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Dáil Éireann díospóireacht -
Thursday, 9 Mar 1972

Vol. 259 No. 9

Committee on Finance. - Vote 48: Health (resumed).

Debate resumed on the following motion:
That the Vote be referred back for reconsideration.
—(Deputy R. Barry.)

When I spoke on this Estimate last Tuesday I was critical about the cost of the health services. I also pointed out that although it is easy to criticise it is not so easy to make concrete suggestions. Last Tuesday I said that the cost of health services should be met in full by the Exchequer. I said that 80 per cent of the people were dissatisfied with the costly health services we were providing and I am making a suggestion in the hope that the Minister will give it some consideration. It is true that the Republic has more beds per thousand inhabitants than any other country in Europe. I understand that a hospital bed costs between £30 and £80 per week.

In 1971-72 the total expenditure on hospital services in Ireland was 70 per cent whereas it was 62 per cent in Britain. According to the census figures our population on 1st April, 1971, was 2,971,200 persons. The lower income group constitute 30 per cent of the population; the middle income group—those who qualify for limited eligibility, farmers whose valuation is under £60 on land, and workers whose income is less than £1,600 per year—constitute 60 per cent of the population; the upper income group constitute 10 per cent of the population.

In the middle income group farmers are obliged to pay £7 per year and insured workers must pay 15p per week. This entitles them to free institutional services. According to the Minister the estimated income from the Health Contribution Act, 1971, is approximately £5 million.

The general medical services covering 30 per cent of the population are estimated to cost £7,850,000. Therefore, to extend the free domiciliary medical services in order to cater for the lower and middle income group to correspond with the institutional coverage would cost an estimated additional £15.7 million. The middle income group constitutes 1.75 million persons and at present those people are obliged to pay for home medical treatment, although they are compulsorily insured for free hospital treatment. Naturally they will opt for hospital treatment and this tendency can be controlled only by providing free home treatment.

At the moment we provide free hospital and domiciliary treatment for 30 per cent of the population. Naturally the middle income group will exert pressure on their medical officers for recommendations for hospital admission. If this extra general practitioner coverage is to be provided only on the insurance principle the cost would be £21 per year for the farmers whose valuation is less than £60 and 45p per week for those who are contributing to insurance stamps. I am not suggesting that changes should be made on this basis but the matter should be considered and a more equitable base should be used.

Some 80 per cent of the people are paying £83 million per year for health services and they are dissatisfied with them. Perhaps if my suggestion were investigated a more satisfactory service for 90 per cent of our population might be obtained. The 10 per cent who comprise the upper income group have the benefit of voluntary health insurance and I think their income is sufficient to meet any charges that might be made. In brief, what I suggested on Tuesday and, again, this morning was (1) that the rates should be relieved of health charges (2) that free medical services covering 90 per cent of the population for hospital treatment should be correspondingly extended to general practitioner services and (3) that the recently introduced compulsory health contributions under the 1971 Act, should be ear-marked for general practitioner services to be administered at local level. I make those suggestions in good faith and I hope they will be helpful to the Minister and his officials.

I referred at some length on Tuesday to drug abuse and the Minister's stated intention of introducing legislation to deal with that menace. Since then I read in the papers of a case heard in the Dublin District Court on Tuesday while we were talking about it here. Five youths were charged with taking LSD or Cannabis resin and one of them was so affected that he stripped himself naked and rolled himself on broken glass. What I said on Tuesday was reinforced by the district justice in regard to this case which he described as shocking and he commented on the present situation in which drugs are so easily available in Dublin.

I appeal to the Minister again this morning not to delay the legislation he has in mind or in hand in regard to the control and use of drugs. I asked him pointedly on Tuesday if he would say when he hoped to bring that legislation before us. When the Taoiseach was asked last week about the business that would be dealt with in the House before the Easter Recess I was disappointed to find that drug abuse legislation was not included. I appeal to the Minister in all sincerity this morning to bring that legislation before the Dáil before it rises for the Easter recess.

