Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Thursday, 17 Apr 1969

Vol. 239 No. 11

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).

When speaking last night I stressed the great need for preventative rather than curative medicine. A tremendous amount of the cost of the health services is attributable to curative medicine and we are not satisfied that the money is being used to the best advantage.

Preventative medicine started a long time ago but it was given greater impetus with the discovery of certain drugs 20 years ago. Most of these were applicable to the cure of TB. At that time there was an emotional outbreak and we had a rash of sanatoria building, despite the fact that the health authorities of the United Kingdom had told us here that the days of the sanatoria were finished——

Is Deputy Moore serious?

——and that drugs would take the place of the sanatoria.

That is the darndest thing I have heard for a long time.


From that day onward many sanatoria here were closed. At least in the city here sanatoria have been closed. We say thank God for this; they are now being used for other purposes. The point I am making here is that it was preventative drugs which made sanatorium treatment no longer necessary. In this city our chief sanatorium is the James Connolly Hospital at Blanchardstown, but it is also being used for general hospital purposes.

According to this year's estimate we shall spend £5 million on health in this city. That works out at about £10 per citizen per year. If the amount people have paid for other services and for medicines from the chemist's shop were included the figure would be much higher. Recently the Minister sent a letter to health authorities asking them to look into the possibility of having economies made. We learn that next year it will cost £4 9s. per day to maintain a patient in a hospital under the Dublin Health Authority. Therefore, I suggest that our great need today is for preventative medicine, as in the case of the treatment of tuberculosis.

If science can some day find a cure for cancer, we shall reach the happy stage we have reached in regard to other ailments, that it will cause less and less suffering and fewer deaths, and it was good to learn yesterday from the Minister that we are taking steps to provide early warning clinics. Years ago people did not want to admit that a member of the family had any specific disease. Fortunately, that type of thing has died out to a great extent, but people are still afraid of going to a doctor in case he may say they have some malignant disease. It is, I think, a matter of education; we must educate people into taking advantage of the facilities we provide for their own protection. It is much better for people to go early for treatment or to prevent disease developing.

This Bill provides for the abolition of the dispensary service. That service is associated with the Poor Law system and, because of that, none of us will regret its going. At the same time we must remember that it did serve a purpose, but we look forward now to the day when the dispensary system will be replaced by a choice of doctor. This will be all to the good.

The chronically ill sometimes spend a lifetime in hospital or in an institution. They are cared for but we could, I think, go just a little bit further. Where persons are detained in an institution over a number of years— say, five years, or even less—the State should make some contribution to enable them to supply themselves with little luxuries. It has been alleged that we have the highest number of people in institutions. One should examine that statement very carefully because a person is very often sent to an institution when there is no one to look after that person at home. To improve the situation of these institutionalised members of our community I suggest the Minister should introduce some system of small weekly payments to enable them to buy cigarettes, stamps and little things like that. I imagine that the local authority does do this at the moment. However, there is to be a change and I think the Minister should continue the practice of giving some little payment to these people.

One matter which is not dealt with in the Bill but which is a health matter is the advertising of cure-alls in the press, on television and on the radio. Simple-minded people put tremendous faith in these remedies. The claims may be ridiculous but, if one is ill, one clutches at any straw in order to effect a quick cure. The manufacturers of these cure-alls should be compelled to provide ample evidence that the drugs and medicines have the powers they claim for them. If that is not done a great confidence trick is played on simple people and the money taken from them is really taken dishonestly because they do not get an honest return for their expenditure.

I mentioned that almost £5 million has been spent by Dublin Corporation this year on health services. There is a great controversy going on as to whether health costs should be borne in part by the local rates. It is all too easy to say that they should not be and leave it at that, but we must recognise that the patient in hospital who has to pay for part of his maintenance there and who has also to worry about rates afterwards will not be helped on the road to recovery. Despite the provision in the Bill, therefore, I suggest we might take another look at the situation. I appreciate that the Government are giving 50 per cent of the cost but, in view of rising costs, I hope the Minister for Finance will find it possible to give a proportionate increase in order to reduce the incidence of local taxation.

I do not think we are keeping abreast of developments in other countries where equipment to ease the lot of the blind is concerned. I have in mind in particular the new typewriters and other devices to help the blind. The blind are very independent. They do not want to be wrapped in cotton wool. Because they are so independent we should, I think, do everything we can to encourage them in their independence by providing all the aids we can to help them to overcome their disability.

Mass radiography has proved a tremendous advantage in the early diagnosis of tuberculosis and chest ailments. The mobile squad must be having a tremendously beneficial effect on health generally. I do not know the statistics of early diagnosis, but I am sure they are satisfactory. It should be possible to extend the system to include other diseases. Our ambition should be to keep people out of hospital. So long as we have the present high rate of bed occupation we will have very costly health services. We have in the city many very old hospitals and the amount of money needed to keep them standing is almost incredible. I think it would be better if we went ahead and provided temporary modern buildings until such time as we have the new regional hospital. I would like here to pay tribute to the governors of the voluntary hospitals. They devote a great deal of their time to raising funds for these hospitals. That is the kind of work that brings out the best in people. Those who spend so much of their time protesting all over the place against anything and everything would be better employed devoting their time and energies to this kind of work so that we can show that we really care for our sick and our aged.

With regard to payment of capitation grants, I know that these must be paid but I think that what members of local authorities resent is that the Minister makes the Order to increase the capitation grant and they say, in effect, that we must increase it as well. If the Minister could sugar-coat the pill for us in some way so that the cost would not fall so heavily on the rates, it would be a great help.

It is often said here and elsewhere that we need a comprehensive free-for-all health service. While I agree that we do need a comprehensive health service I do not think it is possible to have a free-for-all service. It has to be paid for somewhere. We look forward to the day when every person in our society will be sufficiently well-off to look after his own health needs. However, that Utopia is far away. In the meantime, we must examine how we can give the best health service within our resources.

Children's allowances are paid irrespective of the means of the parents. There has been much criticism about that and people have asked why the wealthy should be paid these allowances. Quite true. One might also ask why children from wealthy homes should be entitled to special aid under our health legislation. We must face the fact unemotionally that we must provide to the utmost of our ability the best health service for those needing it most. We just cannot provide a complete health service for everybody because the cost would be prohibitive and we should be back again to the same point where the person who needs it most might perhaps get less treatment because we are trying to spread our resources too widely.

For many years, people here have asked for a choice of doctor. We have it in most cases now under this measure. This is something very good indeed. In many cases in this city we have known the dispensary doctor to be a most hardworking and dedicated man but, human nature being what it is, some people might prefer to go to a different doctor and, not hitherto having a choice of doctor, would refrain from going to the dispensary doctor to have their illness diagnosed and their illness would get progressively worse. I trust the present step forward will be a great improvement on the old system. It will be very difficult in many places to allow a choice of doctor but we have established the principle in this measure.

As with the politician, the doctor is very often looked upon as a friend in need, apart altogether from the medical aspect of his duties. It was said here yesterday that people will still have to approach politicians in order to crave some benefit. I cannot see anything in this Bill which would bring about that position but one thing which encourages people to look for advice is that they do not fully realise the benefits they are entitled to and certainly they should never hesitate to find out the position. Even under existing health legislation, people do not know their rights. One is sometimes amazed when people approach one about something to which they are absolutely entitled and they are equally surprised when they are told "This is your right. You are entitled to it under the legislation. There is no reason for you to have to approach anybody to try to get it for you."

I wonder if the Minister would consider setting up an information centre in the offices of the various health authorities or the new boards so that people will know the benefits to which they are entitled? We do not at the moment seem to get through to people all the time. Not alone must we have a good health system but we must let the people know their entitlements under it. It is realised nowadays, more than it was realised years ago, that medicine and health services are costly. Perhaps it is right that they are costly because if our funds are publicly administered it shows we are doing a good job. The people are prepared to bear some taxation in order to have a good health service.

As I have already said, each Health Bill which was brought before this House has been an improvement on the previous enactments and we shall continue in that line until the day is reached when we shall have as perfect a health service as we can make it. At the same time, we must be prepared to recognise that the service must be paid for and must support all ways of raising taxation for it.

In conclusion, I want to thank the Minister sincerely for the work he has done on this Bill. It has not been an easy task and it has taken a lot of time. However, the Bill was worth waiting for. If there are any defects in the Bill it is not because the Minister wants them there but because they are not easy to remedy. The Minister has great power of direction under the Bill and I hope he will use it. I trust he will always be willing to err on the side of being generous to those people who cannot afford to pay for their own treatment.

Any improvement or any proposed improvement in the health services, even as an interim measure, is to be welcomed. Therefore, we are prepared to support many of the proposals in the Health Bill before us. However, when it comes to deciding on what should be in the Health Bill and on what should not be in it, one occasionally finds that matters which appear adequately to be covered in White Papers disappear in smoke when it comes to putting them in black and white.

Before I go any further, I want to comment on something said by Deputy Moore whom I always recognised as a reasonable man in this House and who usually makes reasonable contributions. I am sorry he has left the House before hearing what I now have to say about him. He seems to be attempting to adopt the mantle of his colleague in the Ballsbridge area and to be aiming for the tony vote there by attacking expenditure which is for the benefit of the middle and the lower income groups. Indeed, I suppose he will come along next week and ask the Minister for External Affairs to state that the regime in Greece is the right one. He would seem to be following along that line. I am glad to say that nobody in Fianna Fáil, any more than in Fine Gael or Labour, ever before referred to the action taken by the inter-Party Government, when Doctor Noel Browne was Minister for Health, in the erection, staffing and carrying on of TB hospitals which almost completely eradicated TB, a dreaded scourge, as emotional outbreaks of hospital building, or the erection of a rash of hospitals. Would anybody except somebody like Deputy Moore, who obviously does not understand what he is talking about, make such a statement? I hope it is the last time that this House should have the doubtful pleasure of listening to comments like that.

The Minister for Health, on a previous occasion, admitted that the attempt made to eradicate TB at that time was a job well started and well done. I heard him saying that myself. Now, 20 years later to find somebody trying to decry it is beyond comprehension and I can only imagine it was for petty political purposes. I regret that it was Deputy Moore who made the comments because he is normally a decent Deputy, and that such an attack should have been made on something generally recognised as having been one of the greatest things ever done in medicine in this country. It did not wipe out TB completely but it was very successful and the fact, as Deputy Moore said, that the hospitals are not needed now proves that it was very successful. I would suggest that the hospitals are needed and furthermore that a number of them have been put to very good use. I suggest further that the Minister will find that if the staff can be made available a lot of things can be done with those hospitals if we do not need them for the treatment of TB.

Thank God it appears that we are needing less and less of them for that purpose. I am very sorry to have to say this and possibly Deputy Moore did not consider it before he made the statement, but it appeared to have been made simply for the purpose of pleasing somebody else who is not here at present. It was a comment that I would not be surprised to hear coming from one of his colleagues and it is possible he is aiming at the mantle and the tony vote of Deputy Seán MacEntee.

That is a long way from what is contained in the Bill. When the White Paper was issued the Minister visited the various local authorities and discussed matters with them, and as one of my colleagues who is now dead used to say, he is very fair, free and frank and he proceeded to answer the questions put to him and made what we consider to be honest comments in regard to those questions. In regard to the choice of doctor—providing the same facilities for eligible patients as are given to private patients of the doctor—this is from my notes of the Minister's visit to Navan—all of us, on every side of the House, for years have been stressing the necessity for having a choice of doctor for patients. One has only to live in the country— I know nothing about city conditions, I am sure they are entirely different— to realise the hardship that can be imposed on a family not, as Deputy Kyne said yesterday, because the doctor and the patient have had an argument, or some members of the doctor's family had an argument with a member of the patient's family recently but because, as I have known to happen, disputes which sometimes had something to do with medical attention and in other cases had nothing to do with medical attention had occurred back in the time of the grandfather of one and the father of the other. As a result, the family had no confidence in the doctor and the doctor would prefer to go anywhere else than to the house of the family with which, to put it mildly, he was not on good terms. Nobody would suggest that the doctor would give less than the best treatment to the patient but the fact that those receiving treatment thought that that was so made the treatment which was being given almost useless in many cases. In many cases they would not go to that doctor and even though they could not afford it I have known cases where they would go eight or ten miles out of the district, even in an emergency, to get another doctor.

