Dáil Éireann díospóireacht -
Wednesday, 3 Dec 1969

Vol. 243 No. 2

Private Business. - Health Bill, 1969: Committee Stage (Resumed).

Question again proposed: "That section 57, as amended, stand part of the Bill."

Mr. Ryan

Section 57 of the Health Bill which is the one which provides for the supply of drugs and medicines and medical and surgical appliances is, like many other sections of this Bill, grossly inadequate. It does very little to meet much less cure the principal shortcomings of our existing provisions for drugs, medicines and medical and surgical equipment. So long as we continue the present system of requiring over 70 per cent of our people to pay the full cost of drugs and medicines or medical and surgical equipment, so long will we continue something which is economically crazy and medically untenable.

True, if a person is obliged to undergo a long and expensive treatment and is aware, as he seldom is aware, of a right to plead hardship and to prove hardship, he may now under the Bill receive some assistance, but the nature and extent of that assistance is entirely within the discretion of the local authority. In many cases it is not given; in some cases it is. There is no certainty that two cases will be similarly treated. We in Fine Gael would prefer to see a national health insurance system which would ensure that everybody, without regard to means, would receive drugs and medicines at half cost. The people who at present enjoy drugs and medicines at no cost at all of course would continue to enjoy their drugs and medicines without charge, but the remainder of the community could receive them at half cost. This is medically necessary because if we do not do this we will perpetuate a practice which, at enormous public expense, is crowding our hospitals with people who need not be there.

The reason we are the most hospitalised country in the world is twofold. On the one hand, we have dispensary doctors, particularly in urban areas, unable to handle the huge number of cases which they are called upon to attend. They are obliged to refer people to hospital so that they may be attended to there and so that they may receive drugs and medicines without any difficulty and without any charge. On the other hand, the present high rate of hospitalisation is due to the fact that people are required to pay the enormous cost of modern drugs and medicines for themselves and their families; they keep postponing consultation with their doctors and their illness becomes more acute and as a result they require hospitalisation which could have been avoided if they had had adequate and timely consultation.

Because of the high cost of modern drugs and medicines people not infrequently fail to purchase the prescription prescribed for them by the doctor. Sometimes they will purchase only part of the prescribed medicines and drugs with two very serious consequences. The first consequence flows from the fact that most prescriptions need to be completely consumed if they are to be of benefit. If they are only partially consumed the second state of the patient may be worse than the first. The second consequence is the inflow into hospitals of people who need not be there. It is essential that no difficulty should be put in the way of giving considerable assistance to people who have to undergo long courses of treatment with drugs and medicines. It is seldom, if ever, that the cost of drugs and medicines outside hospitals exceeds the cost of maintaining the person in hospital. If the person is put into hospital the drugs and medicines will also have to be acquired. It is much sounder economy and it is more humane medicine to provide massive assistance towards the cost of drugs and medicines.

I am not unaware that the greatest rate of growth in medical expenses in the last ten years has been under the heading of drugs and medicines. This is attributable to two causes: first more people are availing of their rights to receive assistance in meeting the cost; and, secondly, the prices of drugs and medicines are multiplying beyond all previous experience. Whether that is directly and fairly attributable to the cost of research or to other factors is difficult to determine, but it is fair to query why it is that we in this State are called upon to pay prices for drugs and medicines far in excess of the cost of equivalent drugs and medicines in the Six Counties, Britain and elsewhere. It cannot be due to the fact that the research work is peculiar to Ireland because most of the research work done by the large medicine and drug manufacturers is conducted abroad and the cost of that research is spread across the world, and it should not be proportionately any greater in Ireland than anywhere else. We are aware that our drugs and medicines are subject to an unfair purchase tax which does not apply to drugs and medicines prescribed for animals, but human beings have to pay this unjustified purchase tax. We are called upon to pay between 25 per cent and 100 per cent more for our drugs and medicines than obtains elsewhere.

I presume under any scheme the Minister might propose that a national list of prices for drugs and medicines will be drawn up. I think it is important that the Department of Health should take much greater care about the cost of drugs and medicines. It appears there is a great deal wrong here. It is because of the excessive prices and the lack of State assistance for the great majority of our people that we have the ridiculous position of having a health pyramid turned upside-down. Ninety-five per cent of our Health Bill relates to hospitalisation because we have a crazy system which pushes people into hospital in order to relieve the case burden of the doctor and in order that the people may get the drugs and medicines they would be unable to get free if they were not in an institution As medicine can do more and more for us it becomes more expensive, but it is cheaper in the long run to pay for this kind of care outside the hospitals and institutions.

Section 57 is not going to achieve the necessary reduction in demand for hospital accommodation. The section repeats once again the Fianna Fáil fable that hardship is not caused to people in the middle income group or in the upper income group in regard to medical expenses. I think it is true to say that there are very few cases in which the cost of providing drugs and medicines does not cause hardship and does not cause a lowering of family standards even for a short time. A prescription may cost 30/- or 40/- and taking that amount of money, even out of a middle income pay packet, in a week causes some lowering of standards, and if this is repeated for a month it means a serious loss. It has to reach almost crisis proportions before any relief is given under the heading of income tax if a person is paying income tax. There are many families who are not regarded as being entitled to a medical card and who are not regarded as suffering from continuous hardship which would justify assistance in meeting medical costs, and they suffer real hardship. Very often necessary family expenditure has to be postponed in order to pay for urgently needed drugs or medicines; or a competition arises between necessary expenses and, I am sorry to say, all too often the expenditure which suffers is the health expenditure. This is something which should not arise in any Christian community. Necessary health expense should be the first priority; it should not conflict with any other reasonable family expenditure.

There is also a danger where inadequate subsistence is provided for expensive drugs and medicines that people will resort to home cures which may accentuate the difficulty and will certainly not relieve the disability but which will result in ultimate very heavy expense. This is something we should all be trying to avoid.

The section also requires that people who are not entitled to full eligibility must prove hardship before they receive assistance. We consider this to be degrading and we also believe that it increases illness. This is the kind of thing which prevents a person—as the Voluntary Health Insurance Board says —being ill with ease because you cannot be ill with ease if you are concerned about the tremendous cost. Requiring people already ill, or their families, to process their family circumstances through the local authority and the local health board is something people should not be called upon to do.

The section is, of course, welcome to one extent in that we hope it will do away with the appalling conditions that people have had to endure in urban dispensaries where they are obliged to attend at an early hour in the morning to get their medicines within stated hours. The result is that mothers with young families have to bring their children along to the dispensaries, wait for two or three hours and not get a prescription, and then have to come back again on another day.