On Tuesday also I spoke at fairly considerable length of the disappointment felt by some 70,000 people in north-east Cork about the future of Mallow Hospital. Yesterday, unfortunately, I had to return to Fermoy to attend a relative's funeral and I met many of my constituents who had read the reports of what the Minister said in the Dáil on Tuesday in this regard. In the Cork Examiner of Wednesday, 8th March, this appeared in black print:

Mr. Childers: I want to make it clear to the Deputy that in no circumstances am I going to go in the opposite direction to the FitzGerald Report. I am willing to leave it at the status quo until time and the examination of the problems show what is needed.

The people I met yesterday represented a good cross-section of the people of north-east Cork and they took complete exception to this, as I do. It means in effect—and there can be no watering-down of it—that it is the intention of the Minister and his officials to downgrade Mallow County Hospital because while waiting until the Cork Regional Hospital is built—the estimated time for that being put into service is five years and the real time, I have no doubt will be seven or eight years— Mallow County Hospital will be floundering along and I have no doubt but that it is the intention of the Department of Health officials to downgrade it and close it. Again, I want to warn the Minister and the House that if that is attempted a serious and nasty situation will develop in that area. I do not like to be part of it but, on principle, I believe as they do that they are being deprived of services they have been enjoying for years.

They will not be deprived of any services.

There is no use in trying to hoodwink the people.

The Deputy is hoodwinking them.

Not at all. I am only representing their views here and in this case their views happen to be mine also. Is it not quite clear that the intention is to continue what the Minister calls the status quo?

But does not that mean that there will be temporary surgeons here and there? No surgeon of any note will take a chance and apply for a job in Mallow County Hospital when he knows that it is only on a day-to-day basis.

It will not be on a day-to-day basis. There will be a permanent surgeon appointed to Mallow County Hospital if the Southern Health Board agree.

Is it not also true that while there is a doubt about its future—and the Minister admits that —the most modern equipment will not be bought and put into it and it will drag on from day to day?

On the contrary, the argument previously of the retention committee was that Mallow Hospital was doing very well and that they were very glad to have the status quo preserved. It was only later that they proposed a big extension of the hospital's facilities.

But the health boards are not going to buy and put into each of four hospitals in each of four counties, for example, in the Midland Health Board, the most up-to-date equipment. It will only be put into one, for example, in the Eastern Health Board and the other three will be neglected. That is well known and we have been told that.

The Deputy is introducing an entirely different argument.

I am not. I am just arguing that Mullingar will be downgraded and we know the hospital into which it is intended to put the most modern equipment. It will not be put into the other three.

You might add to that Roscommon and Bantry.

No decisions have been made about Roscommon or Bantry or Mullingar.

The previous Minister for Health and the present Minister told us they were adopting the FitzGerald Report and they cannot have it both ways. If the FitzGerald Report is adopted those hospitals are downgraded.

The Minister did not say he was adopting the FitzGerald Report.

Deputy Flanagan said it when he was Minister for Health.

To put the record straight, what the Minister said on Tuesday in the House was that in no circumstances would he go in the opposite direction to the FitzGerald Report.

The very same thing in different words.

What I meant was that they would not be upgraded, that certain hospitals close to great regional hospitals would not be upgraded.

Does the Minister not accept the case I have made that what the Southern Health Board want to do is to purchase Mount Alvernia for surgical purposes and integrate it with Mallow County Hospital?

That is upgrading and I am not going to upgrade any hospital within 25 miles of a great regional hospital. I shall be perfectly frank about it.

Has the Minister agreed to meet the deputation from the Northern Committee of Cork County Council that was anxious to discuss this matter with him?

I have left certain instructions in regard to that. There is a meeting on Saturday. I shall not give any preview of it.

That reply is similar to the one I got from the Minister a couple of weeks ago when, by way of Parliamentary question, I asked him what were his views on the future of Mallow Hospital. He told me on that occasion that he had written to the Southern Health Board. When I pressed him further on the matter he told me there was nothing sensational in what he had written. That was no answer and neither am I receiving any answer this morning.