When the last Health Act was passed the matter became very complicated because while previous to that many doctors dealt with people according to whether or not they could afford to pay, when the Health Act and the medical card system was introduced they either had a medical card or they had not and when they went to a doctor who was not the doctor they should attend it meant that in almost every case they were required to pay. In addition to that, I have heard of cases where doctors attending people with medical cards commented that there was a car outside and asked if that belonged to the patient, or perhaps there was a television in the house or the house was well furnished and the doctors asked how did they get a card. I suggest that this had nothing to do with the doctor. Only on rare occasions did this occur but in these cases not only were people ill but they were belittled like this by a person who had not the common savvy to know that questions like that are not going to hasten the recovery of the patient.

Not so long ago I was told in conversation by somebody that he went to a doctor's residence on a Sunday afternoon as he had fallen from his bicycle and broken his arm. When he knocked on the doctor's door the doctor's head appeared through a window and the doctor said to the patient "Could you come back on Tuesday? I am rather busy now". The patient replied that he had broken his arm but that made no difference and he had to hire a car to go to hospital to have it attended to. I am mentioning these as very isolated cases but in this case the fact that the man had broken his arm meant that he was entitled to go to hospital anyway and the local authority would not crib. In normal circumstances there should be a choice of doctor.

I am sure if I mention Nobber the Minister will know what I am talking about. We have cases such as those which occurred in Nobber where there was extraordinary difficulty getting a dispensary doctor. This question of a choice of doctor may not work out and there will have to be a second string to this in order to ensure that there will be medical attention because it is conceivable that there would be areas in which there would be no resident doctor at all. I am sure the Minister appreciates this much better than I do. It is conceivable that there would be fairly large areas to which, unless there was an inducement, the doctors would not come. The Minister mentioned that such an inducement might be offered but I would like to see it spelt out in a better way than it is to show that there is not going to be, as a result of the passing of this Bill, a situation in which there will be large areas in which (a) the population are thinly scattered or (b) the doctors feel that the payments made in the area are not so good and that it would not pay them—they are entitled to consider that—and these people would be left without a doctor at all. This is a very serious matter. Couple that with further proposals in the Bill where the regionalisation of health services is considered and it tends to suggest that a very serious situation can arise. I propose to go further into that at a later stage.

The supply of medicines through retail chemists, or doctors, where there is no chemist, is a good idea. This was suggested in the White Paper and the Minister agreed with this when he spoke to us in Navan. It is a good idea but again we come to the problem which should be dealt with in some way. Chemists, like everyone else running a business, cannot be at their job for 24 hours a day for seven days and they have to have their hours of trading. More than anybody else in business that I know of they go out of their way to open their shops on Sundays, on bank holidays and on other days for certain times. It is not always possible that medicines will be required just when the shop is open. There should be some special provision to ensure that the type of drugs and medicine required would be available when the chemist's shop is closed. The Minister said to us in Navan: "The doctors would be able to supply in certain circumstances." That may be but I can imagine a doctor writing a prescription and saying: "Take that to the chemist." If that happens at 11 o'clock on Sunday and the chemists close at 10 and Monday is a bank holiday it could mean that the person requiring the drugs or medicines would have to wait a considerable time. These are small details that could possibly be dealt with later but I think they should be brought to the Minister's notice now.

The Minister is aware of the question of cost. He says that reasonable arrangements are being made with the chemists regarding charges. At present we know that the difference between buying retail from a chemist and wholesale through a local authority can be as much as 46 per cent. It was 52 per cent. Taking the retail price as 100 per cent the wholesale cost would be 48 per cent. Now, I understand it is about 54 per cent. The retail charges I think are 100 per cent and the local authority can get supplies at 54 per cent. It means a very heavy additional charge unless these matters can be dealt with by the Department before the scheme goes into operation.

It is stated that the Minister will, by legislation, make regulations to fix different income limits for entitlement to general medical services. The Minister should have been more explicit and should have put in black and white exactly what he meant. At present the issue of medical cards is a joke—in some counties, a bad joke— and we all know of the person who says: "Is it not extraordinary? I am married, have £12 a week, three children and I pay 30/- rent and I have no medical card. My pal who works beside me has £18 a week, no family, a free house, or a house for 5/- a week, and he has a medical card. How did that happen?" Or he says: "He is well in with some politician." And he mentions the politician's name. He knows when he makes that complaint that neither I nor any other politician will say to somebody: "Mr. So-and-So should not have a medical card. I want the matter investigated." I will not do it. I do not know whether it is right or wrong. Certainly I have never done so and do not propose to do so. This position will remain until it is laid down in black and white so that everybody will know who is entitled to a medical card and so that when a person tells you his circumstances and complains about not having a medical card you are able to say: "Yes, you are entitled to a card," or, "No, you are not." Occasionally, you are able to do that now but in most cases you are not.

There is also the question of distribution under the Assistance Act which is referred to in the Bill as, apparently, a distinction is being made between the health authority and the public assistance authority. At present both are administered in most cases through the one office and come under one heading. I can see the greatest difficulty arising if the assistance sections and the health sections become separate and distinct organisations following the passing of this Bill. For instance, somebody receiving maternity treatment applies for a maternity allowance, or free milk. One comes under assistance and the other under health. At present the same officer investigates, if necessary, whether they are entitled to this or that. Under the proposed scheme it appears there will be duplication if not triplication in some cases. The Minister will appreciate that I am just taking this as I find it in various documents with which we have been supplied and from the information he gave us in Navan in October, 1966.

It was stated that better and more formal arrangements will be made so that the health authorities will assist persons in the middle-income group in obtaining drugs where undue expense arises. At present people in the middle-income group, at least in my own constituency, are reasonably looked after where the issue of drugs or medicines is necessary. On a number of occasions I have taken up the matter with the Minister or his predecessor and in both cases they were most helpful in trying to get this matter straightened out. If somebody was asked to pay for drugs or medicines and found he had to do so over a period and the cost was exceptionally high, the local authority was advised to provide supplies. A very informative circular was issued by the Department or the Minister some years ago which advised as to how and when this assistance could be given. If an improvement is being made, however, I welcome it.

It was proposed to make arrangements so that the district nursing service would become available free of charge to members of the middle-income group in respect of the homenursing of the aged and chronic sick. This does not appear to be made clear now in the Minister's statement. Perhaps he could not cover all these points. I have difficulty in finding the White Paper and I wonder if there has been some change in the proposals. It was proposed that provision would be made for a home help service in legislation and consideration was being given to the organisation of the service, including the role of voluntary organisations. Again, this is not mentioned in the Minister's speech; possibly it is somewhere in the Bill and I have not been able to dig it out. It is a long time since the White Paper was issued and a short time since the Bill itself was published.

The proposal to abolish charges for out-patient services is excellent. This was one of the most stupid things in the existing Health Act because it meant that people were deterred from going to hospital if they did not have the money. I fear the Government do not appreciate that there are still many people seeking out-patient services who have not 2s 6d or 7s 6d to trot out and who consider it an impost if they are asked to pay such a sum. On more than one occasion I have had to persuade somebody who had gone in for the service to go back again. He had been asked to pay and would not go again because not having the money readily available, he felt he was embarrassing somebody in seeking the service.

Another aspect of the matter which I think the Minister should be able to cover concerns out-patients. For instance, where I live on the east coast within six miles of Drogheda, Drogheda is easily accessible to the people of that area. Is it not ridiculous that if somebody wants an X-ray or a certain type of out-patient treatment which can readily be got in Drogheda, going there either by bus or bicycle, it is necessary to wait either for an ambulance to come 22, 23 or 24 miles from Navan to bring them to Navan, keep them there all day and bring them home again, or for a car or minibus to perform the service at a fairly high cost? Is it not ridiculous that these matters cannot be better organised and I ask the Minister, if he has not already arranged to remedy this position, to do so now. It should be possible for people to get attention at the nearest hospital. As somebody said yesterday, the object of the health services is to ensure that the patient gets the treatment needed with the least possible disturbance. Unfortunately, at present many people feel from their experience of the administrative side that that is not the object; that the object is to have a health service which they can say they are running in a certain way and the patient must do what he is asked to do whether it is good for him or whether he is able to do it or not. To avoid this, a very slight alteration should be included in this legislation, if it is not already provided for.

There is also a reference to the intention to have improved geriatric services developed by the new regional boards and to co-ordinate the work of all the voluntary bodies engaged in the care of the aged. Perhaps there is something in the Minister's brief about it.

The proposal to increase the maternity cash grant from £4 to £8 for each child and to have a further increase in respect of double or multiple births is a very good idea. Again, I do not agree with Deputy Ryan when he says that the money was spent in a certain way. I do not know enough about conditions to know if that is the position but I do know that in country areas where, very often, a child is born at home, the father must stay out of work to look after the other children and even to look after the mother and a man who loses his wages because of that will be very glad to receive the £8. He certainly will not have time to go to the local with it as most fathers at a time like that have enough to do without spending their time in the local.

In a speech which he made in Navan, the Minister said regarding dental services:

It is proposed to expand the present dental services so that there can be a fully effective treatment and follow-up service for the children and others now entitled to priority of treatment and to extend the services to make it available at charges to wholetime pupils of vocational and secondary schools in the middle income group generally.

Again, this appears to be left out of the Minister's speech. Perhaps there is a change of heart with regard to these things or maybe they are being put through in a different way. With regard to ophthalmic services, the Minister said:

It is proposed to extend the ophthalmic services and to make it available to the middle income group at charges not exceeding half the cost, the services to remain free of charge to classes at present eligible.

I should like some more information on that because it appears that charges are being retained in a certain way and either we are attempting to give people a service which is free up to a point or we are not and if we are not we should say so right out.

Coming back to dental services, may I again make an appeal to the Minister to see that some effort is made to do something about the number of dentists available. I am sure the Minister is aware of the fact that during the past number of years many dentists, as soon as they are qualified, go to England where, very often, they can get a junior partnership in a firm of dentists and pick up a very substantial amount of money. Perhaps it would not be possible to compete with that here but surely it would be possible to make some effort to ensure that dentists who qualify here remain here? An effort should be made, in fact, to bring some of our dentists home from England. I have been told by a doctor that bad teeth cause more illness than is realised. It is not just a case of the simple toothache and, indeed, many working days are lost because of the illnesses brought on by bad teeth. This would never happen if people had been able to obtain the right treatment at the beginning of the decay. I am sure the Minister is aware that in most local authorities there is a long waiting list for dental service and even then there is a selective service, and very often children and nursing and expectant mothers may have to wait much longer than anybody should expect them to wait.

With regard to the issuing of spectacles, I have had many complaints as I am sure the Minister has also had in his capacity as Minister for Health, about what is described as a racket in relation to this question. I would ask the Minister to try to ensure that this racket does not continue. I am told that some people are issued with frames that went out with the Battle of Clontarf.

When a person is obtaining spectacles he is shown the frames that go with them and, usually, the person will be horrified and ask if there is any hope of getting anything better. He will then be shown a selection and after he has made his choice he will be told that these frames will cost him another 30s. or, in some cases, up to £4 more. A person should be supplied with spectacles and frames that are acceptable to him. I do not think anybody should be asked to wear something like what one would see in a comic film.

Spectacles did not save poor old Brian Boru.

If he had had spectacles, he would have seen the Danes coming.

A choice of frames is given in England.

I again quote from the statement made by the Minister in Navan:

It is proposed to extend the aural services to the middle income group and provide for charges of £5 for hearing aids.

I am quite sure that the Minister would now put a "2" in front of the "5" as £5 would do very little more than buy a battery for a hearing aid at the present time.

Is that right?

The cheapest type of hearing aid costs about £40 and £5 is only a very small percentage of that.

With regard to the proposals to control the sale of certain drugs, I wonder if the stealing of certain drugs is included under this heading? Most of us are horrified with the situation at present where (a) people get information as to where drugs are available and, (b) they are able to go there and, without much difficulty, take the drugs out of various dispensaries and depots. A case was brought to my notice recently of where a certain chemist was given a prescription written on a doctor's headed paper for a supply of what is generally known as "hard" drugs. A name and address were given on the prescription. Apparently the chemist had been caught before because he telephoned the doctor concerned and asked him why he should prescribe such a sizeable amount of drugs only to discover that the doctor had done no such thing. It is important, therefore, that doctors and people like that should ensure that their headed paper cannot fall into the wrong hands.