At least, it is proposed to allow the drugs and medicines to be supplied through the ordinary retail chemists. We consider that that is an advance, but we express some concern about the inadequacy of the consultations to date with the pharmaceutical profession. We know that there has been some, but we would urge upon the Minister to bring these consultations to a conclusion as quickly as possible in order to ensure that we do not again experience what we experienced in 1953, that is, the machinery for the operation of a health service without having the personnel willing and anxious to operate it. It is essential that we have the full confidence and co-operation of everybody— doctors, nurses and pharmacists—and we will get that only by having adequate consultation.

That, Sir, is our general observation on the section. It is a disappointment. It could have achieved more. We believe that it has been wrongly conceived, that it was conceived on the basis of the false premise that hardship is not caused to most people in the provision of medical aid. That, we are satisfied, is wrong.

The reason why the Department take this view is that the figures on which they make this wrong conclusion are 18 years out of date. If I am right, they base it on a household inquiry made in 1951-52. The cost of drugs and medicine has developed in an entirely different way over the last 18 years and the development of the techniques and knowledge of medicine has also changed immensely over the last 18 years. We think it is utterly unworthy that we should now be bringing in a Health Bill, which the Minister believes will operate for the next 20 years, on the basis of information which is even already out of date, which might even have been inaccurate in 1951-52—I am not going to argue that; I am not in a position to argue it, not having made the necessary analysis—but, it is fair to assume the basis has little relationship to our present day problem.

Mr. Childers

The position is that we are making progress. I do not think I need go over all the arguments on the Second Stage in regard to this section. Deputy Ryan will have the opportunity when the regulations are issued to make further comment about this. The position is that we do propose that for the whole of the middle income group it will involve only the single examination of eligibility and not a special examination of eligibility of any section. We do propose that the minimum amount, which will be the amount that will be recoupable, will be clearly expressed in regulations understood by everybody and the amount above which people will be subsidised for their drugs will be quite clearly stated. A figure of £2 a month was mentioned by my predecessor. That, of course, will have to be examined again and revised, possibly, in the light of present circumstances. In actual fact, we are using the household budget survey of 1965-66, which is near enough to today to enable us to draw some useful conclusions in regard to expenditure on drugs and medicines. According to that survey a household earning £20 to £25 a week was spending roughly 2s 6d a week on medicines and drugs and some 45/- a week on drink and tobacco.

As I have said, it is proposed to have what will be an advance in the attitude we adopt towards drugs purchased by the middle income group. Up to now, as the House knows, there is a question of contribution because of hardship, now arranged by health authorities. When this Bill is passed it will be based on an actual figure of expenditure on drugs and appliances per month above which the cost will be met by the regional health boards, and I think this is an advance. I hope there will be other advances in the years to come as the nation grows in economic strength.

As I have said, this is a Committee Stage discussion and the House has already expressed its views at great length on the Second Stage and there can be further discussion when the regulations are being considered. As the Deputy knows, there is also some income tax relief to people with very heavy illness expenditure in a year, which has been announced on two successive occasions by the Minister for Finance.

The negotiations with the Pharmaceutical Association are going ahead steadily. I do not see any reason to suppose that they will not be concluded satisfactorily. We will do our best to provide a formulary of drugs which can be regarded as a useful guide to doctors in that they will be given some indication that they can purchase drugs of a particular kind, of good quality and with whatever are the necessary constituents in the drug, perhaps at a cheaper price in some cases than purchasing from another source where quality is no better and where the price would seem to be excessive.

The whole business of processing of prescriptions and the issue of payments will be done by a central bureau using a computer, which will reduce the administrative costs as far as possible. We think that the result will be that, although inevitably it will be more expensive to issue drugs through retail chemists, it will be of great advantage to the people concerned. They will no longer have to get their drugs in dispensaries, with all the long waiting described, I think correctly, by the Deputy. They will be able to get their drugs at a chemist's shop. As to the price at which the drugs will be sold in respect of those who have medical cards, the Deputy can be assured that because of this increased turnover of business to chemists we will be able to make a reasonably good bargain with them and the price that will have to be borne by the taxpayer and the ratepayer will not be excessive.

Dr. Browne

I want to express our great dissastisfaction with sections which contain a persistence of the old poor law idea of means test type medicine. We disapprove of them, not, as I have said many times, on doctrinaire, ideological grounds, but simply because we believe they will continue to lead to the two-tier type medicine.

The change in even 20 years is dramatic in regard to this whole business of drugs and charges for drugs. I remember the great clarion call 20 years ago was in regard to doctors' bills. That, funnily enough, would not be such an attractive call nowadays because what really frightens people is not so much doctors' bills as chemists' bills and they are very much more costly a component of any illness these days than they were even 20 years ago. With the cutting down of this service to this pitiful poverty stricken offering made to the unfortunate people in the provisions of the Bill under eligibility, even if they had made a greater range of drugs available to people free of charge, that would have been a great advance indeed.

The trouble is that ill-health is unpredictable. The duration of ill-health is unpredictable. One cannot predict who the patient will be. Is it the breadwinner, the mother, one of the children? What type of illness will it be? What will be the cost of the drugs? It is trying to introduce order into a completely chaotic set of imponderables when the Minister says that they will fix on some sum and that that will be a sum which will mitigate, reduce or even eliminate hardship in any set of circumstances.

It simply cannot be done. This is the most costly component in any health service and, because it is the most costly component, it is the most important component. For that reason the attempt to standardise the charge will not eliminate the hardship that must inevitably be involved when a family is faced with serious illness.

This also creates very serious dilemmas for the doctors. I have known general practitioners who, faced with serious illness in patients, found themselves with very costly antibiotics on the one hand, and relatively cheap but reasonably valuable medicine on the other hand and, out of the kindness of their hearts, they felt themselves compelled to prescribe the cheaper medicine. That is a scandalous dilemma in which to put any doctor. That situation should never arise.

There is no doubt in the world as to the type and quality of service that should be available, namely, the best procurable. The Minister keeps telling us we must discuss this within very narrow confines, but we must discuss the matter in the light of the question as to why he is not able to offer the best service. The Minister is the most consistent advocate of private enterprise. If private enterprise is so good why has it failed to produce the money to ensure that everybody is provided with the quality of health service the Minister would expect, to which he and everybody belonging to him has a perfect right in time of medical need. He is not providing this for the ordinary people. Of that I am quite certain. The only way in which such provision could be made would be by going back to the 1947 Fianna Fáil Health Act. That was not perfect, but it was a fine piece of legislation and it would be infinitely preferable to anything proposed in this Bill. Even the proposals of Deputy Ryan in relation to a contributory scheme would be an advance on the proposals in this measure.