On Tuesday I referred to an article in the Irish Independent for that day, which was headed: “‘Rubber stamp’ status angers Health Board.” At that stage I had referred to the health boards and had given my opinion of them. I agree that the personnel of these boards are all decent men, whether they be doctors, county councillors or others. In this article it is stated that:

A major confrontation looks imminent between the Minister for Health and one of the most influential of the year-old Regional Health Boards. The issue involved is whether or not, as the members of the Southern Regional Board said yesterday in Cork, they are merely rubber stamps without powers to make decisions.

The decision to integrate Mallow Hospital with Mount Alvernia was carried by a majority of 19 votes to nine but the Minister says something different now. A member of the Southern Regional Board, Dr. J.P. Walsh of Listowel is quoted in this article as saying that he had wasted a lot of time in the past 12 months travelling to health board meetings. He said, and I quote: "I am only wasting my time and I am not coming here any more if this is the way things are going." By this decision the Minister has done a great injustice to the members of the different health boards because it appears now that no matter what decision they reach it can be reversed by the Minister.

Obviously Deputy Barry has not read the perfectly clear instructions on the method of establishing priorities for service by the health boards which I issued to every Deputy when I issued the statement regarding the break-down of the increase in the cost of the health services. For about the third time I indicated clearly the powers of health boards in relation to the amount of money made available in the form of an increase in the volume of service for the ensuing year, and in relation to general national health policy; everything is indicated clearly to the health boards.

I have no doubt about that but is it not clear also from this decision of the Department that no matter what the health boards decide, their decision can be easily reversed by the Department. I was a member of a deputation that listened to representatives of the health board and I can understand their annoyance about this.

Neither the county health authorities nor health boards can override the general policy for health as stated by the Minister for Health and passed by this House when the Estimate is sanctioned. That is to be the position. There cannot be two health boards adopting entirely different types of general national policy. The Deputy knows that very well: it was the case when there were 27 health authorities instead of the present set up of eight health boards.

It looks as if this debate could go on for weeks. Are we to have this question-and-answer business across the floor of the House?

I will not allow the Deputy to play politics.

I would not say that the Minister is not playing politics.

I am not, but Deputy Barry is.

I take exception to that accusation by the Minister. Far be it from me to play politics on this issue. I would remind the Minister that on the eve of the last general election his predecessor, who is now Minister for Lands, came to Mallow and gave an assurance that there was no possibility of Mallow County Hospital being downgraded.

The present Minister for Transport and Power made a similar statement.

That is still the position.

Does the Minister think that the 70,000 people in north and north-east Cork will accept that?

If they accepted it from my predecessor, I do not see why they should not accept it from me. Generally, I keep my word on such matters.

Speaking of the health boards on Tuesday last I expressed doubt as to their efficacy and also as to the future of the health services if they are to be left in the hands of these boards. A few weeks ago a committee of the Southern Health Board met at Fermoy Hospital and one of the members of that committee made certain statements regarding Fermoy Hospital which were reported in the Cork Examiner of Tuesday, 7th February, 1972. I consider it my duty to correct what this man is reported as having said. The person concerned is Mr. P.C. Hill and according to the newspaper report he said that the standing committee had looked at Fermoy Hospital, that they had been around many places but the standard of Fermoy was so low that it required the utmost priority, that it was far worse than anything they had seen in the area and was not fit for human habitation. I understand this gentleman comes from Killarney. It is not difficult to imagine the distress which those statements must have caused to people with relatives hospitalised in Fermoy.

Whatever might be said of local health boards, they were composed of public representatives who gave voluntarily of their services for many years. All they received were travelling expenses and I think it is only fair to place on record our appreciation of the unselfish services given by these people down through the years. I am familiar with the hospital in Fermoy. The matron is a sister of the Order of Blue Nuns and there are several other members of that community working with her. It is unfair to them that anyone should make these statements. We all know that the hospital is not a modern one. It is an old building but serious attempts have been made to reconstruct it.

Members of health boards should be more careful in their choice of language when they are describing such places. Incidentally one would have expected that the local representatives would have been invited to attend that meeting at Fermoy but no such invitations were extended to them. For many years the Labour representative for the area and I have attended meetings there and we might at least have been asked for the benefit of our advice on this occasion. It is my opinion that the health boards are so remote from the problems of the people that they cannot work.

