period of, say, a month will be recoupable in whole or in part by the health board.

I should like to have this clarified a little more because I find it too ambiguous and it does not explain exactly what the Minister has in mind.

In regard to the hospital service, and more especially the service for children, I should like to see the family doctor more involved. The present system is inadequate. The recommendations on the school health services were inadequate. They wish to see examinations taking place in the schools with the parents of the children present. I do not know if the Minister has thought about this problem, but surely he must see it as utterly ludicrous that children in schools being examined by school medical officers could have all the parents present during the examination while the school medical officers were trying to elicit facts and information about the children. The whole idea was ludicrous.

Defects are missed. Children are not present on the day when the examination takes place. I hope the Minister will extend the system to include the family doctor. He will admit that it is the family doctor who takes care of the children in the household, and he is in a better position to examine them and detect anything abnormal in the children. If the family doctor were brought into the school health service we might have a much better and a much more satisfactory scheme in operation. To confine the scheme to defects discovered at school health examinations is wrong. I remember the previous Minister for Health admitting this, and saying he would see to it that where defects were discovered by the family doctor the treatment of the child in hospital would be free. I should like to see this operated in the context of this Bill.

Then there is the question of limited eligibility. There is need for something like this because there will be cases of limited eligibility and we should give the Minister power to change the definition of "eligibility" by regulation. This is terribly important because it is a question which will arise from time to time. It is wise that the Minister should have this power. It will be beneficial.

On the question of maternity cash grants we should not decide on a figure, or else in deciding on a figure of £8, there should be some provision for changing it in relation to the cost of living and the depreciation in money values. I am wondering will that £8 ever be changed. It was £4 in 1953 and it is £4 in 1969. The Minister will agree that unless something is incorporated in this providing for a change, depending on the cost of living, it is futile and ludicrous to mention a figure of £8.

On the question of health boards, the Minister and his executive officers have too much power. In all cases there will be an appeal to the Minister. I am opposed to that. I think there should be some other means. I would be very much against the Minister having this power because, as I read it, the Minister and his executive officers have this absolute power. I am very much opposed to that. Where there is a question of appeal it should go to the courts. We must be very suspicious where the Minister has this absolute power or where there is an appeal just to the Minister himself.

I would agree with the Fitzgerald Report on the Health Services. We must have a more rationalised system. The country is too small to permit of the present system of county hospital services. Only by grouping can we provide an economical and up-to-date hospital service. I am just wondering how speedily this can be introduced, because the sooner we do it the better. At present there is duplication and overlapping which results in a tremendous waste of money. All down the years we have had these small units and we were afraid to trample on people's toes in trying to produce a better system. In Dublin city alone there are hospitals providing the same services.

We must congratulate the members of that body who went to so much trouble to examine the situation and who, with great courage, presented a report that conflicted with selfish interests. Unfortunately selfish interests seem to prevail very much in our country. We are always interested in what affects ourselves rather than in what can help the country. We need more men of courage like these people who will make recommendations which are in the country's interests. Again I would pay tribute to these men for their magnificent work. I only hope the Minister will not back down on these recommendations due to any pressurising from any bodies. I understand there are some recommendations he will not accept, and I am informed there is a possibility that he would be pressurised politically in this connection. I should like to know what he intends to do in cases where he will not accept the recommendations of this report.

After this body had studied this matter and furnished its report, a similar body examined the situation in Britain and came up with the same idea, that there should be more rationalisation, that there should be more of these regional boards. I am not unmindful of the fact that a copy of the Fitzgerald Report was submitted to Britain, and it is a great tribute to that body that the British saw therationale of this and accepted the idea, and I know it is being accepted by the Government in Britain.

The Minister has stated that he has no intention whatsoever of interfering in the running of the voluntary hospitals. This is the point I cannot quite understand. He states categorically:

We owe a great deal to our voluntary hospitals, to the religious communities and lay boards associated with them for the standards of hospital care and medical teaching which they have established and maintained during their long history. It would not only be thankless but foolish for me if I were to attempt to end their independent status and put them all in a bureaucratic strait-jacket.

I should like the Minister to decide one way or the other: is he or is he not in favour of retaining the voluntary hospitals? He says he has no intention of imposing restraints on them, but then he goes on to say:

...I can expect those voluntary hospitals participating in the public services to accept certain restraints and conditions in the interests of the hospital system as a whole.