The Minister has given us figures and made comparisons: 2s 6d on drugs and medicines and 45s on drink and tobacco. Human nature being what it is, people want their simple pleasures. They work hard for them. No case can be made for this on foot of the amount spent on drink and tobacco. No case can be made for depriving anybody in time of need of the quality service the individual should get. I do not know if the Minister fully appreciates the enormous strides that have taken place, particularly since the war, in regard to chemico-therapy and antibiotics. The latter are produced at very great cost. The coloured bottles are gone. Now the most valuable drugs are available to help an individual in time of illness, but they cost a great deal in research and production and, because they do, the end product is costly. But there should be no inhibition of any kind on any individual in time of illness.

The Minister is shortsighted in his approach because, as Deputy Ryan pointed out, there will be this fear of illness, this fear of the chemist's bill, a greater fear than the fear of the doctor's bill now. Because of that there will be the fear of going to the doctor to find out if there is something wrong; because of that there will be delay and, because of the delay, the more serious will be the condition and, the more serious the condition, the longer the patient will be disabled and, the longer the disability, the more the disability will cost. It is extraordinary that we should as a society make such claims to being wealthy and prosperous and, at the same time, have this inhumanitarian approach to illness.

I read the report on child care the other day and it was stated in that report that the basic principles of the school health service and the child welfare service have not changed fundamentally since 1920, 50 years ago. How can the Minister pretend that he is now introducing progressive or radical legislation in regard to health services? It is all part of a pattern. There is a gradual movement away by the Fianna Fáil Party from the people, the people who gave them the power, and rightly so, in the early days. There is a failure to build houses, a failure to provide jobs.

An Leas-Cheann Comhairle

The Chair does not want to interrupt the Deputy, but we seem to be getting away from the section.

Dr. Browne

This is all part of a pattern, this Victorian legislation. The Government may think the movement is imperceptible, but it is not imperceptible. People are slow to forget a kindness or an unkindness and I am convinced that it is legislation such as this which will gradually lead to the complete disappearance of the mass support Fianna Fáil commanded in the past because of their progressive legislation.

Dr. Byrne

I welcome the abolition of the iniquitous blue card system.

An Leas-Cheann Comhairle

This section deals with drugs, appliances and medicines. It does not deal with blue cards at all.

Dr. Byrne

Yes but——

An Leas-Cheann Comhairle

It does not deal with blue cards.

Dr. Byrne

I am aware of that but I am merely pointing out that the blue card system which is being abolished by this Bill——

An Leas-Cheann Comhairle

That would be general. We must try to keep to the section.

Mr. Ryan

With respect, this section provides that people who are regarded as having full eligibility are entitled to free drugs and medicines but other people will have to pay for them. This deals with the different categories and the Deputy is in order in describing the conflicts that can arise from trying to treat one section of the community in one way and another in another way.

An Leas-Cheann Comhairle

So far the Deputy has not dealt with the question of drugs, medicines and appliances.

Dr. Byrne

I am coming to the point that in section 7 (1) the patient referred to will merely be a substitute for the previous blue card holder and that, whereas the abolition of the blue card is a very good thing, we are still categorising the patient; we are giving some patients completely free medicines and then we go on to subsection (2) where, in order to obtain any medicines at a reasonable cost, one has to make a separate application to the health board involved. This is an even worse stigma than exists under the present system. We are still going to divide our patients and in the doctor's waiting room they will be divided between those who have completely free appliances and drugs and those who have them at a reduced cost.

There is a dreadful stigma associated with having to ask the doctor, who might be a next-door neighbour: "Would you mind not giving me the bottle you gave me last week as I cannot afford it? Would you give me a cheaper one?" The doctor may reply that the cheaper one will not suffice and ask the patient if he would like him to write to the health authority requesting medical assistance for the patient. This is what is happening. People are not getting the proper medicines because they cannot afford them. Subsection (2) is most important and it is totally inadequate because it will not get through to the people who really need these drugs. There will always be a certain hard core who will look for things to which they are not entitled but the people who are entitled to them will not, because they are too reserved, make the application. Recently, I had the experience of attending a woman who was dying and who could not afford her medicines. When she was asked to make representation to the health authority she explained: "Oh, no, if I did my husband would kill me".

I have three letters here seeking assistance for drugs from the health authority which just arrived today. On average, I write a hundred letters a month for patients to try to help them obtain drugs at a reasonable cost. These are people who are on the fringe and who do not qualify for completely free medicines, drugs and appliances. There is a stigma attached to making this separate claim, to being dragged down to the authority and undergoing a third degree about one's income to see whether one should be provided with drugs for one week, two weeks, or a month at a reduced cost. As I said, this is totally inadequate. What we suggested was that this should be done on an insurance basis. Obviously our recommendations were not acceptable and, failing that, then all drugs should be made available to 90 per cent of the people at half price.

Earlier the Minister referred to the income tax allowance for any hardship caused by the purchase of drugs. This allowance arises after the purchase of £50 worth of drugs for one person in the family. If a man has a wife and six children and each of the eight require £30 or £40 worth of medicine the man is still not going to get the allowance because it only relates to one person. In this sort of case the man is tempted to cross the borderline of justice and get the chemist to give him the bill in one name. Instead of paying the full retail rate, with his income tax allowance being considered, he would be getting the drugs merely at the health authority purchase price. All this could be overcome by introducing a system whereby all members of the public get drugs at half price. This is the only realistic approach and the only approach whereby you can treat patients outside hospital on a long-term basis. The alternative is to transfer patients on ISA forms to hospital specialists when they will be able to purchase the drugs at the nominal charge of 2s 6d. Of course, once again they will have to queue up for long hours in the hospital and be subjected to certain stigmas. However, we know that by putting them down on the long waiting lists we can get some of the more expensive medicines for them. Even though there is a system whereby expensive medicines may be made available, the system is not functionally efficient from the medical point of view. Financially, perhaps, it is. What is happening is that patients in the lower income group who do not qualify for free service are unaware of the other benefits available and they will only take half a bottle of an expensive antibiotic and put the other half in the fridge to keep it there until someone else is ill. Recently, I had a case where two teaspoonfuls of a very expensive antibiotic were given to a child just to see if it would tide the child over the illness. The resultant complications from inadequate therapy like this can be very severe. In one family recently all four children had to be taken to hospital, and are still there, since resistant organisms developed because of inadequate treatment due to the fact that the people could not afford the anibiotics.

As Deputy Ryan and Deputy Browne said, the doctors in Dublin are not expensive. It is something for which we can be very grateful. The general practitioner here has the lowest charges in Europe. People no longer fear, as possibly was the case in 1947, the doctor's charge; what they are really afraid of is the chemist's bill. They will take anything at all rather than go to a chemist. The opposite to that is that when you give a prescription under the present system—and this does not change it any—the parents are inclined to repeat the prescription, to go back to the chemist and ask for the same bottle for Johnny as was given to him on a previous occasion although, this time, he might be suffering from a completely different ailment. The family cannot afford the combination of doctor and medicines, with emphasis on "medicines".

