We missed a great opportunity in introducing this Health Bill. This Bill should have been a charter for the general practitioners of Ireland but, instead of that, we are about to make the catastrophic mistake of modelling our whole health system on the welfare state of Great Britain and on Medicare and the allied health services of the United States of America.
I recognise the Minister's difficulty. Owing to the familiarity of our people with the kind of medical services that obtain in Great Britain and the USA, there may have been a very high degree of expectation that our public health service should follow on the lines of those countries. That is where I think we have gone wrong. We could have shown the world and I say "the world" quite deliberately, an example of how to run a satisfactory and effective health service. I believe that, had we had the courage to do so, countries like Great Britain and the USA — who, in my opinion, are getting themselves into an inestimable sea of sorrow on the road they are travelling — might well have drawn back and said "Let us do what Ireland is doing and see if perhaps they have not found the right answer to the problem which threatens to overwhelm us".
The USA, which is one of the wealthiest countries in the world, have extended their Medicare service, as they call it, to include those whom they euphemistically describe as senior citizens — persons of 65 years and older. They are further burdening a Treasury which is already overburdened and practically crippled. Now they are talking of cutting down on their foreign commitments in order to meet the overwhelming burden of providing a comprehensive health service for that section of their community of 65 years and over before they make any effective impact on the health problem of the rest of the population.
The original estimate for the health service in Great Britain has already been exceeded by 300 per cent and is steadily rising to a point at which the British Exchequer itself is almost at the limit of its resources. We might not mind that if those who are familiar with the services provided had it to tell that everything ordinary people could reasonably seek has at last been made available, but the very reverse is true. The British health services are in a state of chaotic confusion. There is a pretence that the services are universally available. They are not universally available, and neither is it true that what is available is in any sense adequate or effective. There is a story non e vero ben trovata told of the British medical services which describes the case of a lady who applied for admission to a gynaecological hospital for an urgent gynaecological operation and being told that she must wait as the hospitals were overtaxed. Three years later she got a telegram to say that a bed was now available, by which time, in the ordinary course of nature, the lady had recovered and she thanked God that a bed had not been available when she applied because, if it had been, it was likely that half of her inside would have been taken out. But then, of course, there are others, the others who were correctly diagnosed as needing hospital care in order to deliver them from chronic ill-health but who are not able to get it or who, when they did get it, found the hospital to which they were admitted grossly understaffed. It is common knowledge that, but for the fact they had a considerable immigrant medical population in Britain, a high percentage of the general hospitals in Britain would have to close down.
This all arises, in my suggestion, from the wholly illusory approach that the State should accept responsibility for everyone who is smitten with anything from a cold in his head to terminal cancer. There is a horrible by-product of that approach to the public health problem. It is that nobody now who does not describe himself as a specialist is regarded in the true sense as a doctor at all. I would have hoped that we in Ireland would have detected the profound error of that whole approach and that we would have said to our people: "Your doctor is the family doctor. Bring your troubles to him. We guarantee to you that, through the resources of the State, we will deploy behind the family doctor all the hospital requirements that he, in his experience, may consider it necessary to mobilise for the protection of your health." I would have hoped that we would have said to the average member of the public: "Forget the hospital. Your man and the protector of your health is your family doctor. And when we say `your family doctor' we mean your family doctor, not the doctor we choose to impose upon you."
I know it is part of the Minister's intention to provide, in so far as it is practicably possible, that there shall be a choice of doctor freely available under this Bill; but there is then going to be the endless struggle and battle between the Minister and the individual practitioners as to what the appropriate charges are to be. What I do not understand is why he could not have approached this problem on a wholly different basis, and, taking example from the eminently successful principle of the Voluntary Health Insurance, why he should not have set up an insurance fund into which every individual citizen would pay an annual premium. Where an individual is not financially circumstanced to pay that premium, then let the State pay the premium for him. Then declare that any individual citizen consulting his own physician was insured against costs up to a certain limit as prescribed under the new Health Insurance system and that anything over and above that he choose to incur would be his own liability, leaving it to the general practitioner to deal directly with the patient. You might get general practitioners who wanted to charge a fancy fee. Very well then, let those who are prepared to pay a fancy fee go and consult them and pay out of their own pockets the difference between the fancy fee and the standard fee. If that is what they want to spend their money on, let them go and spend their money on it. That would limit the charge falling upon the Exchequer and avoid the detestable task which confronts the Minister of trying to cost every visit and cost every service the general practitioner provides for his patient. That would leave to the individual patient the widest possible discretion to incur whatever medical costs he or she chose to incur at the general practitioner level, and would put an end to the wholly obnoxious belief—I regret to see it growing not only here but in every other country in the world—that the general practitioner is a kind of inferior doctor.