I am also told that it is quite common for children of 13 or 14 years of age to have drugs passed around. The children know that they are drugs but only giggle about the fact that those things can be given to them not realising the seriousness of it. I was amazed a couple of weeks ago when told there was supposed to be peddling of drugs in some city schools. As a result of a conversation I found out that maybe the drugs used are not dangerous, maybe they are aspirins and not dangerous at all, but the fact that people can be given the impression that they are taking drugs which are supposed to give them a feeling of being pretty lively is utterly wrong. We are not dealing with this matter as seriously as we should. The Minister must be as worried about it as everybody else. The big trouble in this country seems to be that we love to pooh-pooh any suggestion that anything serious can happen here; it can happen elsewhere but not here; of course, teenagers in London, New York and elsewhere can be addicted to drugs but not teenagers in Ireland. The time to see this thing wiped out is now, not when something serious happens.

Deputy O'Leary suggested yesterday that drug addiction has got a very substantial hold in this city. If the same thing were done as was done when the TB scourge was here, if very serious steps were taken, we could eradicate this addiction. The Minister would have the backing not alone of everybody in the House but of everybody in the country if he took the sternest possible measures in dealing with drugtaking, which seems to be very much on the increase according to the people who have been speaking about it here.

Under the heading of preventive services the proposals are to control the sale of certain drugs and to provide for screening tests for symptoms of specified diseases in accordance with regulations made by the Minister for Health. I take it from one of the things said by Deputy Moore this morning that many people who are afraid they are suffering from serious disease will not have the necessary test taken. This is a tragedy. Every effort should be made to encourage people who may possibly be suffering from the early stages of certain diseases to have early diagnosis and treatment. Many people are in their graves because of the fact that a couple of years ago they did not take the necessary tests to discover if they had a disease which might have been curable. As was the case in the early days of the TB scourge, people suffering from certain diseases are hidden away by members of the family and the fact that they have a disease is covered up as far as possible. Surely in 1969 we should be getting away from that idea and it should be accepted that disease is not a matter of shame, but should be treated as quickly as possible? For that reason every effort should be made by the Minister to get screening tests carried out. This would help in diagnosis.

Some years ago two of my children went to have a lung X-ray. Both of them were tested and were proved positive by the X-ray which was taken in a bus or caravan which called to the area. They were both immediately sent to the Lourdes Hospital in Drogheda and had an X-ray and a blood test carried out there. These proved negative. I know this can happen but after that time even I had a reaction against mass X-ray for some time and a feeling that it is not being carried out properly. That is many years ago and I am quite sure improvements have been carried out to ensure that such discrepancies cannot happen.

With regard to the disabled person's allowance, it is proposed that only the person's own means plus that of his wife but not of other members of the family will be taken into account. That change is long overdue because at the present time when a disabled person living in a family with a father and mother and perhaps two other members applies for a disabled person's allowance the income of the whole family is checked and is assessed in many cases at £30 or £40 a week. Anybody who has reared a family will understand that when children grow up they may give some sum of money to the household at the weekend but on Monday or Tuesday will certainly be looking for some of the money back to keep going for the rest of the week. Anybody who thinks that children subscribe all their wages to the household is living in the days when so green was my valley and the old lady stood at the door and collected in her apron the money from the men coming from the mines. That certainly does not happen today.

Here is one thing which I feel very strongly about. The Minister may say he was misinterpreted. If I am wrong, he will correct me when he is replying. He said:

It is proposed that local variations in health rates should be disconen tinued. It is accepted in principle that the distribution of the total cost to local authorities of the health services as between health authorities will be determined on the basis of a formula which will make for a more equitable distribution of the cost. Pending further consideration of the methods by which extensions of the health services will be financed in future years arrangements have been made whereby the total cost of the services falling on local rates in respect of the year 1966-67 will not exceed the cost in respect of the year 1965-66.

There are two things wrong there. If I read that correctly, in effect, the Minister is saying that he proposes to change the system so that people in one county will be asked not alone to pay their own health services but to pay the health services of some of the neighbouring counties.

This is something which many of us will not greet with whoops of joy. Take a county like Meath. We have there for many years a responsible local authority. We have been able to keep the rates at as reasonable a level as possible. We have a high valuation and low rates. That is not our fault. It is the fault of Mr. Griffith who in 1877 decided there was excellent land there and he put the highest valuation on agricultural land in County Meath. As a result of that we are able to keep the rates reasonably low. According to what the Minister said in 1966 our high valuation is not to be taken into account at all and we are to be asked to pay similar sums for health services as are being paid in other counties with low valuations and high rates. If the Minister wants this it will bring no joy to the hearts of ratepayers in County Meath.

I can assure the Minister this is one thing we will not accept too easily. We dislike having to pay our share of the health services as it is. We feel we should not be asked to pay the fairly substantial amounts for health services which are being paid by other counties at present. We feel the State let us down when they did not carry out what they said in 1966-67—that the cost would not exceed what it was in the year 1965-66. At that time we were under that impression, the whole country was under that impression and indeed I believe the Minister who was in charge was also under that impression, because it is on record that he said health charges on rates would not in future go above the figure for 1965-66. I know everything has changed since then, even the Minister has changed. This idea of increasing the burden of health charges on local authorities is placing a burden on the ratepayers which they are not accepting too readily, and I cannot blame them. It is a far cry from Dr. Ryan's 2/- in the £ for the health services. I agree he did not mention the public assistance service. I agree public assistance service charges can be added to that, but we have come a long way since then to the present when the rate in respect of health charges, even in County Meath, is much more than we ever expected to have to pay. I am one of the people who believe that if you want a service you must pay for it, but I do not believe it is right that we should be placed in a position of being asked to pay more than we can afford. There must be some other way of dealing with this and Deputy Kyne pointed out that way yesterday evening.

It is proposed to introduce legislation to transfer the administration of the health services from existing local authorities to special regional boards. The membership of these boards would be made up of persons appointed by the Minister for Health and members elected by the county councils and county borough councils in their areas. On this I have a personal view which does not run entirely in line with my Party view. I am scared about what is likely to happen as a result of regional boards being introduced. At present in my local authority area of County Meath if somebody is sick and the doctor has asked that they be taken to hospital, and if for some reason an ambulance or a bed is not available, I know that I, or any other member of the county council or indeed anybody who has any contact with the local authority, can get in touch with the health officer and explain the position. In 99 cases out of 100 the matter can be dealt with fairly speedily. What will happen if, instead of having our centre in Navan with officers who know us, the centre is in, say, Tullamore and we have to get on the phone and contact somebody down there who never heard of us, or who, even if he did, would not give two damns about us, and who will deal with the application for a certain type of service according to the book? If that is what is proposed, and as I read it it is, then I am afraid we are likely to have a lot of trouble on our hands.

In addition, there is the idea that this new kind of board will be set up in a certain way. It appears to me as if the Minister is making sure that, not alone will the board have representatives who are selected by him but he will select half of those on the board. Deputy Kyne pointed out yesterday that the chairman and vice-chairman will be nominated by the Minister. If that is democracy, then I am afraid I do not think in the same way as the Minister on these matters. You do not appoint a chairman if he is merely put in as a kind of manager.

Local authority members will be appointed from various local councils. At present, many councils are dominated by one Party or the other. If it happens that there are ten council members from five counties to be elected on a board and if those five counties are dominated by Fianna Fáil, Fine Gael or Labour then it simply means that the representation on that board will be entirely that of one political Party and the others will not have any representation on it at all. This can happen and I am afraid it will happen. I feel that the regional boards are not the best idea.

There is a suggestion, of course, that in addition to the regional boards it will be possible to have local committees. Section 7 provides for the appointment of local committees which will include local authority members. The local committee would be something like the health committees we have in many counties at present. For what those health committees are appointed I do not know. They have no statutory function and in many cases they never meet. If it is a question of just giving an air of respectability to the whole thing by referring to local committees, it will not work out properly. I suggest to the Minister that he reconsider this local committee suggestion because it will not work.

The Minister refers in Chapter I of the Explanatory Memorandum to health boards. He says:

The functional area of each health board, and its constitution will be specified in regulations made by the Minister. He will be obliged to consult the relevant local authorities before making these regulations and it is required that drafts be presented for approval to each House of the Oireachtas before they are made.

This is a lot of cod. If the Minister wants to have these boards, here on the floor of the House, where they can be debated, is the place to have them written into the Bill and let us cause when making regulations afterwards he may consult the local authorities but he does not have to take their advice. We all know what happens when an order comes before this House. Either it is not debated at all or there is a limited debate on it and the majority of the House carry it. We are not able to discuss it or put the points which we could put on the Committee Stage of a Bill. The Minister should, even at this stage, write into the Bill what the constitution of each board will be and how its functional area is to be made up rather than do it by regulation.

What does the functional area mean? I live on the east coast. Counties Meath, Louth, Monaghan, Cavan and Westmeath are known by the Managers' Association as the north-eastern region. I understand that that is not the way this will be set up. The region will be broken up in such a way that County Meath will be added to Westmeath, Kildare, Offaly and so on. The centre is most likely to be in Tullamore and the regional hospitals will be set up in such a way that they will be very inaccessible to many people who want to see relatives. The idea is not a good one. When it was being written in here I suppose the general idea was that it would ensure that a certain number of specialists would be available in one place rather than scattered around a number of hospitals—that idea must be good. I believe that it is more important to bring the service to the patient than to bring the patient to the service and that seems to be what is proposed.

In the Hospitals Report reference was made to the setting up of regional hospitals and to what the Minister called health clinics, which are our existing local authority hospitals. Is it being suggested that patients who are not so bad but who may require hospital treatment should be sent to those hospitals? That would mean that most patients would continue as they are at present. If it is intended to remove quite a number of senior staff from those local hospitals what is the point? Will they become just glorified nursing homes into which people are going more to recuperate than to receive treatment? What way will they be serviced? Surely if there are a number of patients going to the hospital the kitchen staff, the nonnursing personnel, the ambulance staff, most of the doctors and a considerable number of nurses, will still have to be retained. Is this a duplication of service?

I asked at a meeting some time ago how much the regional hospitals were likely to cost and I was told it would be something in the region of £20 million. Now, £20 million will not be found this year, or next year, or the year after. We all hoped that in the health services proposed in the Bill something would be introduced which would take effect within our time. It now appears from the way some of these things are phrased as if they may not take place for very many years. Even if they do, the Minister is rather woolly about what he intends in the Bill. In my opinion there is a distinct difference between what is in the Bill itself and what was in the White Paper. I would suggest—I may be wrong— that while we were told we would be getting the Bill in early February and then in late February, in early March and then in late March, and eventually we got it, it appears to be a rushed job, as if with an election coming along someone decided: "No matter what we do we must have something down in black and white or in black and green", and something was prepared rather in a hurry and dumped into the House and we are now asked to debate it.

I think the Minister for Education who is at present representing the Minister for Health will agree with me that, if one reads the original White Paper and reads the one issued with the Bill, and reads the Bill itself, one cannot be blamed for saying that at least two schools of thought are involved. This is not a continuation of something which was started. It appears as if someone has changed horses half way across the stream. I am not quite happy about the whole situation. I am as anxious as anyone else to see improved health services. I am particularly anxious that something should be done as quickly as possible about the system of choice of doctor, about the system of issuing drugs and medicines and about the system of issuing medical cards for free treatment. I am prepared to agree with Deputy Kyne that, even if we ourselves were in power, we would not be able to do it tomorrow or the next day or next year but, at the same time, I feel that a more definite effort should be made to provide the type of health services which the country is looking for.

One of the biggest complaints ratepayers have is that if they go to hospital and if they are not entitled to a free service it very often happens that the bills they get when they come out of hospital are likely to give them a relapse. I knew one man who was in hospital for treatment. He had heart trouble. The bill he got when he came out of hospital seemed to me to be completely outlandish, and he was not a wealthy man. There is another aspect and I do not know if it can be dealt with. When the wife of the farmer or a working man or someone who is retired and living on pension dies in hospital, there is nothing so bad as the people who are trying to pick up the broken pieces of their lives and wondering where they will get the necessary money to carry on receiving a whopping big bill from the health authority saying: "This bill is due for Mrs. So-and-so", with no reference to the fact that the person has died and saying: "We will be glad to receive payment in a certain number of days." That is something which will have to be looked at. I am not suggesting that everyone who dies in hospital should have their hospital bills written off, because that would mean that very wealthy people would not have to pay hospital bills, but I feel that before the bill is sent out to the representatives of someone who has died an investigation should be carried out to ensure that the bill can be paid by the persons who are left.