It is a very good thing to make everything completely free to the destitute section of the population. We must bear in mind, however, the gross lag in the provision of appliances and drugs for certain prescribed diseases or disabilities of long standing. Children suffering from spina bifida can now be saved. Yesterday, the Minister said facilities are available. He asked a Deputy if he had a specific case in mind. At 2.30 p.m. I had left a child who was dying. Over the week-end I applied for assistance for it. The child is still in a very bad condition. It is 18 months old. The mother had not had any free medicines or appliances for that child; nor was she aware of any until I was consulted in a dual capacity. The National Council for Spina Bifida, which is in process of being set up, would greatly appreciate the immediate provision of free drugs and appliances for this type of patient.

A figure of 2s 6d was quoted as an average expenditure on drugs. There are many things at the chemist's shop which are essential for health and which may not be included in this figure although, at the moment, I shall not dispute it. I do not see the relevance of the figure of £2 for drink and cigarettes apart from the fact that so much seems to be spent on cigarettes, which we all now know beyond doubt do promote illness, yet neither the Minister nor his predecessors attempted to introduce any legislation whatsoever to restrict the advertising and sale of cigarettes.

I do not think that the availability of medicines at the chemist's shop will change anything. People who have had to queue at dispensaries for medicines will not have the same accommodation at the local chemist's shop where there are not such facilities for waiting. Many people, too, will be asked to return to collect a prescription when it has been filled. All of these factors will give rise, I think, to a certain amount of hardship.

An important omission here in local medicine is the provision of these drugs free of charge on a 24-hour day basis and at week-ends. There is nowhere in Dublin where a prescription can urgently be filled after the chemist has closed. There is no dispensary where an eligible person can collect drugs which may be prescribed in the middle of the night and which the attending doctor may not have in his emergency bag. I urge the Minister to make provision for the establishment of a centre, or certain centres, in Dublin which will be open to the public on a 24-hour day basis for the filling of emergency prescriptions. With the improvement in the standard of medicine in this country and, indeed, all over the world, there will be increased side effects——

Mr. Childers

On a point of order. That does not arise on this section.

Dr. Byrne

I am referring to subsection (3) which relates to disability of a permanent or long-term nature.

Mr. Childers

Not under this section. We have a Drugs Advisory Board to deal with these dangerous drugs. It does not arise on this section.

Dr. Byrne

I do not agree with the Minister.

An Leas-Cheann Comhairle

The section deals with drugs, appliances and medicines. The Deputy would seem to be enlarging the scope of the debate in dealing with specific cases.

Mr. Childers

It is a matter purely of the finances in connection with drugs. We cannot discuss whether or not drugs should be issued. The debate would be endless if we got down to that kind of argument.

Dr. Byrne

I am pointing out that, with the higher standard of medicine in the world today, there is already and there will continue to be an increase in the number of people suffering from side effects. I merely wish to draw the attention of the Minister to the fact that these will be free medicines. I do not think he has given sufficient attention to costings. We must remove the stigma attached to the forgotten people of the Health Bill who must now apply for assistance in individual cases for medicines.

Mr. Ryan

I want to deal briefly with the figures the Minister gave to justify his argument. In my view, they undermine his argument and assist the Fine Gael argument. He says that, in 1966, the average expenditure on drugs and medicines was 2s 6d a week. That is an argument in favour of entering into an insurance scheme in which, on payment of a premium of 2s 6d a week, drugs and medicines would thereafter be available free.

Statistics should be repudiated entirely in medicine. While of assistance in determining the finances, they have little relevance to the human beings involved. It is no consolation to a person who is dying, a person who is chronically ill, or to a person who is in pain, to be told that statistically they have no significance. They have great significance in the eyes of their Creator and in the eyes of their fellowmen and their families, and in their own eyes.

It is not adequate to say that statistics show that their average expenditure is only 2s 6d a week and that, because statistics prove that, they will not get assistance towards meeting their bills which in some cases are £2, £3 and £5 a week. You could argue that there should be no such thing as fire insurance if you used the same argument as the Minister has used. The average loss occasioned in households by fire insurance is 5s a week. Is this an argument against fire insurance? It is not. It is an argument in favour of it. People should be encouraged to insure so that the community, by each person paying a little, insures their less fortunate neighbours against the immense cost involved in fire insurance.

The basis of a health insurance scheme which would provide, if not free, at least subsidised drugs and medicines, would be that the community, by paying a small amount, would insure any family or any person against having to pay an undue amount such as £2 and £3 a week and more for drugs and medicines. I think the difficulty the Minister is in is that he and his colleagues got themselves in a strait-jacket in opposing the Fine Gael scheme. I have with me a cutting from the Irish Press of 4th April, 1965, in which the Minister, who was then Minister for Transport and Power, is reported as objecting to the poll-tax system Fine Gael wanted to bring in, a system, which he said was ludicrous. I think he has got himself into that difficulty and he and his colleagues are now unable to get out of it—the difficulty of assuming that they could not accept what was proposed by their opponents, when their own figures go to establish the justification for our scheme. Our scheme was to provide a subsidy of 50 per cent of the cost and that would be 1s 3d a week and not the 2s 6d mentioned by the Minister.

The figures given justify all we have said. Therefore, we urge upon the Minister to use the same statistics, if he considers them respectable, as the basis of a system which will provide a comprehensive subsidy for drugs and medicines which the two medical speakers in this discussion, Deputy Dr. Browne and Deputy Dr. Byrne, have emphasised are the principal cost in medicine today.

I appreciate that this is an enabling section in some respects, and particularly the subsection which would allow the Minister to specify the particular long-term chronic conditions which would be entitled to free service without a means test. I endorse what Deputy Dr. Byrne has said about spina bifida. We must take into account the kind of assistance which it is necessary to give to children who suffer from that ailment. Assistance must of necessity be applied immediately and it is not the kind of condition which tolerates delay. Therefore, we believe that the benefit should be applied without any hestitation.

We appreciate that in recent times provision has been made for diabetics, and quite rightly so. There is another condition which also imposes considerable and continuing expenses, that is, the condition of epilepsy. I would urge the Minister when he is drafting the regulations to bear these conditions in mind. I can sympathise with the Minister if he does not want to prepare an exhaustive list at this stage but those two cases are certainly worthy of mention.