I have been a long time in this world and I want to say with great deliberation that the general practitioner in a properly organised health service is the most important element in it. We are all familiar with the progress of science, which has been summarised as people knowing more and more about less and less. You can get a degree of specialisation building up in the science of medicine to the point at which if you go to one practitioner of high distinction in one particular branch of medicine, whether you have a pain in your toe or a lump on your head, he will determine that it is due to cardiac malfunction, if that is his particular line of country. Then you can go around the corner to another specialist of the highest distinction who will tell you "Kidney malfunction is at the root of your trouble, my dear friend. Place yourself in my hands and the lump will disappear." Both men speak in perfectly good faith. Both are men of the highest distinction in their own particular sphere. But both of them have become so immersed in one particular sphere of therapeutics that their whole instinct is to relate the syndrome presented to them to the speciality in which they are primarily involved. However, the patient presenting himself to a general practitioner presents himself to a man who, by his very training, is not only a doctor but a psychologist who if dealing with a sore foot first looks at the foot to see has the man got an ingrown toenail and then proceeds from that, step by step, through the various syndromes with which his training has made him familiar until he reaches the end of his capacity. At this stage he says, and has the courage to say: "I do not know what is wrong with you and because I do not know what is wrong with you I am referring you to so-and-so so that he may find out." I remember once a distinguished specialist in this city saying to me about colleagues who did not belong to his hospital: "Ah, those fellows, if they were walking through Stephen's Green and heard sparrows singing in the bush, they would not admit they were sparrows until they had eliminated the possibility of their being canaries".
What I think is so tragic is that we have not grasped this opportunity of restoring in Ireland a full realisation of the importance and of the significance of the general practitioner, a realisation of the standing he should have in the community he serves and of the reliance that ordinary people should put in him, and have not, given an assurance that the State would mobilise behind him and place constantly at his disposal in the fullest abundance the scientific equipment and laboratory facilities that the best hospitals can provide when his diagnostic capacity has been exhausted by the problem presented to him.
Had we done that, and had this Bill been designed on the basis of insurance in so far as the charges between the family physician and the family were concerned, I would have said to the Minister: "You have got to face the facts in the modern world in which we live, and in the hospitals reorganisation programme on which you are embarking, and on which I think you are right, you have got to say to the Government that the only way to meet this is to make it a charge on the Exchequer." The people have got to make up their minds, do they want first-class hospitals, economically administered, to support the general practitioner down the country, or do they not. If they want them, they have got to pay for them. If they are not prepared to pay for them, they have got to do without them.
I believe the people would have said: "We do want them. We are prepared to pay for them, and we recognise that this is a charge which ought to be carried on the Exchequer to be met by the taxpayer of the country as a whole," because they are not for the service of the rich, and they are not for the service of the poor; they are for the service of everyone. It does not matter whether you pay your family physician a consultant's fee of three guineas, or a consultant's fee of 10s. Once he has reached the end of his diagnostic capacity, with the equipment available to him in his consulting rooms, the same hospital facilities are available to the 10s doctor as are available to the three guinea doctor, and it is for the head of each family to determine for himself then. Why have we not tried to do that?
I do not want to go into a detailed examination of this Bill on Second Stage. I do not profess to be a specialist in public health problems. I have not had the experience of Deputy Ryan and other Deputies who have served on public health authorities, although I was a member of the Roscommon County Board of Health 35 years ago, but the world has changed so much since then. We do not build hospitals any more in fields adjoining graveyards, because the man who owned the field beside the graveyard wanted to sell his field for twice the price he would get from anyone else.
I have some experience of our local county hospital and the surgeon who operates it. I will not go into his political affiliations, although I have a pretty shrewd suspicion of what they are. Leaving that out of the question, he is a great and dedicated servant of the people. He is one of those doctors who would work 18 hours a day if he thought there were people who wanted his care. He is a great general surgeon. Of course he is something more. He is a great psychologist and he loves his patients.
I am prepared to concede, looking at the overall problem in the country, that the Minister is probably right in his desire to have general hospitals and regional hospitals. He is probably right in his belief that, with the progress of medical science, and laboratory techniques, and the requirements of modern equipment, it is no longer possible to maintain a multitude of small hospitals, but we should not forget in this House that 70 per cent — and I think that is a conservative figure — of all the cases going into a county hospital are eminently within the range of the competence of a general surgeon. I am sure 90 per cent of my neighbours would sooner be treated by the county surgeon near their homes and families, than by a high-powered panel of specialists in regional hospitals 60, 70 or 80 miles from home.
We have to recognise that, in effecting what we believe to be a desirable reform of regional and large general hospitals, we are taking from rural people an amenity which is very precious to them, and that is the ability to have their operation or their illness within reach of their neighbours and friends. We have to ask ourselves with great anxiety, are we completely sure about the price we are going to pay for withdrawing the hospital facilities, inadequate as they may be in some cases, from the immediate locality and will we get an adequate return in a superior service in the regional and general hospitals which it is our pur pose to create in the years that lie ahead.
We have to ask ourselves — and this is something on which I have not heard the Minister give statistics to the House — what percentage of surgical problems are presented to the county hospitals which are well within the competence of what we habitually regard as a county surgeon?