There is one other matter with regard to hospital bills to which Deputy Kyne referred last night, perhaps in a kinder way than I will, and that is the question of the amount of money which is collected from people who attend hospitals. In the normal way Deputy Kyne said possibly it may be £250,000 in the whole country. About three or four years ago I had a question down to the then Minister for Health and I was amazed to find that the normal amount which any local authority collected in any 12 months from people who had been what is known as paying patients in hospitals amounted to not more than £6,000 in any case and was down in one case to as low as slightly over £2,000. Multiply that by 32 and even leaving an average of £5,000 which would be pretty high—I am sorry. I am moving the Border much quicker than Deputy Boland, the Minister for Local Government, or Deputy Blaney, the Minister for Agriculture and Fisheries. Multiply that by 27, I understand the figure is £135,000, and it is less than the £250,000 to which Deputy Kyne referred. If you take the expense of collection and assessment out of that you will find that the net amount being collected by the local authorities is so small that there does not seem to be any good reason why any attempt should be made to collect hospital bills at all.

So far as we in the Labour Party are concerned, let me make this very clear. Our aim is free medical treatment for everyone who needs it. Deputy Moore gave examples last night of what happened in Northern Ireland and Great Britain. If you want to shoot something down all you have to do is look around until you find someone who has failed. I would suggest that, no matter what it costs, it would be much better for us if we could ensure that all those who need treatment and are unable to pay for it can get it free, even if that involved someone who did not need free treatment getting it for nothing. That is the really important thing. If we are genuine about doing something about our health services we must have two aims. One is the short-term one— and I am sorry the Minister has not approached it in this way in the Bill— which would give free choice of doctor, free medicines and as far as possible free hospital treatment. The second is the long-term one which would deal with the financing of the health services and ensure that eventually we would be able to produce a free health service for all.

This Bill does not do anything about the most pressing problem in regard to the health services as far as the local authorities are concerned. We were given the impression from time to time by references by the Minister and other members of the Fianna Fáil Party that something would be done to relieve the impact of the health charges on the rates. I do not think the provisions of this Bill will have any proper impact on the rates. This is an important matter for people all over the country. For instance, in my constituency, as I mentioned in this House already, over £2 of a £5 rate is assimilated by the health charges.

As Deputy Ryan said last night, the conviction of members of our Party is that the only manner in which the health services can be operated equitably is on an insurance system which has been persistently advocated by the Fine Gael Party. I should not like the fact that the suggestion emanated from this side of the House to inhibit the Minister in his approach to this matter. In fact—and I do not say this with any gloating undertones—the Minister has, in this Bill, accepted our proposition that the dispensary system was as out of date as the dodo.

Many years ago Deputy Tom O'Higgins, then our spokesman on health, indicated that the aspirations of the people was to have a choice of doctor and that, if they were unfortunate enough to become ill, they would not be sent compulsorily to a doctor whom they might personally have detested. Although I can pay tribute to the great majority of the dispensary doctors throughout the country, all of us have from time to time come across dispensary doctors whom we can easily understand being detested. I am personally thankful that I have not been forced to attend some of the doctors whom some of my own constituents have had to attend if they want to get medical treatment. For that reason we welcome the proposals in the Bill, all Fine Gael suggestions which have been pressed time and again in this House, by local bodies and from public platforms.

There are all sorts of provisions in this Bill. It pretends to be a far-seeing Bill, but I think it has forgotten one very old adage, that is that prevention is better than cure. There should be enshrined in this Bill somewhere very plain and distinct provisions for either preventative medicine or preventative measures which could be taken, generally speaking. However, provision has at least been made for the Minister to take on himself powers to finance bodies which would investigate such things as diet. A number of patients who are going to doctors and even going to hospitals at the moment are eating themselves into hospital and eventually some of them eat themselves into the grave. I suggest to the Minister that we pay some attention at this stage to the popularisation of wise diet. Similarly I think a better approach could be made to advising school children and, indeed, adults of the dangers of smoking, the importance of hygiene, rodent control and various other matters of that nature. While we are on matters like that I might say it is my firm conviction that much of the ill health with which we are scourged at the moment could have been avoided had the Minister's counterparts in the Department of Local Government over the years paid more attention to what was said from the benches on this side of the House in this regard. Much ill health, a great deal of the pulmonary diseases and an even greater amount of the mental afflictions, the treatment of which has had to be paid for out of health funds, would have been avoided had the Government attacked the housing problem with the same vigour, the same courage and the same fearlessness as we on this side of the House attacked it when we were given the privilege to govern the people. There would not have been the same need for hospital treatment on the large scale on which we have had to provide it had the Government carried out its Christian duty in that regard.

Whilst on the subject of large institutions, I thought that Deputy Moore was rather unfair to the last inter-Party administration in this country when he pooh-poohed what that Party had done by way of provision of hospitalisation. He made the point, as far as I can recollect, that there really was no need for this hospitalisation and that the real reason why TB had been more or less eradicated was that modern drugs had been made available.

Deputy Moore overlooked this, that drugs are not the sort of thing you can administer to a person on a bus, in the street or at home. He overlooked the fact that at the time when this policy of hospital building was initiated by the last non-Fianna Fáil Government these drugs were not as readily or as widely available as they are now. The least the Minister could do to make restitution for the misrepresentation of Deputy Moore is, when he is replying to this debate, to pay tribute to the progressive policy of the last non-Fianna Fáil Government.

When I speak about progress I mean in actual bricks and mortar. We have plans and revised plans for regional hospitals in various places. As far as my own constituency is concerned the regional hospital has not yet clarified itself by the production of one stone upon a stone.

Another thing which Deputy Ryan referred to last night and which I would propose to the Minister is that when people are hospitalised as a result of the negligence of other persons —and I do not refer just to road accidents—it should not be made a charge on public funds. These expenses are usually provided for under private insurance of the offending person. It is wrong that under the proposed dispensation in this Bill the ordinary citizen should have to pay for cases of that nature.

In passing may I say that many hospitals do not avail of the provisions of the present Road Traffic Act under which they can reimburse themselves in such cases. The Minister should very fully investigate this and, pending the amendment of legislation along the lines suggested by Deputy Ryan and myself, send a circular to the hospitals referring them to the provisions of section 119 of the Road Traffic Act, 1961, which provides for the reimbursement of the hospital in the case of people who are injured in road accidents. I am quite sure that if the Minister circularises these hospitals and asks them what steps they have taken in this regard, he will be quite surprised by the response of those hospitals. I think he will find that very few hospitals have availed of it at all and that the only people who are gaining as a result of this are the insurance companies.

We can have mixed feelings about the disbandment of health authorities as we know them, but I should like to give the Minister one word of advice which is based on my own personal experience of health authorities as they did operate in my constituency. If the health boards which are to be set up are going to meet the Minister should, I think, require them—they are not required at the moment under any of the Schedules —to state after each meeting the length of the meeting. There are, no doubt, expenses involved in travelling to these meetings and I have no hesitation at all in saying that the manner in which the Cork Health Authority has operated up to this has been most expensive. It usually does not meet until about a quarter to twelve and it often finishes the meeting by one o'clock and it solemnly meets again and enacts the same thing about a fortnight later. I have always felt that one meeting per month would be quite sufficient for the Cork Health Authority and the implementation of such a system would be very much in aid of the rates.

There is provision for Government nomination to membership of the new health boards. Apart entirely from politicians, the ordinary man-in-the-street is as suspicious as he can be of provisions of this kind. If these provisions are finally enacted I hope the Minister will be most careful not to make these nominations matters of political patronage and I hope that the people who will be nominated will be nominated purely on their merits.

On the question of the termination of membership of these health boards, the provisions are a bit arbitrary. If a member does not attend for three months he will cease to be a member and the board will proceed to elect a new member. If a person does not attend for three months, without a reasonable excuse for non-attendance, then I think he should cease to be a member but, under the regulations as they are at present drafted, a man who may be ill for three months will thereby have his membership of the board terminated. Some modifying provisions should be inserted in this regard.

A medical certificate.

Something like that or something like what is provided in the Harbours Act. A harbour commissioner, unless he can show reasonable excuse for non-attendance, ceases to be a member if he is not present at a certain percentage of the meetings. Some provision of that nature should be inserted here.

It is open to the board to reappoint.

Usually it is, but it is not stated definitely in this Bill. Just in case of accident something should be done. One of the things which horrify me in this particular Bill is the power the Minister is taking unto himself. The powers given are absolutely impudent, in my opinion. He will have power to appoint the chairman and vice-chairman of a health board. I do not know why the Minister should take this power unto himself. I do not know if there is any precedent the Minister is following in this regard. I should be glad if he would justify these powers when he comes to reply.

I cannot understand why the Minister would not pay these boards the compliment of allowing them at least to appoint their own chairmen and vice-chairmen. There is grave danger in this provision. There is implicit in this—I do not suggest this in respect of the Minister or the Fianna Fáil Government; I suggest it in respect of any Minister and any Government— the idea that a man who never participated in public life and who was nothing but the creature of a political Party could be rewarded by being made the chairman of a regional health board. There are people who would be more than ready to give generously to the funds of a Party which would thus reward them. I am talking now about a hypothetical Party and a hypothetical Government who would appoint some objectionable hypothetical Party hack as chairman of a health board purely as a matter of patronage. If the Minister insists on taking this power it is inevitable that these nominated chairmen and vice-chairmen will be regarded as political nominees and as creatures of the Minister.

Mark you, they will have fairly wide powers, apart altogether from the powers an ordinary chairman or vice-chairman has. In this particular instance the chairman will be given an extra power over and above those normally held by chairmen. Under subsection (2) of section 12 it is provided that, whenever a chief executive officer is on leave or is, through illness or suspension, or for any other reason, incapable of carrying out the duties of his office, the chairman or, in his absence, the vice-chairman, shall appoint an acting executive officer. I think that is a very dangerous provision and one this House could not welcome. The Minister might have a look at the manner in which it is proposed to appoint the chairmen and vice-chairmen of these boards and at the extra powers which it is proposed to give them.

I regret the Minister has not seen fit to codify health legislation. The Minister may say that would be a monumental task. That is all very well, but this House went to great pains to codify companies legislation. I think health legislation is more important generally to the country than companies legislation.

With regard to the Schedule, which shows the enactments which are repealed, only portions of the Public Hospitals Acts, 1930 and 1933, are being repealed. The same applies to the Mental Treatment Act, 1945, the Health Act, 1947, the Health Act, 1953, the Health Authorities Act, 1960, and the Nurses Act, 1961. There might also be Acts anterior in time to the Public Hospitals Act, 1933, which will have a bearing on the health services in this country. As we are legislating for health at this stage—it may be difficult to do it now that the Minister has initiated the Health Bill along the present lines—I think it would be much better for all concerned and in the public interest if the Minister had come to this House and had thrown down a document and said: "What everyone wants to know about health is contained in that document". This is not purely a problem with the Department of Health and I am not blaming the Minister. This is a general trend which we would hope would show itself increasingly in legislation——

This would be a very hefty job but Deputy Stephen Barrett, in his retirement, would be a very useful man to do the groundwork on it.

I agree and, when the document is completed, it would be a pretty hefty one to carry around.

It would be a useful piece of work.

Nevertheless, I think the Minister is half in favour of my suggestion at least. I hope that when our Party gets into power after the general election, whenever it is, the Minister's successor will bear my valedictory remarks in this regard in mind and produce for the country a comprehensive health code so that anybody can examine in the index how his or her needs are dealt with by the Acts.

I am glad to see that provision is made for home help and home nursing. In that regard, referring to sections 58 and 59, I hope that, in regard to home nursing the Minister will not forget or disregard or discard the wonderful bodies of voluntary workers, mainly religious, who have done such wonderful work in the towns and cities of our country. It would be a shame if they were more or less thrown on the scrapheap or compulsorily retired or rendered unnecessary by the provision of alternative sources of home nursing. Having brought succour and assistance to tens of thousands of people—not by any means people who are members of their own religious community —I think the Minister, in dealing with these particular matters under these particular sections, should certainly consider the claims of these particular bodies.

In regard to the home help service, under section 54, that is the provision of out-patient services, it would appear to me that the health board for the area has no function whatsoever in this except to provide the money because, under section 59, it is the chief executive officer who can decide to assist in the maintenance at home of sick and infirm persons or their dependants or in the case of persons eligible for institutional assistance without charge, such charge will be what the chief executive officer considers appropriate.