Mr. Childers

I would be very glad to examine any such list. I would point out that under this section we could have a contributory scheme. The section does not forbid a method of contributions to be used. We are simply arguing on the fact that the health boards would have the power to give the whole of the cost or a proportion of the cost of drugs and, having reached Committee Stage, I would ask the House not to continue to repeat arguments of a Second Stage character. This section of the Bill could permit 100 per cent of the drugs to be paid for by the health board to the middle income group. There is nothing to stop that.

Mr. Ryan

Except the spirit.

Sir Anthony Esmonde

I would be inclined to welcome the section so far as subsection (1) and subsection (3) go but subsection (2), to put it mildly, is somewhat ambiguous. Some of the phraseology used is, to my mind, rather confusing. It provides:

When a person with limited eligibility, or a person with full eligibility who does not avail himself of the service under subsection (1), satisfies the chief executive officer of the health board that, in respect of a period and to an amount determined by regulations made by the Minister he has incurred expenditure on drugs, medicines and medical and surgical appliances which were obtained on the prescription of a registered medical practitioner ...

How exactly will he satisfy the chief executive officer? There is a section in the existing health legislation which, as far as I know, enables the chief executive officer, who would be the county manager, to allow drugs to certain persons who had incurred the expenditure. What exactly is the difference in this section? What is the difference in this so-called enabling legislation? How is a person to prove to the chief executive officer, any more than he could prove it before, whether he is entitled to drugs or not? I am not dealing with subsection (3) which I accept fully.

A person goes to a general medical practitioner and the practitioner prescribes for him. He incurs considerable expenditure with the local chemist or whoever it may be. Then he discovers that he is unable to meet his commitments and he applies to the chief executive officer who, of course, is the county manager, for payment of the bill. That is the position at the moment. If anyone comes to me and says: "I have been attended by my doctor. He prescribed such and such a drug. It is extremely expensive. I cannot afford to pay for it"—as a public representative I am in a position to make representations to the county manager to pay the bill. Where is there any difference in this section?

Mr. Childers

The Deputy was not in the House and he did not hear me tell the House about this. He is asking me to explain something I have already explained.

Sir Anthony Esmonde

I am very sorry but it was not my fault that I was not in the House. I was at an interparliamentary meeting.

Dr. O'Connell

There are a few points I should like to mention. We know that tuberculosis patients are given free treatment but we have in the country today a number of ex-TB patients who are suffering from the after effects of TB with chronic bronchitis, fibrosis of the lung, and they have acute exacerbations every year, every winter. By virtue of the fact that their TB is not active they are not given any treatment. These people need treatment. They need broad spectrum antibiotic treatment of their acute bronchitis that recurs. I have fought in vain for so many of these patients. The reply always is that the TB is not active and nothing can be done for them.

I should like to hear what the Minister has to say about this because they are as fully in need of treatment as are active TB patients. These are the end results of TB. I should like to have the Minister's views about these cases. Will he provide for those cases? The other cases are diabetics. I know there is provision for the free treatment of diabetics but what is forgotten is that diabetics also suffer from concurrent illnesses and vascular disorders. They are very prone to infection but they are not provided for—the mainly antidiabetic therapy. Am I out of order?

An Leas-Cheann Comhairle

The Chair is in some difficulty in regard to this matter in the sense that the section seems to deal with the supply of drugs, medicines and appliances. The question of eligibility seems to have been dealt with in previous sections, whether it was full eligibility or limited eligibility. What this section would seem to the Chair to be dealing with is the supply of drugs, medicines and appliances.

Dr. O'Connell

That is what I thought it was about.

Dr. Byrne

We could not discuss this earlier.

Mr. Childers

Regulations will have to be prepared under section 57, and all those can be debated on the Estimate. This is an enabling section, and in regard to the tuberculosis posteffects described by Deputy Dr. O'Connell those in the middle income group will, in the case of 99 per cent of such persons, know that they are in the middle income group. Knowing that, they can take a doctor's prescription to the chemist who will know they are in the middle income group and that a given proportion of the cost of the drugs per month or per week will be defrayed by the health authority. It will no longer be a question of the vast majority of cases not being certain whether they are in a hardship category or not. There will be other cases of patients with long term disabilities, matters which we can examine, such as those mentioned by the Deputy in relation to conditions associated with diabetes or some other disease. All those can be looked at in relation to the long term disabilities where quite evidently the patient cannot be certain that he necessarily will qualify for long term disability except in the case of diseases which have actually been published and are known to everybody such as spina bifida, hydrocephalis or one of those.

Dr. Byrne

Could the Minister clarify the point made by Deputy Dr. O'Connell? He was doing so but his last sentence got a little muddled. In the case of associated illnesses, the TB patients, the associated mobility of the ex-TB patient, the diabetic, the epileptic and the mentally defective people, even though these would be prescribed diseases and you would make drugs available free to them for the specific illness which they suffer from, will you make drugs free to them for any associated illness? They have a higher incidence of associated illnesses, chest infections, vascular diseases et cetera than the normal population. You could provide that once they are in the category of a permanent or long term illness they would be covered for all illnesses from which the patient may suffer where this is a permanent or long term disability.

Mr. Childers

Regulations can be prepared of a fairly substantive kind in which many illnesses will be specifically mentioned and, perhaps, associated conditions with those illnesses.

Dr. Byrne

Could the Minister give us an indication now?

Mr. Childers

We simply cannot proceed in this Parliament on the basis of doing a job now that must be done later. We shall have the regulations in regard to this. We shall have to await the regulation that will be published and laid before the House in relation to the standard conditions for medical cards and the general conditions attaching to the middle income group. We can have all that out and I shall be far better equipped to mention specific maladies, and we shall consider all the things that have been raised by all Deputies. It is not fair to ask me now to spell the whole thing out in detail. I have gone as far as I can in regard to this matter.

Dr. Browne

I do not know whether the Minister is making debating points with Deputy R. Ryan or not, but he said something about this being potentially a contributory scheme. We could all make that point but I would be obliged if the Minister would clarify what he means. I would clarify it in this way: that no matter what scheme is brought in, whether it is the kind we would like in the Labour movement, a free no means test scheme, or this type of scheme where you have the old poor law Victorian type health services brought in, it is a contributory scheme in so far as the money comes from the rates, from direct or indirect taxation or it comes in the forms I spoke about before, national health insurance contribution and other kinds of payment. Would the Minister tell us what he means by contributory? I know what Deputy Ryan means by contributory. The Minister makes it quite clear in section 43 that there are certain conditions for eligibility and each person here is specified as a person with or without full eligibility or partial eligibility, and this is then referred back to a person who cannot afford to pay, and so on, in legal jargon. However, to suggest that it is the same type of thing that I have in mind as a contributory scheme or that Deputy Ryan has in mind as a contributory scheme means to me that the Minister does not know what he is talking about or he is playing politics. If it was a scheme on the lines Deputy Ryan suggests he would be quick to tell the public; if it was on the lines we in the Labour Party would implement, if we had the power to do so, I am quite sure he would tell the people. He should be more specific on that point.