That is certainly a contradiction. If he proposes to impose restraints on them, surely this must be an interference with the freedom and the rights of voluntary hospitals? Is it the Minister's intention to have a say in the appointment of doctors to these hospitals?

I agree with the Minister that the cost of running hospital services is the largest element in rising health costs. I accept the fact that the administrative machinery will aim at reducing these costs, but I maintain that a little more will have to be done to bring down the cost of the hospital services. I have made recommendations before to the Minister. I think the fee-per-item-of-service method of payment to doctors would be one way. I suggested that the Voluntary Health Insurance Board provide some kind of incentive to patients to avail of the family doctor service, but the Voluntary Health Insurance Board will not accept this.

We must endeavour at all costs to reduce the number of admissions of patients to hospitals in cases where we do not jeopardise the health of the patient. I also believe we can reduce the number of days spent by patients in hospital. I should like to see the Minister setting up, without delay, a committee to look into this to see what could be done to effect more savings in this, the costliest element in the health services. More beds could be provided over a period, and more support should come from the voluntary hospitals for the bed bureau which experiences so much difficulty at times with voluntary hospitals in regard to the provision of beds. We should not have to build more and more hospitals if we could reduce the length of time spent by patients in hospital. If necessary we might have more convalescent homes associated with hospitals where patients could be ambulatory or might go home during the day and return in the evening. This would reduce the cost of the hospital services. It is imperative that the Minister should look into the matter very fully and, perhaps, set up the committee I have suggested.

The Minister has stated that these health boards shall be constituted of persons appointed by the relevant local authorities, persons appointed by election by registered medical practitioners and such ancillary professions as are specified in the appropriate regulations. I think these boards should also include nursing personnel because they are involved in the running of hospitals. So are hospital administrators; I should like to see them appointed as members of these boards. If we are to have effective health boards then we should have on those boards those most closely involved in the running of hospitals and health services.

I should like to know, too, how these elections will be carried out. Will people be elected for periods of one year, two years, or five years? Will associations of these bodies have the final say? I do not think the Minister has said how many he will appoint or what the balance will be on these boards. It is all very vague. Because it is so vague it is open to abuse because the Minister could have too much power on these boards. That would be very dangerous. I should like to hear from him what exactly he proposes to do. I wonder why, when the Bill took so long to draft, all these things could not have been thought out in advance and incorporated in this measure.

There are glaring omissions. The Bill gives the impression of being drafted rather hurriedly. There are a great many omissions. That is why I said at the outset that the Bill was something that simply had to be produced. It had been left on the long finger and then it was decided that it had to be produced for the election. It should have been much more carefully thought out. Surely it should not have taken three years and three months to produce? In 1966, the then Minister for Health said that discussions had taken place with the interested bodies on the formulation of the new health services.

What are the omissions?

I shall elaborate on them shortly. The Bill does not spell out exactly what the new health services will be. We do not know how long the proposed negotiations will take. The Minister has been lax in these matters. I should have liked a decision on the method of payment and that decision incorporated in the Bill. I asked the Minister would the passing of this be dependent on agreement being reached with the profession and the Minister said "No". What has to be appreciated is that the implementation of the Bill will depend on agreement being reached with the profession. Over eight months ago the Minister stated he had almost reached agreement with manufacturers, wholesalers and retail pharmacists. Nevertheless the vagueness is there. The Minister is not sure. He is not sure how patients will receive their medicines and drugs. I thought the delay in producing the Bill was due to the fact that the Minister was awaiting the outcome of negotiations and agreements and that these would have been finalised before the Bill was introduced. I think the Minister would have preferred to have had everything settled before introducing the Bill but, because of the imminent general election, he was forced to produce the Bill.

The provision giving him power on the health boards is typical of departmental policy. The Department is anxious to retain power and authority. No Department wants to let authority pass to anyone else and no Department ever wants to co-operate. The Department of Health wants to retain absolute power. That is evident in this Bill. It is a great pity. Our civil servants should realise that it is only by more and more co-operation with the public they will be able to adapt themselves to the new era. In every Bill introduced here one sees the efforts made by civil servants to retain this special power and to give this power to the Minister for the time being. When I say to the Minister I mean to his advisers. That is wrong.

On a point of order. It is the rule of this House not to permit a Deputy to impute motives to the advisers in the Department of Health or in any other Department. The Deputy is obliged to impute these motives to the Minister, and only to the Minister.