There seems to be a worse proposal in it, in my opinion. The CEO, having been given these powers absolutely independently of the health board, is completely under the thumb of the Minister because subsection (2) of section 59, having given the CEO these powers, proceeds to invade these powers immediately by saying: "In making a determination under subsection (1), the chief executive officer of a health board shall comply with any directions given by the Minister"—let me say "by a Minister". Again, we have the ordinary man and woman in the street left with the impression— just as they are left with the impression that a Minister can make one of his pals the chairman or the vice-chairman of a health board—that, if a Minister wishes, he can direct any expenditure he likes without going through any set formula in respect of the treatment of any of his pals down the country. That is bad. I think, in some way, the powers of the Minister should be subject to some discussion, some review or something like that. But, here, we have a most wide, enabling enactment that in making a determination under subsection (1) of section 59, which is about the assistance and the maintenance at home of sick and infirm persons, the CEO of a health board shall comply with any directions given by a Minister. I should like the Minister to look into that. I think that, on second thoughts, he will realise that there are certain objectionable matters in it.

I want to go back to the question of the appointment of chief executive officer which is provided for under section 12. Frankly, having read and re-read the section, I do not know —and this might be entirely abysmal stupidity on my part—how a CEO shall be appointed. The Bill, in its very first words, breathes the intention that a CEO should be appointed. I should be very glad if, when he is replying, the Minister would tell us where, in the section, there is solid provision for the appointment of a CEO. Subsection (6) of section 12 says that the Minister may, before the establishment of a health board, request the Local Appointments Commissioners to select such a person and take other steps. It does not say that the Minister "shall": it says the Minister "may". Then it goes on to say that, on the establishment of the appropriate board, a person selected in accordance with subsection (6) shall become and be the CEO of that board.

What happens if the Minister does not request the Local Appointments Commissioners to select, under section 14, a person for appointment as CEO of the board? I do not know if there is anything in section 14 which would come to aid in that regard; I do not think there is. I am so confident of that that I defy the Minister to tell me where there is power for anybody to appoint a CEO of a health board unless the Minister, before the establishment of the health board, requests the Local Appointments Commissioners to select such a person. There definitely is a need for some sort of amendment of this particular section. Even if the Minister made it "shall, before the establishment of a health board, request the Local Appointments Commissioners to select under section 14 a person for appointment", I do not think it would be sufficient. There will be occasions when the health board will already have been established and when, say, the first CEO has gone to his reward either by way of eternal bliss or obtaining a pension. What will the Minister do then? I would be very glad to hear the Minister's views on this.

Would section 12 not cover that?

"Shall be appointed".

But by whom, where and in what circumstances? I do not think the section says how it shall be done.

Look at subsection (8).

"The appointment of a chief executive officer pursuant to a recommendation by the Local Appointments Commissioners shall be a function of the board." This is only where the Local Appointments Commissioners have been requested by the Minister to select a person under section 14. I suggest to the Minister that the drafting is somewhat woolly and he might find himself on a limb and appointing someone irrespective of the statute and that would be a very bad thing. While on this I want to go back to the Minister's friends, the chairman and the vice-chairman of the health board. These may be matters which are more suitable for a later stage but the Minister will understand why I am mentioning them now. Subsection (9) of section 12 says that a temporary appointment of a chief executive officer may be made by the Minister. That is a terribly dangerous provision. As the Minister knows, this country is studded with temporary officers who have been temporary officers for 10, 20 or 30 years. The Minister should limit himself and his successors in regard to the use of that dangerous word "temporary". The Minister should tell the House and the country what exactly is meant by "temporary". We might find ourselves in the situation that a man has spent a long and honourable career of 40 years as a temporary chief executive officer of a health board, at the pleasure of the Minister.

As I said, these points might be more rightly made on other stages but probably I will not have the opportunity to mention them again. I want to reiterate that I am glad that the Minister and his Party have at last come around to the Fine Gael point that a choice of doctor is a proper thing for every free citizen in a free country. I hope we will live to see the day when we will also have the payment of public health charges met under an insurance scheme rather than by the provisions made in this Bill.

Mr. O'Malley

I want to welcome the philosophy underlying this Bill and the Government's decision not to extend free medical services to everybody because, as Deputy Moore pointed out, that has not worked well in other places. It seems to me that it would be very foolish that the whole community should be taxed to provide free medical services for everybody including those who can afford to pay for them. In health as in every other sphere of Government activity funds are limited and the Government are correct in their decision to apply as much of the funds as are available to people who need help most, the people who cannot afford from their own efforts or through other lawful means to pay for health services.

I want to deal with a matter which has been causing concern both to me and to many people in Limerick for some time past and that is the system whereby some local authorities are saddled with subsidising patients from other local authority areas. Some months ago in reply to a question here from me the Minister said that he would be meeting a deputation from the Limerick Health Authority and that he hoped to straighten out the matter. Subsequently he stated that it was hoped that the new health board would result in the difficulty being overcome but he did not mention it in his Second Reading speech and I hope he will be able to give an assurance to Limerick city and county, and to several other counties which are in the same position but do not suffer so heavily that this problem will be overcome.

Briefly, the position is that the average cost to the Limerick Health Authority of maintaining a patient in one of the various regional hospitals or health institutions is over £3 a day but the health authority is refunded only about 42s a day by the local authority responsible for the patient. The obvious result is that the Limerick Health Authority is at a net loss of approximately £1 a day for patients from other local authority areas. Unfortunately for them, that net loss must be met by the ratepayers of Limerick city and county. I hope the Minister will be able to give us an assurance that under the proposed health board system that arrangement will be discontinued and that the ratepayers of Limerick city and county, who are already very hard hit, particularly those in the city, will not continue to suffer because of this arrangement. There are one or two other places where health authorities cover more than one county and where the problem also arises but not to the same extent because the Limerick Health Authority is catering for patients from all or part of five different local authority areas.

With regard to the question of regions and regional hospital boards and health boards the Minister has outlined the position broadly but he has not yet made up his mind about the precise size of these boards or regions. I would like to urge him to adopt the existing Limerick region which organisationally is probably one of the most advanced regions in the country. It covers Limerick city and county, County Clare and the North Riding of County Tipperary and it works out quite well in general administrative matters, particularly in regard to tourism and I believe it should be the basis of a health board area. As far as possible the Minister should try to base the health boards on the areas suggested for regional development by Dr. Lichfield because they have been very well thought out and they are generally reasonably homogeneous areas that are quite easy to administer. It does appear from the Fitzgerald Report, which has been referred to by the Minister, that while two or three health boards might be set up in Munster, Munster would be one region for the purpose of a regional hospital. Munster constitutes an area of over one-third of the Twenty-six Counties and it seems remarkably big as a unit. I agree equally wholeheartedly that a county unit is far too small. The Minister might well consider splitting Munster into two regions with two, three or four health boards and two regional hospitals, one in Limerick and one in Cork, rather than having one in Cork as at present proposed. For example, there will be people in County Clare who will be over 125 miles from a regional hospital in Cork. All the facilities exist in Limerick at present to make it the headquarters of a region serving the northern half of Munster. No great additional expense would be involved in dividing Munster into two regions with two sets of regional hospitals rather than one, as seems to be proposed in the Fitzgerald Report. Under the report, however, I am glad to note that the Limerick hospitals would in no sense be downgraded; indeed their development and further extension is advised in that report.

In section 55, I am glad to see, the Minister has dealt with a matter that is of some concern to me and to us in Limerick, the question of ambulances, because up to quite recently we had the unfortunate situation that individual counties seemed to be responsible for their own ambulance services. Frequently, we had instances of persons being knocked down and seriously injured on the Limerick-Shannon Airport road, which is one of the busiest and most dangerous roads in the country, within a mile or two of Limerick city and because they were knocked down within the administrative area of County Clare an ambulance had to come from Ennis to take them back to Ennis, a distance of about 23 miles each way. It often took several hours to have such accident cases in hospital in Ennis whereas they could have been in hospital in Limerick within a matter of ten or 15 minutes. The consequent delay might very easily prove fatal.

Within the last year or so, the Minister gave specific direction to all local authorities that that sort of situation should not be allowed to continue but now he has given statutory effect to this in section 55. I am glad that it is specifically stated that the ambulance service provided by any health board may convey patients to or from places in or outside its own functional area. I hope that the regulations which the Minister will make under this section will require local health boards to install radios in ambulances and have a 24hour service available within their functional areas because there are many instances at present of very long delays and unavailability of ambulances and persons having to try various hospitals and health authorities in order to get an ambulance.

Deputy Barrett, for some reason that I cannot follow, regretted that this Bill did not do enough in the line of preventive medicine but it seems to me there are about a half dozen sections specifically aimed at preventive medicine. I am glad to see them; they constitute most welcome parts of the Bill. There are many diseases which it is difficult to treat and difficult to cure at a late stage of development but which can very easily be cured if diagnosed at an early stage. There is provision for screening tests in this Bill; the Minister may direct each health board to set up facilities for screening tests and various other forms of preventive medicine. I am extremely glad to see that because the number of lives that can be saved is very large and the amount of suffering and misery that can be avoided is very significant.

Within the past year or two the Minister gave directions that newly-born children, if at all possible, were to be tested for a disease which I shall not attempt to pronounce but which the Minister mentions in his speech. I understand from Deputy Dr. Gibbons that since that scheme began no less than 59 cases have been detected. If those cases had not been detected those very young babies could not have been cured and would undoubtedly have died at quite an early age. That scheme which deals with only one obscure disease, is proof positive of the great benefit that will accrue to the whole community from the principle which has been accepted in this Bill of screening tests of various kinds for various diseases.

I am glad to welcome section 67 which deals with maintenance allowances for disabled persons. Only in the past few weeks I have had several instances where a person had no income or possibility of an income and was excluded from payment by Limerick Health Authority on the grounds that brothers and sisters were in good jobs. In other words he was being told that he was expected to live for the rest of his life on the charity of his brothers and sisters. That is a very unsatisfactory and an almost unchristian approach to things and I am glad that the Minister has done away with that in section 67.

I am also glad that in sections 58 and 59 the Minister accepts the principle that old people who are, perhaps, chronically ill should be helped in their own homes. This is not alone socially but economically very desirable. We complain legitimately about the cost of health services and, in particular, of hospital services. Speaking subject to correction, as an approximate figure, the cost of maintaining a person in a county home or city home is on average £15 per week. I think, and I believe many others also think, that the payment of perhaps £2 or £3 a week to a member of an old person's family to enable him or her to keep the old person at home and look after him would have the great social consequence of keeping the family together and the great economic consequence that the State and the ratepayers would, perhaps, be saved £10 or £12 a week. I am glad that in sections 58 and 59 that principle seems to be recognised. I urge the Minister not to be afraid to make regulations allowing payment of £2 or £3 or even £4 a week to a member of the family of a chronically ill old person to enable that person to be looked after at home.

Perhaps the greatest step forward in the private sphere in regard to preventive medicine in recent years is the work being carried out by the Irish Heart Foundation. About 50 per cent of deaths in this country are attributable directly or indirectly to heart disease in some form. The excellent work which these people have started —they have already raised almost £250,000 to enable them to carry out research and so on—deserves every encouragement from the Minister, financial and otherwise. They are doing something that can be of tremendous long-term benefit to the whole community.

The Minister has asked for suggestions with regard to the question of the appointment of chief executive officers. I see that a suggestion was made to him to the effect that of four chief executive officers one should be a doctor. The Minister was not prepared to accept that suggestion and I certainly agree with him that he should not accept it because the whole basis of a chief executive officer's work would be purely administrative and it would be most unsuitable for a doctor to act as chief executive officer.

There might be an inclination on the part of the Minister or on the part of the Local Appointments Commission when appointing chief executive officers, that is if they are appointed, to appoint either county or city managers to this post with the expectation that they would hold the post in conjunction with their own post of county or city manager. This would be wrong for many reasons. The Minister might well consider adding a section or even a line to the effect that the chief executive officer of a local or regional authority would not be eligible for appointment as chief executive officer of a health board. It is undesirable that an official of a health board who is highly experienced and competent and who has given long and loyal service to the health authority should be deprived of the possibility of appointment to the highest office on that board or authority. The duties of a city or county manager are already adequate if he is to be enabled to concentrate full time on his job.

Once again I must say that I am very glad, as most Deputies in the House are glad, to welcome this Bill which makes for such major advances in many aspects of health and which is of such great importance to all our people. I am indeed very glad that the Minister has come in here in such an open and frank way and that he is prepared to listen to suggestions, is prepared to make amendments where they would be appropriate and that he is not anxious in any way to push anything down anyone's throat.