Then there is the question of the long-term illness. This makes tremendous demands on any family: there are the emotional demands as a result of the fact that a person is chronically disabled; there are the physical demands of knowing there are nursing duties that must be performed by the person looking after the ill person; then there are the financial demands, money going out day after day in respect of somebody whom they love and want to have around but who is a constant burden. Would the Minister even in regard to subsection (3) provide, as his predecessors did in relation to diabetes, that in relation to any long-term illness such as spina bifida and disseminated schlerosis, the person would be eligible for free treatment? This would be some concession to the genuine concern expressed by all Deputies.

Mr. Childers

The Deputy can take it that we shall be as generous as possible in regard to these long-term illnesses, but we have to await the regulations. I was not trying to play politics. If the Deputy reads section 57 (2) he will see that it would be possible in theory to pay 50 per cent, 75 per cent, 85 per cent or even 100 per cent of the cost of these drugs. There is nothing to prevent the Government introducing a Bill into the House which would provide for contributory schemes with either flat rate payments or payments on the basis of the income of the person.

Dr. Browne

I accept that, but it could be done under this section?

Mr. Childers

What I mean is that it is possible under this section for almost 100 per cent of the cost of drugs to be made available to the middle income group.

Dr. Browne

That is a different thing.

Mr. Childers

My predecessor dealt with the general question of our attitude towards the middle income group on Second Stage. I have spoken about it at considerable length on earlier stages of the Bill and I have noted all the comments made by Deputies in my own party and all the objections made by Deputies in the Opposition parties. All I have said is that I thought we were making some progress in regard to ensuring that people in the middle income group would be able to get drugs at a reasonable cost or at low cost under long-term disability.

The question of whether or not we have a contributory scheme, whether we lower the rates or raise the taxes, does not arise on this section and I think the Leas-Cheann Comhairle would agree that the method of raising money does not arise on this section. When the regulations come before the House Deputies will be pleased or disappointed, depending on which side of the House they come from, with the actual amount that we propose to pay people already classified, marked and registered in the middle income group towards drugs which they buy for ordinary illnesses, and the many varieties of long-term illnesses; that will all come before the House for discussion. It is impossible for me to commit myself further except to say that my predecessor made a rough guess that he thought that any expenditure above £2 might apply. We do promise a substantial contribution, and no longer will the middle income group have to apply to see if they can be regarded as a hardship case if they want to get a contribution towards their drug expenditure. When this Bill is passed they will know what they can get in relation to ordinary diseases and specifically in relation to long-term illnesses.

Sir Anthony Esmonde

I want to ask the Minister two questions. The section we are dealing with is largely subject to regulations and the Minister has said that an opportunity to discuss these regulations will be given on the Health Estimate. My first question is: how soon after the passing of this Bill does the Minister anticipate he will put these regulations before the House? The second question relates to the fact that these regulations require the sanction of the Minister for Finance in subsection (4) and, therefore, even if the Minister issues certain regulations, which one debates in the Health Estimate and accepts, is it not possible that they may not obtain the sanction of the Minister for Finance and as a result the regulations may not become fully operative?

Mr. Childers

We shall have to get the consent of the Minister for Finance before issuing the regulations.

Sir Anthony Esmonde

When does the Minister expect to introduce these regulations?

Mr. Childers

It depends on the Parliamentary steps and on the many administrative steps we have to take in order to bring the Health Bill into operation. Many of these fresh steps to aid the health services will be implemented in our health services on the 1st April, 1971.

Dr. Byrne

Does the Minister agree that the contribution under subsection (2) will be in the nature of a forced contribution?

Mr. Childers

Again, the Deputy misunderstands me. I was trying to relieve Deputies' minds. They expressed their belief in a contributory scheme on this section as though the section was so written that there could never be a contributory scheme. A contributory scheme is being examined by the Government at the present time. We could introduce a contributory scheme and funds available for that scheme could be used to implement section 57, subsections (2) and (3), and as a result relieve the middle income group from paying a portion of the medicine costs. Deputies should not imagine that in agreeing to this section they are agreeing there will never be a contributory scheme or that rates and taxes will continue to be levied in the same way. This is an enabling provision and if all enabling provisions are going to take an hour to be passed, this moderate measure will never be accomplished.

Dr. Byrne

I agree with the Minister, but I do not think he has grasped the point I am making that under subsection (2) the people are already contributing in the form of rates.

Mr. Childers

I was using it in the form of a contributory insurance scheme such as suggested by the Deputy's own party and as advocated by Deputy Dr. Browne as a second best alternative to the scheme outlined in Labour Party policy.

Dr. Byrne

For 90 per cent of the population?

Mr. Childers

For a portion of the population.

Dr. Byrne

Under subsection (2) a person may get 100 per cent, 90 per cent or 50 per cent of his drugs free but it is entirely based on the decision of the chief executive officer.

Mr. Childers

Yes, but we can make regulations enabling the chief executive officer to give from 75 per cent to 100 per cent. The money has to be raised from somewhere.

Dr. Byrne

But the contribution which will be made by the patient will be a forced contribution. If the patient still cannot afford 25 per cent of the total cost—and we are still not clear here whether this cost is going to be the retail cost or the wholesale cost of these drugs—he might not get any financial assistance at all. The contribution to which the Minister is referring is a forced contribution which he will have to pay in order to obtain his drugs.

Mr. Childers

The Deputy totally misunderstands.

Dr. O'Connell

The Minister has said he will bring in as many of these regulations as possible by April, 1971. Does the Minister agree that some of the regulations with regard to the 1953 Act have not been brought in yet?

Mr. Childers

That does not arise on this section.

Dr. O'Connell

No, but I am wondering how many regulations will be brought in.

Dr. Browne

I do not think the Minister is helping himself by being so impatient with us. We have waited 20 years for this legislation and we can wait a little longer, particularly as it is not that much better and the public will not be that much better or worse off when it comes in. In the 1953 Act there was a clause which gave the right to look for supplementary health grants or a subsidy in relation to middle income groups. Does the Minister think it is correct in this Bill that application should be made to the chief executive officer instead of to the chief medical officer? It is rather a delicate situation for a person who is ill to have to go along to a layman and explain his position. I think it would be more appropriate for him to go along to the chief medical officer because ideally it would be better for doctors to deal with these matters. I have found the clause in the 1953 Act practically useless as far as my own constituents are concerned. One has to attempt to build up a case post factum after the illness and it is very difficult to do so. I have got no value from this clause as far as any representations which I have made on behalf of my constituents are concerned.