Patients are becoming mere numbers.

We have no national health policy. The Minister says we must wait for the chief executive officers and programme managers to be settled in their jobs before presenting them with a health policy. That is not good enough. Over the years he has had all this advice available to him.

I will not be misquoted by the Deputy. I never said anything of the kind. What I said was that there is a national health policy but the application of that policy to each health board must await the implementation of Volume IV of the McKinsey Report and a system of administration which will enable health boards to choose priorities in their areas, having been told what money is available and having been given quite clearly——

This is really scandalous. If the Minister is going to reply to every point when it is made no one but Deputy Barry and himself will be able to take part in this debate.

The Deputy will agree that that is not my fault.

Deputy Tully does not deliberately misquote my statements.

The Minister says there is a national health policy and I am saying that there is not. That is about the only point of difference between us.

There are 46 pages of it.

The rejection of all the advice and opinions offered to the Minister by Opposition Deputies and the rejection of the Private Members' Bill and motions on health matters— twice in the last few weeks the Minister has rejected these—is not the best way to get the best legislation in relation to health matters. The amount of money looked for stands at the frightening figure of £83 million. That must arouse the conscience of every Deputy. We owe it to those who sent us here to ensure that those who foot the bill will get the best value for the money. It is our duty to examine this Estimate in detail and try to find out if we can prune this figure of £83 million and, if we cannot prune it, then we must endeavour to ensure that the people get good value for their money.

I compliment the Minister on one thing. Like his colleague, the Minister for Education, I believe he must have had by him for the last few years a copy of the Fine Gael policy on health. A few nights ago the Minister for Education on television agreed to such an extent with the Fine Gael policy on the Irish language that we, on this side of the House, could not but be happy at his conversion to our policy. I believe the Minister for Health must have a copy of this little booklet too, "Winning Through to a Just Society", because of the references to a "free medical service based on the family doctor. A free choice of doctor will, where possible, be provided." I am glad to note that this policy will be implemented in the Eastern Health Board area on 1st April and that the Minister hopes to have it extended throughout the country on 1st October next. That is part of the Fine Gael policy. Also mentioned in this booklet are free hospital and specialist services; drugs and medicines at substantially reduced prices for those who do not get them free; Fine Gael will provide generous grants to bodies engaged in cancer research, to hasten the discovery of a cure for cancer; Fine Gael will provide increased State aid for the prevention, early diagnosis, treatment and cure of cancer, and provide, free of charge, the best medical treatment, drugs and care. If I remember correctly, this policy document was published four or five years ago.

The first was in 1961. That is the 1965 edition the Deputy has.

It is Fine Gael policy to abolish the vexatious means test and the medical card system. I am glad the Minister has accepted Fine Gael policy to some extent. Good medical and health services are vital if all our citizens are to be guaranteed the opportunity of developing to the full their talents and personalities. A national health policy is urgently required and this policy should emphasise the early recognition of illness. There should be proper health education, financial support for hospitals, reforms of the existing laws dealing with drugs, foodstuffs and poisons. The nursing profession should be reorganised. There should be support for research in all areas of health and medicine, including environmental hygiene.

The Minister and I differ on a few things, nevertheless I hope that my contribution will be helpful to him and his Department. My intention was to be helpful. I appeal to the Minister now to have a chat with his colleague, the Minister for Social Welfare, in an effort to resolve the dental dispute. Those who are suffering are not the Minister and his officials; they are the unfortunate people down the country who cannot get the dental services they require.

The Minister concluded on the following note: "If I were asked to give my No. 1 priority, I would answer the development of social service councils throughout the country". If I were asked to give my No. 1 priority, I would answer the further development of accommodation and the extension of up-to-date treatment for mentally retarded children. We owe it to these unfortunate children and their relatives to tackle this problem much more seriously and much more urgently.