Finally, there is something I should like to say with regard to the general principles of the Bill. A great deal of what the Minister wants to do will unavoidably have to be done by regulation. As a matter of general principle, that is regrettable; but I can see that in something so complex as this it is necessary in many instances. However, there is one section to which I should like to draw the Minister's attention. That is section 81, the second last section which, to my mind, could be abused by some subsequent Minister who might decide that he wanted to make very drastic changes in the whole health code without having to come before the Oireachtas. If the Minister considers that section, he might well come to the conclusion that section 81 should be narrowed very considerably because, as it stands, many Statutes relating to health matters on the Statute Book at present could be amended by a regulation made by the Minister who would not have to come before the House. I think it is important, not just from the point of view of health but from the point of view of legislation in general, that such a general sort of section as that should not be allowed to exist. I am not for one moment suggesting that the Minister or any successor of his would try to abuse it but as a matter of principle, if the principle underlying that section were extended to our legislative powers in general, we could find a situation in which, after a general election, Deputies could come into the House and pass an Act of one section which would say, in effect, that the Taoiseach, by a statutory regulation could amend any Statute existing on the Statute Book. We could then pack our bags and go home for five years. I appreciate the necessity for a lot of regulations under this Bill relating to specific matters but I would point out to the Minister that it is not desirable to have as wide a section as section 81 for the making of regulations.

Although this Bill is being introduced in the dying days of this Dáil and in the shadow of a general election, I consider it to be a very disappointing Bill. It has been brought in, shall we say, rapidly and without several necessary conditions being fulfilled to create a stable and useful health service.

I can only say that this is an up-to-date edited version of the 1953 Act which proved inconclusive and which created a lot of controversy and dis-satisfaction in the country. I also appreciate the fact that the Minister has had to have a triangular structure with the Government on the one side and on the other side the Custom House pressing for greater power. Therefore, I cannot regard this Bill with any degree of enthusiasm. I say this not only as a public representative but as a medical doctor.

I wish to deal with four major issues. First of all, there is nothing in this Bill to deal with the financial position; secondly, the Minister has brought in the Bill without finalised agreement with the medical profession, although I know that he has been having discussions with them during the past couple of years; thirdly, there is the innovation in regard to the regionalisation of hospitals and, fourthly, this Bill, to my mind, is specifically designed to increase the power of the Custom House. I have nothing personal against the officials of the Custom House, who have always shown the greatest courtesy, but I do not think they are the best people to recognise what is requisite in regard to medical services.

First of all, I want to deal with the financial aspect. It is quite obvious the Minister must have had his troubles in the Government to try to get something to enable him to deal with the unfortunate financial situation which exists in relation to medical services at the moment. Everybody knows one of our major local authorities, Dublin Corporation, stand at the point of being dissolved due to the fact they are facing financial difficulties in relation to the health services. Exactly the same situation arises in every local authority in Ireland. I am not exactly sure by how much the rates will be increased in my own county but the county manager today told me practically all the increased rate, except what is necessary to pay increased salaries due to the rise in the cost of living, will go on health services. The same position obtains everywhere.

The Minister in his opening speech said there would be an increase in the cost of the services due to overhead charges in hospitals, increased salaries which have to be paid to nurses and increased expenses generally, but he did not give us any indication as to how that money was to be met except a vague statement that a regional authority was to be set up and that a donation or grant would be got from the central government. However, he did not specify in what circumstances that grant would be made nor did he make it clear to the House where exactly the money was to come from. We are entitled to know this. There is a considerable amount of money going on administration. The Administration are spending 1/- to try to save a penny. That is what the whole thing boils down to. There is general agreement in the country that the whole financial situation in regard to health services is not being dealt with in a satisfactory manner, either at local or central level.

We now come to the question of agreement with the doctors. I do not know if the Minister is a hard worker or not. I hope he is because Health seems to be one of the most demanding Departments in the State. I know the Minister received the doctors and had discussions with them. I know they have broken and there is disagreement on one point, which is a major one, remuneration to doctors.

We have not broken.

You have not got anywhere.

We have got somewhere.

The Minister said in Killarney in an after-dinner speech that he had gone a long way to meet the doctors' requirements. Let me tell the Minister, the doctors want to maintain the patient/doctor relationship as an entity and they are not going to do that by introducing the Minister's system.

Sorry to interrupt the Deputy.

I will even give way to the Minister if he wishes.

I do not think the Deputy intended to use the word "broken".

Final agreement has not been reached.

Well, then, it is futile to bring in a Health Bill without final agreement having been reached with the doctors. I admit the Minister's relations with the doctors are far happier than his predecessors' were in that he is going to their dinner parties and meeting them but he has not reached fundamental agreement with them on the major point of how the services are to be financed. I know the medical fraternity want this fee for service. It is not an impossible thing. We are not the only country in the world who are looking for that. It has been tried and proved successful in other countries. What has been suggested is a capitation system. That is the old panel system which existed in Britain at one time and which I think still exists whereby you get a certain sum per patient. Human nature being what it is, you know you are already getting this certain sum of money and you will not give the same consideration as if it was a private consultation.

It can be a private consultation at every level. I would like the Labour Party to realise this because they always feel that doctors are not treating poor patients as they should. If a contributory scheme is accepted you have the private patient and doctor relationship, you have the same benefits for the poor, the lower income group, the middle income group and the higher income group and there is no distinction. If those who advise the Minister could grasp that point we could have a happier situation in relation to the medical profession. The Minister has had no agreement with the profession. He is trying to get an agreement with them but he will not get it unless he accepts the fee for service. I believe he would like to accept it but those who are advising him tell him that it will not work, that it will be too costly and so forth.

That brings me to the increasing power of the Custom House. I do not see why the Custom House should control medical services. I never have seen why. We have a Department of Health for the purpose of assisting us to have proper medical services but not to control them. That is where I join issue with the officials. We do not want bureaucratic control. This Bill is only prolonging the bureaucratic control of the 1953 Health Act. I want to see medical services which are acceptable to the people, which the people own and control. That may sound socialistic to some of my colleagues but I do not think anybody can accuse me of being a socialist. For that reason I believe the whole set up—and this is what the Minister accepts—is really a central Government-controlled system. I do not want to see that and I am sure the Minister does not want to see it either. If he wants a satisfactory system, he will get away from that.

Before I deal with other points I want to refer to the question of hospitals. There is nothing which has aroused as much suspicion and objection as the attempt to regionalise hospitals. Only today I got to what is known as the Fitzgerald Report. It is entitled Outline of the Hospitals System but has been referred to here as the Fitzgerald Report. It is a report of a committee set up by the Minister to study the hospital system. That committee consisted entirely of consultant physicians and consultant surgeons, men who have worked all their lives in the sheltered atmosphere of hospitals. These people were all county surgeons or county physicians. There are four big centres: Dublin, Cork, Limerick and Galway. If one studies the map describing the regional hospitals system one sees what existing county hospitals are to be closed. The existing hospitals are to be called communal health centres which merely means that they will sink into oblivion and will no longer deal with surgical emergencies or anything like that. There are only three exceptions outside the large centres.

I am not criticising those who were on the board but outside of Dublin, Cork, Galway and Limerick the only three places where this board have hospitals where they were before are Kerry, Sligo and Mayo. One can see the unanimity of agreement among the consultants when they sat down to define the future of Irish medicine. These people who live in the sheltered atmosphere of hospitals would never think how these changes would affect the general public. They would never take into consideration the fact that instead of people having their nearest and dearest in the existing county hospital quite close to their homes, they would have to go up to 50 miles to visit them in hospital. They would never think of things like that and the reason is that there was no general practitioner who would appreciate this on the board. This is purely a consultants' scheme which is totally unacceptable to rural Ireland. It does not matter in the big centres where one has only to take a fourpenny or sixpenny bus ride to see relatives in hospital but persons in rural Ireland might have to travel miles to visit patients or, if they could not afford to visit them, make telephone calls. We have a rotten telephone service. One can ring Dublin all right but if one wants to enquire about a patient 50 miles away it is more than likely that one cannot do it. I cannot blame the Minister for Health for that but I am pointing out to him the snags that exist.

I come now to my own county of Wexford. The Fitzgerald Report says that there should be 300 beds. They regret having to mention beds as being a proper criterion but they do mention a population figure. I have had more representations over the suggested transfer of the county hospital from Wexford than I have had on any other single matter since I came into public life 18 years ago. I have had representations from every organisation that ever existed. This interesting document compiled by Dublin consultants and those who sat on that board says that the population should be 120,000. As I read the map we will be located in Waterford. If I were to come under the health scheme I would have to travel 58 miles to Waterford. It is supposed to cater for 120,000 people. The nearest hospital to Waterford is Cork. That is a big centre; it has a regional and a general hospital. There is nothing else nearer than Offaly, Limerick or Dublin. I take it that the Waterford hospital is supposed to cover Wexford and during the tourist season we have a population of nearly 150,000 and that is for four or five months of the year. That is 30,000 over the prescribed ratio per population per hospital in this interesting document. It also has to cover the population of Carlow, Kilkenny and Waterford itself.

It has been suggested that we in the south-east of Ireland, where, of course, we get nothing and have got nothing for years although we have had various Fianna Fáil Ministers, should have a hospital based in Waterford which is miles from us, with a population outside the tourist season of somewhere in the neighbourhood of 200,000 and, in the tourist season, presumably 300,000. The thing is farcical. I do not know whether the Government propose to go on with the regionalisation of hospitals or not but I would very much doubt it because they will find that if they do the ballot box will come into the question and Fianna Fáil throughout the years, though they may not have given any sort of good government, do consider the ballot box. I advise them to forget the regionalisation of hospitals.

The people of Wexford have been waiting 40 years for a new hospital. At the end of 40 years we have been offered this insult of a regional hospital 50 or 60 miles away. Is it any wonder that all Wexford is up in arms?

There are many things in the Minister's speech which are rather difficult to understand. With regard to prescriptions I was approached by the chemists some time ago. The chemists are prepared to work a scheme under which they are prepared to dispense drugs at cost price for a very small prescription fee. That is the considered opinion of all the chemists throughout Ireland. If one looks at the register of chemists in the country as a whole one will find that they are gradually being reduced in number due to the encroachment of State medicine. Heretofore, they supplied drugs but the new State-controlled health centres coming into existence are pushing them out of business. I would be sorry to see the chemists of this country going but the close down has started. The Minister and his advisers should look into that. There is an extraordinary reduction in the number of chemists. We will soon have a situation, unless they are co-opted into this scheme, where there will be very few chemists in the country and one will have to travel 20 miles in parts of rural Ireland to find a chemist. That is due to the fact that drugs are being supplied in the health centres.

There is another point I want to raise with the Minister on this Bill because it is the sort of thing that must be raised on a Bill like this because it may or may not be legislation. I do not know. I asked a question yesterday regarding the number of vacancies for assistant county medical officers. There are 14 vacancies at the moment.

With all the talk about better school services, better examination of children, better health services and so on, the fact that there are 14 vacancies for assistant county medical officers presents a serious problem.

The answer is that doctors are not available because their remuneration here is not as high as it is elsewhere. We also face the situation in the modern world that in other wealthier countries the same numbers are not going into the medical profession as heretofore, because there is an easier and cheaper and quicker way of earning a living by becoming a sales executive or something like that, rather than studying for seven years to become a doctor and then struggling for the rest of one's life. I struggled for many years as a doctor and I found it very hard to make ends meet. These assistant CMOs are not available. There is a simple remedy. There are quite a number of married women in this country who are prepared to take on that job, but it will not be given to them because of something in a regulation or in the Health Act. I do not know. If there is something like that the Minister should introduce legislation to deal with it.

I want to say a final word about the insurance scheme, about the scheme propounded by the Fine Gael Party. The Fine Gael Party suggest a comprehensive insurance scheme to cover the country. That scheme would do two things. It would save the people from walking the streets over the rates— which will happen in the not too distant future—and there would be a return to some sort of financial sanity in the administration of the health services.

The question of compulsory insurance leads to the question of how it will be administered. We do not have to go very far to see how it has been administered in other countries. It has been administered in different ways in different countries. In a country such as this there seems to be only one solution. It seems to be a very simple solution. Here we have approximately three types of individuals. We have those in the lower income group, those in the middle income group and those in the higher income group. These groups are being renamed according to the parlance in the Bill. They are to be known as the eligibles and the not-eligibles. I think that is what they are being called. Whether we are pandering to some socialistic thought on the part of someone or other I do not know.