Dr. Byrne

Subsection (2) in its present form is totally inadequate to cater for the needs of the section of the population for which it is intended.

Question put and agreed to.

SECTION 58.

Question proposed: "That section 58 stand part of the Bill".

Mr. Ryan

Section 58 provides that:

A health board shall, in relation to persons with full eligibility and such other categories of persons and for such purposes as may be specified by the Minister, provide without charge a nursing service to give to those persons advice and assistance on matters relating to their health and to assist them if they are sick.

We would urge that the Minister would expand this and give us an indication, if he would be good enough, of the categories he has in mind. We feel that this kind of service should be given to all aged persons, to all retired persons and that their means should not come into this at all for the reasons which I referred to at Question Time today. In the light of experience of the Dublin Health Authority region there is a clear case for giving immense assistance to aged people, particularly, when in urban areas today the elder citizens tend to become more remote from the younger members of the family who are forced by reason of the growth of the city and so on to live very far away from their aged parents. That has produced a tremendous problem in the care of the aged. In the ordinary natural run of events the expectation would be that the younger would look after the elder members of the family, but in the modern more complicated days in which we live the younger people are frequently not available because they do not live within reasonable distance of their parents.

The practical problem, for instance, in Dublin is that 90 per cent of people wanting public housing have been forced to take it on the north side of the city which has put them anything up to half-a-day's remove from their parents who have been living on the south side of the city for generations. This has helped to make more acute and more difficult of solution the problem of elderly people of all ages, of all conditions and of all social backgrounds. We feel that these people should receive tremendous assistance. We believe that a great deal of this assistance should be given before people are distinguishably infirm because quite frequently we can prevent our elder citizens becoming infirm if they are adequately supervised and assisted in advance. One of the greatest problems, for instance, is the difficulty which elderly people have with their feet and the provision of chiropody and home nursing and home care and home visitation would certainly prevent a lot of these elderly people from becoming house-bound which in itself multiplies many of the difficulties of old age.

We, therefore, need to emphasise the importance of keeping elderly people in the community, of keeping them out and about so that they do not develop the physical and psychiatric problems that are almost inevitable if they become house-bound.

Section 59, perhaps, deals more with the element of home help and we will come to that in a moment.

Mr. Childers

Sections 58 and 59 could almost be taken together in regard to what I say in reply to the debate on section 58. It is the object and policy to do our utmost to provide domiciliary care for all those in need. There are very good proposals in the report on the aged poor and we have had proposals in regard to domiciliary care in the mental illness report and also in the mental handicap report and in our own Department we have been investigating this matter continuously.

As far as public nurses are concerned, 580 posts have been filled and there, are about 600 in all to be appointed. We have had many nurses retrained and there are 250 nurses who will have been trained by the spring of 1970. For the lower income group, the public nurses, without charge, provide all domiciliary nursing. In the middle income group they do domiciliary midwifery care, care of the aged, nursing of the chronic sick, domiciliary after-care of patients discharged from mental hospitals and the care of mentally-handicapped children maintained at home; and in the higher income group we also provide nursing care, domiciliary care, after-care of patients discharged from mental hospitals and the care of mentally-handicapped children at home and also domiciliary care in this group to the extent that the nurses' duties in relation to the lower and middle income groups permit.

I am very keen, and so are the officers of my Department, on the public nurse undertaking health education and hygiene education, on becoming a friend of the people where she lives, on being able to persuade people to go to a doctor, people who are not going to the doctor very often because they are afraid to go, allowing a malady to become more and more serious because they are not actually bed-ridden by the malady. All of that work is very important. There is also immunisation, maternity and child welfare and the school health service to continue and public nurses will be taking part in the extended child health scheme in which we hope every child of pre-school age will have at least two good examinations, not only at the child health clinics that we now have but also through a service to be provided by a number of practitioners who will see these people in their surgeries.

That is all linked with the inevitable development of social workers and home help. Home help will obviously have to be carefully considered and as to how far it should be linked with voluntary associations. I believe a great deal of this work in regard to home help can be done better through voluntary associations. Tremendous work is being done in Cork and Limerick and the health authorities are giving subventions to those bodies for a wide variety of social services and health services of one kind or another.

So, the answer is that we do intend to develop domiciliary care in health for a wide variety of conditions and we regard it as of very great importance in the coming years to keep people out of hospitals, to look after them at home. There are many matters still to be examined coming before us in the report on the aged poor. Some of them are very evident to us already. Some of the proposals are more definite and succinct and will be examined not only by myself but by the Minister for Local Government. Deputies can take for granted that we do regard this aspect of the health service as of very great importance.

Dr. Byrne

In section 58 I see a great pitfall for the nursing profession in that they shall provide free of charge a nursing service and give advice. The Minister has suggested that many old people might not go to a doctor because they might be frightened to go. They would be frightened for no reason. Here we have a nurse going to these people and advising them regarding their health.

With regard to assistance on matters relating to health, we still at this stage have had no consultation between the nurse and the doctor.

Mr. Childers

The nurse will have to be in touch with the general practitioner.

Dr. Byrne

Should that not be clear? Are we not putting an onerous burden on the nursing profession? Have they not enough to bear already?

Mr. Childers

The Deputy knows very well that the nursing service will operate under the auspices and direction of, first of all, a superintendent nurse in each area and, secondly, the county medical officer. It is inconceivable that nurses would do anything over and above what would be regarded as desirable by the medical profession. The Deputy can put the whole thing out of his mind. The medical profession are well able to defend themselves against any attempt by nurses to supersede the work of doctors. In fact, nurses are already doing what is provided here, and doing it quite successfully, in full co-operation with the local medical practitioners.

Dr. Byrne

But this does leave the nurses wide open.

Mr. Childers

The nurses would, of course, have to ask the doctors as to the kind of advice to be given.

Dr. Byrne

It does not say that here.

Mr. Childers

We are not spelling everything out in the Bill. If we did that the Bill would be six times as big as it is.

Dr. Byrne

But the provision is here and this is something which could give rise to trouble. Sections like this have been passed in other measures and have then been thrown at the nursing profession and the medical profession when difficulty arose. It is provided here that the nurses will give advice without charge. There is no question of consultation with a doctor beforehand.

Dr. Browne

The Minister should not get so angry about this because he is being advised by someone who presumably knows what he is talking about. A conflict can arise between a doctor and a nurse. A nurse who is left on her own a good deal can come to feel that she is as good as or, perhaps, better than the doctor because of her experience and there can be conflict. This is a practical point. It could be a practical issue. If the Minister were to put in a clause "in accordance with the advice given to her by the practitioner in charge of the case" that might meet the point.

