I move amendment No. 95b:
Before subsection (2) to insert a new subsection as follows:—
"(2) Regulations made by the Minister under this section shall make provision for the employment of medical officers in psychiatric services on a sessional basis and the designation as consultant psychiatrists of properly qualified medical officers engaged in such services."
This contains two components. The Minister is probably long enough in office—I realise he has been a short time in his present office—to know that in relation to the psychiatric service he is dealing with a very difficult problem. It is not uniform in any way, in its qualities or defects. He will probably have to apply himself to it with an enormous amount of dedication over the years during which he hopes to be in office.
I think the Minister knows that the designation of consultant is really in line with the recommendation of the Commission on Mental Handicap, in their report at page 131, recommendation 190. The whole pattern of the officers in the mental hospitals has changed. The old days are gone when the medical superintendent was appointed primarily as a farmer, and, secondly, as a clinical psychiatrist. We now have more emphasis on the clinical side, and less emphasis on the administrative side and certainly less emphasis on the ability of the medical superintendent to look after the farm. I doubt that the Minister will have any great objection to this proposal.
In the psychiatric service there is, of course, much greater cross-fertilisation clinically with the voluntary hospitals and the status and standing of the individuals in the voluntary hospitals, and the nomenclature of the individuals in the voluntary hospitals should be applied appropriately to the local authority hospitals. I am not a great defender of the local authority health services. I have in many ways criticised the voluntary services. I do not think anyone will deny—and I certainly will not deny—that the prestige of the voluntary services has been higher than in many aspects of the local authority services. I should like to go on hurriedly and say that the quality of service provided in many parts of the local authority service, in the county hospitals, the regional hospitals, the clinics, and so on, is of the highest possible standard. Wonderful work has been done also in relation to infectious diseases, and so on. There is equally no doubt that the quality of service in the voluntary hospitals is particularly high.
What we want to do is to take the best from the local authority service and the best from the voluntary hospital service and merge the two, and try in that way to get the best possible joint service for the community as a whole. Working as they do side by side with the voluntary hospital service, I think it is only rational to accept that consultant status will be accepted for the psychiatric service run by the local authority as it already is accepted for the psychiatric service run by the voluntary hospitals. As I say, it is also in line with the recommendation in the report of the Commission on Mental Handicap. I think the Minister is sympathetically disposed towards many of its recommendations.
There are other points which I will not raise at this stage. It is possible that the Minister is already in agreement with me and, for that reason, there is no point in my introducing other supporting points in substantiation of this proposal. I want to go back to the other component of this amendment, that is, the sessional basis. May I make haste to say that, as an individual, I do not agree with the idea of the sessional basis. I have always believed in the full-time medical officer. I do not believe in private practice or this kind of thing, but I am simply an individual in the service and I would not dream of trying to impose my own personal views on a group of individuals.
I put it forward for this reason. The Minister is finding it very very difficult, indeed, to staff the psychiatric hospitals. I think there are something like 140 vacancies, about 60 of those are occupied by temporary staff, and about 18 of those have the basic DPM qualification. The Minister is finding it particularly hard to staff the peripheral hospitals, the hospitals out in the provinces, with high quality and good level personnel. There are plenty of good level people in them but they are grossly overworked and are carrying an unfair burden.
One of the ways in which the Minister's predecessors got around this—and I include myself—was by allowing private practice. As I have already said, I believe in the full-time concept but, as Minister for Health, I accepted the realistic situation that a generation of doctors had been put out by the medical schools who believed in this type of practice, whether on a sessional basis or private practice. Therefore, it would have been absurd and futile to ignore that reality, and I accepted the principle of private beds and private practice in certain instances for the local authority doctor, in order to attract into the local authority service the quality of man I wanted for the community. I knew he would not come in as a full-time salaried officer. I knew he would come in—and many of them did come in and are giving excellent service in the local authority service—if they had either private beds or private practice. As a by-product of this I got the service which I wanted for the community from high-level and high-quality practitioners, surgeons, physicians, anaesthetists and gynaecologists.
I would put it to the Minister that of the two, sessional as opposed to private, there is a greater danger in giving permission for private practice in so far as you can give a basic salary to an officer and he can then carry on a private practice. We have the old dichotomy of interests which we find in general practice and, again—I made the case for this earlier and I do not want to repeat it—the need for a one-level service which can be established only by a fee for service, or direct payment, or whatever it may be.
Where there are two types, private patients and public patients, there are two qualities of service. The better the doctor is the more likely he is to be drawn away by his private practice from his local authority practice. It is very difficult to curb this. There may be a genuine need for him. He may be of a quality that is badly needed by the people who can afford to pay him. There is this division of interest which eventually will lead to the officer in the local authority service probably spending much too much time in his private practice and much too little time in his public practice.
The Minister's predecessor—and I think he is too—was inclined to accept the reality of this situation in his proposal on the fee for service principle in the new general medical service. On the other hand, on the sessional basis the health authority know precisely what they are paying for. The usual thing is to divide the week into 11/ 11ths and a person does 9/11ths or 3/11ths or whatever it may be. It may be two sessions a day or two sessions a week or five or six sessions, whichever he chooses, but the health authority know what they are paying for.
They know they are getting value for money because a person has to be there for a specific period and has to attend full-time at health authority work. For that reason I think it is a safer device for the Minister if he is not going to have a full-time officer. If he must attract high quality personnel into the psychiatric service, it would be wise for him to move over more towards this idea of a sessional basis rather than a private practice basis also as there is this interchange between the voluntary private and the public local authority hospitals. He already has accepted the principle of the sessional basis where he uses a private voluntary psychiatrist in the local authority service. That is already in operation, so he is not creating a precedent; the precedents are already there. For that reason it is not in any way a great break away from what is already accepted by the Minister.
There are certain occasions when a health authority may require limited service from specialists within the service. In this way they could avail not only of the private voluntary type doctor, specialist, or consultant whom it already uses, but also might make use of their own specialists or consultants by being able to employ them on a sessional basis. I recommend this subsection to the Minister as an attempt to help him to deal with what I happen to know is going to be his greatest single problem, the upgrading of the psychiatric services. In some areas they are extremely good. In Dublin they are improving at a very rapid rate, and in areas down the country they are at an extremely high level. However, there are other areas in which they are regarded as being fairly backward.