As I say, we have three different financial groups. It is highly desirable that we should get out of the financial chaos which we are in, and it is also desirable to preserve what I consider to be the sacred doctor-patient relationship. The contribution of the lower income group should be paid in its entirety by the State. That is where the Custom House comes in and that is where the Custom House enjoys its control, with the pale shadow of the Minister at the head of it answering to Dáil Éireann. The middle income group will not be able to pay the entire amount and, therefore, they will make a contribution in accordance with their income and the State will make a small contribution towards them. There again the Custom House can come in and watch and see that everything is in order. Thirdly, the higher income group can pay their own contribution.

From that we will have a full and comprehensive medical service for which the Labour Party are crying out, but unfortunately we are not told how they would finance it: whether the rates are to go to astronomical heights, or taxation is to be up by millions. This insurance scheme would not increase taxation. It would involve a contribution annually, or monthly, or whatever you like, by the individual concerned. I cannot see why it should be Government-controlled. That is not the case in other countries. I do not see why it should not be run by a private non-profit-making corporation on the same basis as the Voluntary Health Insurance Scheme. It could be run as such and it could give a full service to the public. It could be run by a board whose responsibility would be solely to see that they do not get into debt and that it is fairly and properly administered.

I do not think it would need a huge regional board or a lot of sub-committees such as are envisaged in this Bill, which would mean more bureaucratic control and more expense. It would be a private corporation run by an insurance company or by someone competent to run it. It would be on a non-profit-making basis and everyone would get the treatment he required. All would get what they were entitled to and it would not be a question of having to go to some official. I can see the chief executive officer of the regional body being a very busy man in the future if this bureaucratic dream introduced by the Minister comes into force.

People would go to the board and get what they were entitled to. You do not hear of people in the Voluntary Health Insurance Scheme having battles royal with them to get money out of them. It is a private non-profit-making concern. It is a private enterprise. The sooner this country gets back to thinking on private enterprise lines the better. Nothing has yet been found that is better than private enterprise. Admittedly in the modern world the State which is collecting so much money out of local and central taxation must provide subventions and help. Why should the State control? Why should the State control medicine? That is the whole failure of the 1953 Act and really today we are discussing only a furtherance of it.

There is very little in this Bill. It is very disappointing. I realise the Minister brought it in because he had to, because he is facing an election in the last dying days of the 18th Dáil. If this is all Fianna Fáil have to offer to the Irish nation in the way of medical facilities in the dying days of the 18th Dáil God help them and I hope they will not control the 19th Dáil.

I welcome this new Bill, this approach to giving our people a better system, a wider system, a system designed to give them improved benefits within the existing financial structure, and the amount of money which the State can afford to contribute to the health services. I do not think the Minister or the Government are attempting to suggest that this is the most perfect system but it is designed to give the best system within our resources. That people should have a choice of doctor is an all-important point here. I find throughout my constituency and as a member of a local authority for many years that people, particularly where doctors are concerned, like to have a choice. They like to be able to wander around and to get a second opinion in many cases. This is of vital importance to them. It is a fact that the people who suffer the most illness are the poorest of our people, probably because of a lack of the essentials of life, and because the family background creates conditions that are not prevalent in families who are better placed.

We want to provide a better service out of the money available. It is an obvious fact that large sums of money are channelled into the health services and we cannot say that our people have been getting the best out of it. There is room for a close examination of the whole system. There is a belief prevalent that there is extensive waste in the system, which is very costly. If the rumours we hear are true that drugs and tablets of various types become out of date quite quickly, and that many of the drugs supplied are not used, there is a case for tightening up the system and checking up on supply and distribution. We hear—and I do not know whether it is true or not—that in many cases travellers for druggists and manufacturing firms call on doctors and it is not a question of what the doctor orders but of the traveller examining the stocks and writing up the order form. This again must and does lead to waste. The new system should help to solve this problem. I agree with the previous speaker that the best system of distribution of drugs and tablets is through the chemists. They are people who have been in the business for years. If the doctor can prescribe for a patient a week's or a fortnight's supply of drugs there will be a tendency to save drugs. At the moment—again if the information we hear is correct—when a patient comes into a doctor he gets a supply of drugs for two or three months, but if the patient finds out after a fortnight's use that the drugs are unsuitable he goes again to the doctor and gets a new supply. There is no question of his returning the old supply. I have noticed in the accounts presented by the Kerry County Council that there is a very large increase in the cost of drugs over the whole county although it would appear that the patient attendance remains static. When we tried to get answers to this we were told that more expensive drugs are being used now. This may be correct but there is room for examination of the system, because by and large our people do not appear to be getting the overall improvement in the service one would expect from the very heavy costs.

I am not saying that we have not a satisfactory service in Kerry. By and large I have no complaints from patients. Apart from ancillary services, the health service seems to be working very well and our people are getting top-class attention both from the dispensary doctors and in the hospitals. However, the high cost facing us in Kerry is a headache. The demand for an extra 8s 5d in the £ in the rates this year is a very substantial increase, especially as we do not appear to have any increase in the number of patients. I have tried to suggest to Kerry County Council that it would pay us to get help to investigate on a permanent basis the heavy costs involved in order to see where we can save money.

The regionalisation of hospitals must be a help because many patients have to be transferred from Kerry to Dublin hospitals. It will be of great benefit to have a hospital service closer than Dublin and where friends can visit patients. We are, I understand, to get a new county hospital in Tralee which is, indeed, urgently necessary. Existing county hospitals are not suited to modern needs. There is a very able surgeon and staff there and I should like to see this new hospital materialising at an early date. If we had this it would mean a very large saving for the county.

Deputies on the other side of the House have spoken about the system they will employ if they are elected as the Government. I cannot see how such a scheme would suit our people in Kerry. I do not know how a person who is hard put to find the necessaries of life such as food for his children, could contribute to a health scheme. Eighty-four per cent of our people earn under £10 and 46 per cent earn under £5 a week. These are people who can never be brought under a contributory scheme and for that reason alone the Fine Gael scheme would never be acceptable to the people of Kerry. It may be a suggestion to save the ratepayers of the county, but it is the duty of every Government to look after people who are suffering from ill-health. All too many of our people need assistance in a big way today. In the past people in the western areas were maintained, by and large, by the sons and daughters working in America, Britain and other places. All too often the letters are now coming without remittances and in many cases no letters at all are received.

I am particularly concerned about disabled persons and other people in ill-health. Some system must be devised to give these people something worthwhile by way of social security. At the moment they get disability benefit only. For a single person that benefit amounts to £2 per week. It is never more than £3. It is very far from meeting the needs of those who are up against it, and the sick are always up against it. Some scheme must be brought into operation to give these people worthwhile help. Every day is a difficult day for them. The Government and its successors will have to accept the responsibility of ensuring that these people get something out of the pool of wealth produced.

I am particularly interested in the provision of suitable homes for the aged. We are making efforts in Kerry to provide such homes. One will be erected in Killorglin shortly. In Kerry there are a great many old people living alone because their sons and daughters have emigrated. Homes are needed for these. Anything that makes life easier for these people is important. Because of increasing industrialisation there is plenty of money floating around and it is only right that some of this money should be skimmed off to help those in difficult circumstances through no fault of their own.

I am glad steps are being taken in regard to the early diagnosis of cancer. This is the dreaded disease today. Any system of early detection will be more than welcome. Early detection might help to prolong life by checking the disease. At the moment people are inclined to regard a diagnosis of cancer as a death warrant. Any money spent on curbing this disease will be money well spent.

I should like to direct the Minister's attention to the fact that we are still waiting for an improvement in Valentia Cottage Hospital. This hospital is run by a local committee and it attends in particular to old people. They are taken in periodically for treatment. The hospital is doing very useful work and it is of great benefit to the people on the island. I trust the improvement needed will be carried out soon.

In Kerry we have no complaints with the health system except from the point of view of dental services and ophthalmic services. People are waiting two and three years for false teeth. They are waiting six to nine months for extractions. The system has fallen down. There is difficulty too in getting glasses. Whatever is at fault should be corrected as quickly as possible. I can give the Minister individual cases. When I have made inquiries I have been told that there are no dentists or doctors cannot be found to administer gas.

This Bill is an honest attempt to devise the best possible system and to correct deficiencies in the existing system. Giving a choice of doctor will be a great help. We have been compelled in Kerry to give a choice of doctor on occasions and the health authority has accepted responsibility where a patient was sent outside the dispensary area. A choice of doctor is a step in the right direction. I think both patients and doctors will welcome it.

Some years ago a hotelier in my county was going to build a new hotel. The first thing he did was to build an annexe for the staff because, he told me, unless he had a satisfactory staff and a staff who were satisfied with their conditions, no hotel could be a success. We are now going to re-organise our health services. The first thing we should do is to try to come to some agreement with the people who will operate the system, namely, the medical association. But the Minister has told us in his opening speech that he is still in negotiation with the IMA on the most important matter, namely, professional fees. Unless we have a satisfied medical profession we cannot possibly hope to operate this Bill when it is enacted.

One of the first objections to the old Act was its cost. When it was introduced by the then Minister for Health, who is now Senator Dr. James Ryan, most of us were worried about its cost to this country. That question was posed to the then Minister by many Opposition Deputies and his reply was to the effect that it would cost not more than 2/- in the £. Now, we were prepared to experiment with the Act on the basis that it would cost not more than 2/- in the £. That 2/- has escalated to 35/- in some counties and almost as high as 40/- in other counties. Protests have been made and the Minister has received deputations from many counties protesting against the burden of the Health Act on the local ratepayers. In fairness to the Minister and to his predecessors, I must say that they received these deputations and were generally concerned about the matter. What has this Bill done to alleviate that serious burden?

We are told today that the burden of administering this Health Bill, when enacted, will be borne by the State and the ratepayers but no idea has been given to us as to the proportion or the percentage which will be borne by each. Possibly the Minister is afraid of falling into the same error as his predecessor, Senator Dr. James Ryan, by telling us the percentage he proposes to seek from the ratepayer. We are asked to accept this bag without it being disclosed what is in it. That is one of the things about this Bill which are worrying not only the Opposition but also the ratepayers of this country.

When the late, lamented Deputy Donogh O'Malley, then Minister for Health, introduced his White Paper, we were told that we would have a completely revolutionary Health Bill with a choice of doctor and a practical free medical health service for all. He told us he thought there was some merit in the insurance system proposed by Deputy Thomas F. O'Higgins and that he would examine it carefully.

I am afraid that the principal item in this Bill is jobs for the boys. Under Part II we are to establish a chief executive officer and to set up new boards with new local authority servants. I thought we had reached the limit of officials in this country but here, under Part II, we are to have a new board with the usual filling-in of civil servants or local authority servants. It will have not only a CEO but other officers and servants who will be financed by the State and by local authority contributions.

Certain people not now in receipt of free medical services will become entitled to limited eligibility: what that means, I do not know. Under the Health Act, as at present operated by local authorities, it is possible to get a medical card giving free medical service but it is possible also to get a medical card which will entitle the holder to limited medical service. I know, for instance, that in my county a number of people who would not be entitled to a medical card for free medical service would be entitled to a medical card for free drugs and medicines which would otherwise be beyond their means. Is that what "limited eligibility" will be? If it is, then there is no necessity for this particular section in Part IV of the Act.

In another part of the Act, the Minister promises us what the late Deputy Donogh O'Malley spoke about—a free choice of doctor. However, he does not tell us how it will be provided. Under the Bill as it now stands—I refer particularly to Chapter III—it is necessary for a health board to provide without charge general medical practitioner and surgical services for persons with full eligibility. Further on, it says that a choice of medical practitioner shall be offered. This is something I cannot understand. If the new health board will provide a dispensary doctor somewhat similar to what we have at present and if another dispensary doctor wishes to set up practice in the locality, will they both be paid a salary by the health authority or by the health board? Who will be paid the salary? If one of them will be paid a salary then surely it cannot be expected that the other medical practitioner will give the same service. It is something I really do not understand.

It is the duty of the board to set up a medical practitioner and to make him available to the public. I presume it is the duty of the board to pay him a retainer and that retainer will be something on the lines of the salary now being paid to the dispensary doctor. But what will happen to the second medical practitioner if a patient wishes to consult him? I know of no provision in the Bill as it now stands for such an eventuality. Therefore, I say that the free choice of medical practitioner is nothing but pure cod.