The Minister for Health and Deputy Barry have made long and detailed statements of their particular points of view. I agree with many of the points made by the Minister and by Deputy Barry and I disagree with others. I wonder if making these long, detailed points in the month of March on an Estimate which will run out within a fortnight or three weeks is really what we should be doing here. We are being slightly dishonest, all of us, in pretending we can influence future policy by debating a past Estimate. The Minister is a senior member of the Cabinet and I would ask him to do something to ensure that debates on Estimates take place as soon as possible after the Estimates are introduced. It is ludicrous that we should be debating the amount of money mentioned here at the end of the financial year.

I propose to be critical of a number of things in the Minister's speech but, before I criticise, I should like to put on record that the comments I shall make will not be of a personal nature. I have always found the Minister unfailingly courteous, not alone in his present ministry but in those he occupied in the past. I disagree violently with some of the things he says and does, but I give him credit for the fact that he never acts discourteously. He has certainly never been discourteous to me. It is only fair to put that on the record because so many of us find that discourtesy is the stock-in-trade of some of the Ministers in the Government and has been for many years. There are a few who have changed but the Minister for Health is one person who has been unfailingly courteous and it is only proper that I should put that on record.

We talk about the necessity of doing something about the people in the Six Counties and we are always anxious to build bridges and encourage the people of the Six Counties to come in here. Then we get an expensive report on health services which, if put into operation, will, in my opinion, cement for a considerable number of years the opposition of the people in the North to come in with this part of the country. They can reasonably say that an effort is not being made to level off the health services. Indeed, more and more people seem to be put into special categories which means they have to pay for whatever services they are getting. This is a big mistake. While I know that money does not grow on trees, an effort must be made some time, and now is as good a time as any, to try to raise the necessary money to pay for the type of service which we must introduce if we are ever to have a Thirty-two County Republic.

There have been comments on and criticisms of the health boards. I am a member of a health board. I have expressed the opinion and I repeat it, that we went off at half-cock with regard to the health boards, that we accepted something as gospel which had not been tried out. While the people in charge of the health boards, the staff of the health boards, are attempting to do what they think the Department want done they are making very heavy weather of it. I find it extremely difficult to come away from a health board meeting, and I understand the same thing applies to other health board meetings, feeling that we have done a good evening's work. There are certain matters we deal with which possibly will improve the health services in the area but very little and they could have been improved just as much under the old regulations. If I may use the expression, I feel there must be a revolutionary change in our approach to health if we are to get anywhere.

Deputy Barry referred to, and I suppose rightly condemned, words used by a member of a health board about a hospital in his area. I have been on a hospital visiting committee in my area and while we have not used the expression "the standard is low" we have found that the conditions under which patients and staff exist in some of those hospitals were absolutely unbelievable if we had not seen them for ourselves. We have reported to our board that in at least one hospital, possibly two, there is a serious fire hazard. We felt that people on the upper storey of that hospital could not get out of it alive if a fire occurred. This is a shocking condemnation to have to make of a hospital but it is true. There are hospitals which are very much under-staffed. One finds a hospital with, say, 50 or 60 seriously ill patients and into which accident cases are brought, with one surgeon and three nurses, all of whom must leave the wards and go out in the night to help to bring in accident cases, with toilet facilities almost non-existent. In fact, the female patients have to go through the male ward to get to one bathroom and there are no other toilet facilities on that floor. It is hard to believe that this sort of thing exists in 1972. We went into one physiotherapy section of a hospital in the afternoon. It was very cold because the heating system was not, and apparently has never been, effective. When we inquired about it from the lady in charge she was very local and said it had been very sunny in the morning and if we had been there then it was quite warm. Anybody who tries to tell me that the way to heat a physiotherapy ward in this country in January is to have big windows for the sun to come through is asking me to believe more than I would be prepared to believe. I am not blaming the Minister or the Department of Health for this but the task is far greater than FitzGerald realised it to be. By simply writing down plans and figures without getting the necessary knowledge from people on the spot, and it appears from the report that this was not done as it should have been done, we are bound to find people who apparently are living in a cloud-cuckoo land, who believe that the State possesses a bottomless purse and all we have to do is make plans and if the figure is £20,000 or £20 million for new hospitals that is all right because it will be done if it is written down. The fellow who writes it down will get paid anyway so why worry very much?