The Chair was about to draw the attention of the Deputy to the fact that it is the Minister who is responsible to the House and not the civil servants in his Department. It is the practice not to reflect on civil servants. It is Ministers who are responsible and criticism must be directed at them.

I said I did not mind what Minister was there. It is the Department which has the power. I am not reflecting on the civil servants. I am saying it is the Department and in 50 years time it will be the same.

No Department, as such, and no civil servant has any power. It is the Minister who has the power and the responsibility and it is the Minister who exercises the power. The civil servant does not.

We had Deputy Dillon making it clear a short time ago that there is great danger of power passing out of the hands of the Minister.

The danger of something passing out of the hands of the Minister does not necessarily mean that it will pass into the hands of civil servants.

I accept that. I do not want to engage in any argument on this point, but the Minister should see to it that he and his Department do not usurp the authority of these boards. I would ask that the Minister be prepared to share. Only by the Minister sharing with the other members and saying, in effect: "I do not want to retain the full authority on these boards" can we have a progressive health board that will function in the interests of the public. What the Minister has in this Bill is dangerous. It is not in the interests of the public. It is open to political abuse. I am very much afraid the Minister may not quite have realised what he was doing in the proposal to establish these health boards. I would ask him very seriously to look at what is incorporated in that proposal and to see what amendment can be made to it in the interests of the public and of the country. This is very important.

I would say that the health boards will meet with a great deal of opposition. There will be people who perhaps will not have the authority they would like to have. Where we have doctors, nurses, administrators, hospital administrators, members of local authorities and members of the Department of Health, a CEO operating our health services, it cannot but be beneficial to the community. I would hope that councillors would not object very strongly so long as it is understood that absolute power will not be vested in the Minister.

I am glad to see that, with the rationalisation envisaged by the Minister, there will be no need for the Hospitals Commission. I have often wondered about its purpose, who established it, how it was established and who decided how the money would be spent. The Minister said it has served its purpose from the time it was established in 1933. I am wondering what will happen now, with the dissolution of the Hospitals Commission, because in the Minister's brief, page 19, it is stated that conditions were, of course, much different then from what they are now. I am wondering what will happen the money derived from the Irish Hospitals' Sweepstakes and, if the Hospitals Commission is to be dissolved, what body will act in this matter because surely the Minister has not in mind that there will be no more money coming from the Irish Hospitals' Sweepstakes. As far as I can see, he has not mentioned here where this money will be placed and who will administer its distribution. I might ask him to clarify this point. He will admit that we have received a considerable amount of money from every Irish Hospitals' Sweepstake draw.

In regard to the financing of the health boards, the Minister states that the Government will meet one half of the total running expenditure and that local contributions will meet the balance. This means that, again, rates will have to bear the burden of this cost, or the major part of the burden. The Minister or his colleagues were investigating the possibility of some other means of financing it. The Minister for Health himself stated he was looking into this question of how to finance the services. He is merely restating what is already in existence at the moment, namely, that the local authorities pay half of it. I thought the Minister stated some months ago he was investigating alternative methods. I would ask him if any decision has been made or if any recommendations are forthcoming on how the health services envisaged in this Bill might be financed. Perhaps, when he is replying to the debate on this Stage of the Bill, he might mention this fact.

I am glad to note the transfer of the administration of the Dundrum Mental Asylum to the appropriate health board. I am very pleased that it will result in more co-ordination of the psychiatric services already in operation. It has existed in isolation for too long. This is a very beneficial measure. I am wondering why it needed legislation to bring this central mental asylum more into co-operation with the other psychiatric services we have available. Surely, it should have been possible to have this operating without the introduction of this Health Bill?

I see no mention in the Minister's Bill about drug quality control. Nothing whatsoever is mentioned about effective measures on the quality of drugs and more restrictions on the sale and distribution of addictive drugs. These are not incorporated in the Bill. We all know that the burning topic at the present time is this question of drug addiction. I see nothing here about it and I am wondering if it would be necessary to incorporate in this Bill anything about the treatment of drug addicts and treatment centres for drug addicts. I think we shall have to have specialised centres for them. We cannot provide for them in psychiatric hospitals, as such, unless we have special centres.

Debate adjourned.
The Dáil adjourned at 5 p.m. until 3 p.m. on Tuesday, 22nd April, 1969.