There are many things in this Bill which are good but which are nothing like what we were promised. I thought that when the late, lamented Deputy Donogh O'Malley undertook, when he was Minister for Health, to study the scheme suggested by Deputy Thomas F. O'Higgins, we might have a health service such as was envisaged by Fine Gael—free medical attention for the lower income group and the middle income group based on an insurance scheme, with small farmers and indeed farmers generally, being permitted to join in such a scheme, the cost of which would be paid for in equal shares by the employer, the employee and the State. In the case of farmers the contribution would be based on the farmer's poor law valuation and the State would pay the balance of the contribution. In the case of the higher income group they would have an opportunity to secure the services which are now offered to them under the Voluntary Health Insurance Scheme. In that way a free service could be provided for all, the local authority being recouped in the manner I have mentioned. However, that is not being done. What is going to happen to the middle income group? They are ratepayers and they contribute towards the free health service which we provide for the poor but they will get no benefits whatsoever under this Bill when it becomes an Act.

I note that regional hospital services are being provided. I wonder are regional hospitals the success the Minister and his advisers think they are. It is suggested that a regional hospital be erected in Sligo to serve several counties, particularly Donegal which has very little contact, if any, with Sligo. We have across the Border, outside Derry, one of the most modern hospitals in the British Isles. I wonder if the Minister and his counterpart in the North—unless the rantings of the Minister for Agriculture and Fisheries recently have frightened him off completely—who are both practical men, could not come to an arrangement whereby the services which are available in this hospital could be made available to some of our citizens, as they are at the moment on a private basis. This would save the health authority considerable expense and also save the State the expense of erecting a regional hospital such as that at Sligo. We would also be in a position to provide surgical services for the counties. We have at Letterkenny a very good surgical hospital and something similar could be provided in the south of the county. These are matters which the Minister should consider before embarking on a scheme involving the spending of millions of pounds erecting surgical regional hospitals.

The previous speaker referred to the scarcity of doctors and there is no doubt that we have a scarcity of medical practitioners. I cannot see any carrot being dangled before their eyes in this Bill to encourage them to come back and take up practice here. At the moment the British Army are subsidising medical students in our universities for a consideration, the consideration being that they should join the British Army Medical Service for a number of years after qualifying. A number of them are taking advantage of that scheme and they are being lost to us. In their third year if they sign an undertaking to serve for three or five years in the British Army Medical Service their fees will be paid for them by the British authorities while they are completing their course. A number of the students have taken advantage of that scheme. We pay for their education up to their third year medical and then they are completely lost to us. As Deputy Esmonde pointed out, he was told in reply to a question the other day that we have about 40 vacancies for assistant medical officers and we are unable to fill them. We have a number of vacancies for dentists and we are unable to fill them. Most of our schemes are falling down through lack of personnel. That is a serious matter and one which should receive considerable attention from the Minister. That is one of the reasons why I say he should have entered into some agreement with the Medical Association before introducing this Bill and changing the present medical scheme.

I am delighted to know that a nursing service may be provided by the health authority. That is something on which we have fallen down considerably. Many of our hospitals and institutions are occupied by patients who normally would be out-patients and attended in their own homes if we had an adequate nursing service but we are unable to procure the personnel. Local authorities would like to employ nurses and it is costing the local authority much more because these people who would be attended at home are being removed to institutions and hospitals. I should like to see the nursing service being improved and a better agreement for remuneration entered into between the health authority and the nursing profession. In that way we might encourage them to remain on and to give to this country what is a very essential service.

I wonder if the medical card system is the success we would all like it to be? In my constituency there are some dispensary districts in which 80 per cent of the residents are holders of medical cards. I remember in the old days a dispensary doctor telling me that in seven years all he saw was one red ticket, which was the counterpart of the medical card at that time. That did not prevent him attending those who could not pay for his services. He knew the people and knew their capacity to remunerate him for the services he gave and medical cards or red tickets were not necessary. The medical card system is being abused and the holders are not getting the services to which they are entitled because the dispensary doctors are not being taken into consultation with the local authority in investigating the means of applicants for cards. People who are not entitled to, hold cards and no person knows that better than the dispensary doctors.

In many cases the doctor is not giving the service he should give to some people, or may only give it in an emergency because he is unaware that they hold cards. I have asked several people who are holders of medical cards if they pay the dispensary doctor and the reply I got was that the doctor did not know they had a medical card and that the only reason they had the card was in case they had to go to hospital. This is quite common. The doctor is receiving remuneration from patients who are really holders of medical cards although he is unaware of this and he has not been told this by the local authority. The card holders do not wish to receive the free medical services to which they are entitled from the doctor because they think that possibly they would not get the same service free as if they gave the small remuneration they have been accustomed to give in the past. They merely hold the card to relieve them of fees due if they go to hospital. This Bill is essentially a Committee Stage Bill and will be dealt with in detail on Committee and for that reason I do not propose to say anything more.

The approach to the question of the medicine of this country is adequately dealt with in the Minister's statement, where he says that the policy of the present Government has always been to design the services, and the provisions and eligibility for them, on the basis that a person should not be denied medical care because of lack of means. It should be stated once more here that it is true that no person who cannot afford to pay for medical services is deprived of them. The Minister has said that up to 30 per cent of the people are entitled to those services and get them. I feel this is a conservative number: I think it goes much higher and that the statistics are wrong in some way. However, the legislation that has been operating for a number of years and which is now being extended is—and it cannot be denied— fulfilling the primary object of medical legislation under such circumstances, that is, ensuring that nobody entitled to medical services and nobody who cannot pay for them is denied such services.

There are other groups which are now named as the middle income group and the higher income group. Their names are about to be changed by this Bill. Granted that those groups have their own difficulties but they are all able to pay for some medical services. The two points that seem to be outstanding in the debate here are how those groups should be covered and how they should be classified. The Labour Party propose to cover everybody with a free health scheme such as operates in Britain. I cannot understand any Party introducing here or in any other country a scheme such as that operating in Britain. It is soul-destroying and anybody who meets doctors coming back from Britain hears complaints about the burden of overwork, the unsatisfactory working, that it is not medicine at all but, in fact, clerical assistance in most cases. On the other hand, patients complain about crowded surgeries packed out by people who should not really be there, crowded waiting lists and so on. The situation over there at present seems to be that there is a drift into private medicine again. About 18 months ago I remember reading statistics dealing with the organisations corresponding to our Voluntary Health Insurance and they reported then to the effect that the number of people seeking their services was increasing.

The Fine Gael Party are opting for insurance. It was said by Deputy Sir Anthony Esmonde that this would operate by the State carrying the lower income group and paying their premiums. The middle income group would make a contribution and the higher income group would pay the full premium. This brings me back to something I raised before in the House. Fine Gael, and particularly Deputy Ryan when he was speaking, made great play with the means test. Nobody has yet satisfied me as to how you could operate the Fine Gael system of medicine without a means test. How could you decide the group for which the State would pay? Or the amount of money each person in the middle income group would pay? There must be some outsider who decides this. The name of the officer may change; the system by which he investigates may change; it may not be called the means test but an eligibility test or something else but, in fact, this scheme cannot be operated as stated in the House today without a means test. If there is some other way of doing it I should be interested to hear it. Valuation may work in some cases but a man may also have a job, or money in the bank or other resources so that that is not the answer to the problem.

Dealing with the Bill itself much has been said but there is one point I want to make that has not been made so far. It refers to the eligibility of the higher income group. It is stated in section 44 that anybody who has a rateable valuation of not more than £60 will be eligible but, unfortunately, this £60 will include farm buildings. I think this is wrong. Granted, they may be the more prosperous section of the farming community but on principle the inclusion of the valuation of farm buildings in the £60 is wrong because it is not done in the case of the people in the £1,200, the middle income group. In other words, the person who has an income of £1,199 does not have the valuation of his property added on thus excluding him and putting him into the higher income group. The money that is put into housing on farms could hardly be considered productive: it might be more productive if it were put into stock on the land. The section has a tendency to keep this type of farmer from putting money into housing and I urge the Minister to introduce an amendment on the Committee Stage excluding those words.

Screening tests have been mentioned. Deputy Tully mentioned one screening test that, so to speak, failed his family or proved unsatisfactory. This must be accepted in medicine. Everything does not run black or white. There is a border between those tests. There is always the shaded areas in between and this, in fact, in most cases is where the specialist is needed to interpret what I refer to as the shaded area in a test, whether it is X-ray, biochemical, chemical or otherwise.

In different spheres of medicine the Government are being urged at present to introduce screening tests but it is well to put on the records of the House the fact that some of those screening tests are under doubt. First, they are expensive and whether the return is justified is one matter that is questioned —and this is purely economic—but as far as I can gather from what I read about it, the tests themselves are also questionable. When two pamphlets were issued about this some months ago I did not find myself in a position to read them but I have no doubt that the contents have been made available to the Minister and his advisers. I mention this because these are expensive tests and it is very easy for certain sections of the community to organise themselves and others and make demands on local authorities or on the Government to have those tests. The relatives come home from England or America or some other place and people are told these tests are being done and a big organisation is mounted to do those tests here and then we are informed that they are not worth doing and that, in fact, medically they do not stand up. I would suggest to the Minister that this is one thing that the Department should get down to and reach a definite decision so that we, the doctors, will be better able to make adequate use of the tests.

Some doctors are very anxious to do those tests but there are others who have not got the time. There is a case to be made here for this investigation and the Department should be in a position to recommend to the doctors of the country that those are tests that we should do or should not do. As I see it, a large amount of money may be spent in doing what may be useless tests. This point was mentioned last week in the Medical News in which there was an article by some Australian specialist. This is about the fourth time that I have read something on this question in different pamphlets, the titles of which escape me. In any case, I did not read the originals but only the reviews of them.

With regard to the Mental Health Act, a person going into a mental hospital must have a form signed by a relative which, in effect, means that the patient is not able to make a decision himself as to whether he should go into a mental hospital, but at the bottom of the form it is also stated that there is an obligation on the person making the application to tell the patient that he may get another doctor if he wishes. There is something contradictory in this. If a person is not in a position to make a decision for himself, there is not much point in placing a legal obligation on the applicant to inform him that he is entitled to have another doctor. To get another doctor might prove very difficult in certain circumstances, such as in the middle of the night. I would ask the Minister to give some thought to this and if he agrees with my view that this should be amended, perhaps he would see to it that something will be done to make this a practical operation.

Much has been made of the question of patients going to hospitals and being treated as out-patients. This is a very good idea. It is to be recommended and accepted but here again there may be more work for clerical assistants. Perhaps if machinery like, for instance, tape recorders were made available the work would be expedited. I hope the Department will keep this in mind in expanding the services.

Deputy Barrett made reference to accident cases and to the fact that local authorities could not recover their expenses arising as a result of accidents to people in the lower income group. This has been changed in the Road Traffic Act but from the doctor's point of view, there are still some difficulties. Most doctors will agree that in cases of accidents and especially motor car accidents, a patient is inclined to visit a doctor more frequently. The Minister, as a solicitor, will appreciate that in order to do one's work conscientiously, it is necessary to make lots of notes which have to be kept carefully and for the doctor treating accident cases in the lower income group, there is certainly much more work and extra writing. Therefore, I should like the Minister to consider compensating doctors in some way for this.

I should like, as a doctor, to pay tribute to the Minister in that it is obvious that he is prepared to make this scheme as workable as possible within the means available for the patients and for the doctors of the country. I know the Minister has his difficulties with regard to the doctors but as I have a vested interest I shall not go into those difficulties. There is no harm in saying that doctors are becoming just as time conscious, if not more so, than they are money conscious and they do not wish to have to keep working seven days a week every week of the year. The Minister recognises this and has put on record his intention of doing something about it.

Notwithstanding all the strikes that we have had it is well to put on record that the stated policy of the medical profession is that they will take no action that will deprive the community of medical services.

Hear, hear.

This is still the policy of the doctors despite all the turmoil of the past and I sincerely hope that nothing will be done in the future to force the doctors to change this policy.

(South Tipperary): I doubt, a Leas-Cheann Comhairle, if very much will accrue from this Bill. I consider it to be a Bill that is being forced on the Government by the Opposition Party on this side of the House and by the Labour Party. The Bill comes before us at a time when a general election is imminent. From the very nature of things, I find it difficult to see how any Minister can put it into operation in the immediate future. It covers two points and is largely based on these aspects.

The two main features of the Bill are that it is proposed to disestablish existing local health authorities and to establish regional health boards. There are several other smaller items but those are really the main features of it. The Bill differs in its conception from what we on this side have been proposing. Fine Gael's approach has been that it should cover a large percentage of the population, that there should be a more comprehensive service and that it should be financed on the basis of insurance. This Bill, as I said, covers 30 per cent of the population and is framed to continue the financing in the same fashion as hereofore.

Debate adjourned.