One of the priorities we must look at is what are we going to do with the old hospitals that are not capable of doing the job for which they are being used. In what way can we see to it that the necessary money will be made available to turn these hospitals into good local hospitals? The Minister is talking about not upgrading a hospital within 25 miles of a good regional hospital. The fact that FitzGerald talks about regional hospitals seems to be overshadowing the fact that existing hospitals can, if a certain amount of money is spent on them, be turned into hospitals which will do exactly what is required in an area. The Minister is making a mistake if he thinks that spending a relatively small amount of money on a pretty good smaller hospital is up-grading it. There is no question of up-grading it but surely we must do something to keep existing hospitals in proper repair and capable of doing their job until such time, in the dim and distant future, when the necessary money can be provided to carry out what is recommended in the FitzGerald Report.

In many of these hospitals the old routine has been there for many years and things have been done in a certain way. With the changes in the hours of work of staff it has been necessary to make changes in the running of a hospital. This is as it should be but some of them apparently have not got around to doing what is being done in neighbouring hospitals and we find one or two senior staff bearing the whole brunt. I could mention one surgeon who appeared to be the general factotum. I do not know when he got sleep because the number of patients he had to look after day and night— there was nobody to relieve him— meant that he seemed to be on duty all the time and he was not a young man. Something must be done to ensure that existing hospitals are staffed properly and the very best use made of them.

When the Health Act was going through here a number of amendments were suggested and a number of amendments accepted. A mistake has been made in one or two places. I want to highlight one. There is a hospital which is known as the country infirmary. Originally there were three trustees who helped to run the hospital and the balance of the board was made up of nominees of the county council. The original trustees died. They included the parish priest, or administrator of the parish, and the Church of Ireland minister in the area. At one time these two gentlemen or their successors were nominated as county council representatives on the board. Eventually there was nobody on the board except representatives of the county council. The clergymen apparently consider themselves as still being trustees. According to a section of the Act it appeared that since the hospital was in this position it should have passed to the health board from 1st April last, but it did not. The result is that it is now neither fish, flesh nor good red herring. If the county council with draw their representatives because, if the hospital continues as a voluntary hospital it is doubtful if they are entitled to have representatives, there will be nobody left but the parish priest or administrator and the other clergymen. Recently, when the hospital got into financial difficulties the legal advice was that the county council had no authority to make a grant towards the hospital or even to guarantee a loan. The Department of Health maintain that it is a voluntary hospital.

When the matter was taken up with the Minister he referred to the fact that the hospital had a big credit balance which they should use before talking about anything else. It was then discovered that either somebody in the Department of Health did not read the balance sheet correctly or that the person who prepared the balance sheet had not made the matter very clear because a figure of £30,000 shown to the credit of the hospital was found to represent the buildings and the contents of the hospital and that, in fact, there was a bank overdraft of several thousands of pounds.

Over the last few years the hospital has been losing money, mainly because the capitation rate is low, about one-third or one-fourth of the charge in other hospitals. When an application was made to have the capitation rate increased from 1st April last they were told that it would not be increased from 1st April last but it could be increased from 1st April of this year and that then everything would be all right. I mention this because the matter has not yet been solved. The Department have admitted that somebody misread the balance sheet and that there is a heavy overdraft. The fire officer has insisted that the top storey be cleared. Unless money is made available to provide alternative accommodation now—not next month or the month after—the fire officer will make an order that the hospital be closed. In that case the patients will have to be accommodated elsewhere but there is no alternative accommodation for them. The Minister may be able to do something about this matter which I have already discussed with him. I had a letter from him to which I replied but have had no further reply from him. I assume he is having the matter considered. I would ask the Minister to ensure that the financial difficulties being experienced by the county infirmary in Navan, which is a very old and very good hospital, are solved. The cost of providing alternative accommodation for the patients there would be far greater than the sum required to keep the hospital open.