Mr. Childers

This is practically a repeat of section 102 of the 1947 Health Act. There is no change of any importance in the wording.

Dr. Browne

It might be a good idea then to change it now.

Mr. Childers

It has worked all right so far.

Dr. Byrne

It should be changed. To all intents and purposes there are three subsections here: she shall give advice; she shall give assistance on matters relating to health and, thirdly, assistance if people are sick. The advice could be of a prophylactic nature and it might not be altogether in keeping. This throws too much responsibility on the nurse. If she gave the wrong advice she would later have to "take the rap" for it.

Mr. Childers

I shall look into this to see if it is necessary to do anything by way of amendment on Report Stage.

Dr. O'Connell

I am very pleased the Minister is conceding this. Deputy Dr. Byrne's point is a valid one. I have known this problem to arise. I have known treatment to be changed by nurses with resultant friction between the nurses and the doctors. It does not arise very often. I am glad the Minister will consider amending this on Report Stage.

Mr. Healy

I took it the intention here was to advise patients who were reluctant to see doctors. Some people are afraid to approach doctors in case their worst fears are confirmed. Suppose a patient has no doctor would it not be the duty of the nurse to advise the patient to see a doctor? Very often nurses have the confidence of the people and can persuade them to consult a doctor in their own best interests. The nurse should be allowed to continue to do that.

Mr. Childers

Surely that activity is accepted by everybody.

Mr. Ryan

Is this service classified as one in which the State makes its statutory contribution and, if not so classified at the moment, is it a service which will be regarded in future as one in respect of which the State will make its appropriate statutory contribution?

Mr. Childers

The service is in operation and there is a 50 per cent grant for it. There are already 580 nurses engaged and there are 20 more to be appointed. This is not a new service.

Question put and agreed to.

SECTION 59.

An Leas-Cheann Comhairle

Amendment No. 85 in the name of Deputy Ryan has been ruled out of order.

Question proposed: "That section 59 stand part of the Bill."

Mr. Ryan

Section 58 and this section dovetail into one another. The position at the moment is that there are some services provided for the care and support of the aged which are not treated as eligible for a State contribution. There is the chiropody service, the old folks clubs, the provision of meals on wheels, a service of immense benefit to the elderly and one which contributes significantly to reducing the demands for institutional accommodation. In the Dublin region, for instance, for the first time in 30 years the point was reached this year at which there was no longer a waiting list for entry into the geriatric institutions. The position is getting out of hand again now for another reason. Because of the less challenging nature of geriatric care nurses are finding the work unattractive and the result is that there are now a number of units in the geriatric section closed because of lack of nursing personnel. The way in which to overcome this problem, apart from giving the nurses better conditions of service, is by providing a community social service which will maintain as many as possible in good health in the community.

Therefore, I have some reservations about the final words in section 58, although I see that something like them exists in the 1947 Act, which says that the assistance of nursing care should be given only if people were sick. In the 1947 Act the health authorities were entitled to assist sick persons. We must get away from making it a condition precedent to nursing attention that people should be sick. The last section did endeavour to get away from that.

This is something which we cannot over-emphasise. Section 59 is a move in the right direction, to provide a service at home for sick and infirm persons. I think it is a new section and one we greatly welcome. I expressed some disappointment on Second Stage, and I do so again, that it does not go further. At present the Dublin Health Authority, and I am sure other authorities, provide home care and domestic help in cases where mothers are confined to hospital, perhaps, because of a confinement or for some other reason. It may be that that could be done under this section because the children would be regarded as dependants of sick or infirm people. Of course, a confinement is not a sickness or an infirmity if it concludes with a happy birth. Perhaps, it is so regarded but I do not know the statutory basis for that. Assistance is also given by way of domestic help where widows want to go to work to provide an adequate income for the family and which would be impossible if there was not some domestic help to give, say, a midday meal to the children.

The section, as drafted, would not allow that assistance to be given. It might be open to the board to continue to give that assistance in the future as in the past but there is the difficulty that at the moment the health authority could send in domestic help and receive no help from the State for doing that but make it a total charge against the ratepayers. This is charged completely against the rates and it is proper that the community should provide some service if we do not, as we should, provide an ample widows' pension, either contributory or non-contributory, so that widows can go out to work. This cannot be done without disruption in the home. Under this section the authority will not have discretion and will not be able to go one penny beyond the authorised expenditure. I fear that there may be a possibility of a termination of this essential service in urban areas where families are becoming divided, where the old family obligations cannot be performed because of the physical distances between the young and the old and so on. There should be an enabling provision inserted and this should be considered before Report Stage so that assistance could be given to families without requiring as a condition precedent to such assistance that somebody should be sick or infirm.

Dr. Browne

I support Deputy Ryan on this matter. It does appear as if these people are excluded. This is a very important section and one about which I have been concerned. There is a great need for providing home help, particularly in relation to infirm persons. One of the great scandals in our society which is referred to infrequently, usually by heads of psychiatric hospitals, is the number of old people to be found in mental hospitals, and who are put there simply because they are old and nobody wants them but in theory because they are mentally disturbed. This has been a reflection of our failure to deal with this very sad and very great problem in our society. Because of the high level of emigration of the very best and the very active, of those between 18 years and 40 years, we are left with the very young and the very old. We have an excessively high proportion of old people, which is one of the by-products of emigration over half a century. Not only have we not dealt with emigration but with this consequence of emigration.

Above all it is most important that we should try to keep old people out of hospital. Knowing the computerised mind of the Minister on matters of finance and statistics even if he looks at this from that lowest of motives, the financial one, the community would be saved a lot of money if we provided organised and co-ordinated community services directed particularly towards the old in addition to those mentioned by Deputy Ryan. Most of us know of the work being done by Dr. Birch in Kilkenny in an attempt to mobilise the emotional, spiritual and physical resources of the community. I came across this problem many years ago in tubercular cases where the mother was isolated in hospital. It was a problem which I am afraid we did not solve. One proposal I remember making was that it was something which was specifically designed for visiting religious orders who could go into houses three times a day to prepare the meals, get the children out to school, or help a widower or a disabled or infirm person. Whether the people involved were religious or lay it would be a very fine Christian work. Those of us who work in our constituencies know of the many people who would be greatly assisted by a serious and significant development of such obvious services as the meals on wheels, or the laundry service, or domestic help, or assistance from somebody who would tell them what benefits they were eligible for, or the chiropody service to which Deputy Ryan referred. Recently we had a look at this problem in the Dublin Health Authority.

Progress reported; Committee to sit again.