I should also like to know from the Minister whether, in fact, it is a voluntary hospital and whether it should be passed to the North Eastern Regional Health Board on 1st April or to tell me who now owns the hospital. There seems to be doubt about that, which should be removed.

Another matter in which the local health board have taken a hand is the matter of medical cards. At present-I am not blaming doctors for this because, like everybody else, they must get an increase in income—it is an expensive matter to attend a doctor and an even more expensive matter for the doctor to attend at a patient's home. In the latter case, the fee charged represents in many cases a day's pay for the breadwinner. If the household has not got a medical card and the doctor attends at the house and charges £2 or £3 per visit and gives a prescription for which the local chemist could charge anything from £2 to£5, it is obvious that this imposes a serious strain on the household. The person who is sick and dependent on social welfare benefit may find that he is unable to buy food for the family or to pay the rent. Therefore, in my view the new arrangement in regard to medical cards is not a great deal better than the old one and in some cases it is a great deal worse. According to the North Eastern Health Board scale, a single person earning under £10 a week can have a medical card; a married couple with under £15 per week can have a medical card and there is an allowance of £1 extra per child.

Take the case of a man earning £23 a week who drives 40 miles from the middle of County Meath to a building site in Dublin and returns home in the evening and is doing this five days a week. He applies for a medical card. He may have a wife and six children. If he has over £21 per week he is not entitled to a medical card. It costs about £4 per week to drive in and out to work. This is not taken into account when assessing income for medical card purposes and therefore this man is disqualified. This is not an extreme case.

This matter should be considered by the Department. The health board officials tell me they have no jurisdiction in the matter, that they are allowed to make a certain allowance for rent but for nothing else. In such cases as I have instanced, if the person becomes ill and the doctor's fees amount to £8 or £10 and the cost of medicine is £5, that represents almost a week's wages, but the man does not get a week's wages for that week. If he is the type of person who does not like to absent himself from his job and stays out for only one week, he will get an allowance in respect of only two days from the Department of Social Welfare because the first three days are not paid for.

When I am told of how well the poor are cared for, cases such as I have mentioned come to my mind. In my view the matter of providing health services for those on the bottom rung is not being approached as it should be. A great deal more must be done for these people. I hope I am being fair. I am prepared to produce evidence to sustain my allegations, if the Minister has any doubt about them. It is too ridiculous for words to suggest that a medical card should not issue to a married couple who have no more than £15 a week, having regard to the fact that the minimum rate for agricultural workers is now approximately £17 per week. The system in operation is the sort of thing which causes trouble and annoyance. I would ask that something be done about this matter.

We now hear that choice of doctor is coming on 1st April in the eastern region and on 1st October in the rest of the country. I hope the Minister will be able to ensure that there will be no change in the date. He did promise that it would come into operation on 1st October last year but that did not happen. People come to me and say that they are paying 15p on their insurance cards for choice of doctor, and that they have not got a medical card. Anybody who has not got a medical card can choose the doctor he likes but will pay for the service. Therefore, the 15p does not apply in that case. I am not quite happy about the service being given to those covered by the new scheme, either the 15p or the £7. A number of local health authorities have attempted to introduce certain restrictions. The Department of Health, apparently, are not prepared to agree that those restrictions should apply. Until I asked the Minister for Health about X-ray and pathology charges there was at least one health board who were not prepared to pay for these services and who indicated that they were not covered by the new scheme. They now say they are covered by that scheme. Before the scheme was introduced if somebody went for treatment to a hospital outside his own region arrangements were made for payment of such hospital charges. In my constituency it is quite common for patients to go to hospital outside the region because most of the patients from County Meath and County Kildare go to Dublin hospitals where they are able to get quicker services. It is now being ruled that if patients go outside their own regions for treatment it is not possible to pay for out-patient services. I am also told that drugs and medicines obtained in such circumstances cannot be paid for.

In-patient or out-patient services given to a patient should be paid for provided a recognised hospital is used. It is often very difficult to get beds in the particular type of hospital needed. It is only right that if somebody can get a bed and be taken into hospital that he should be paid for in that hospital if the cost is not more than it would be elsewhere. I see no point in building up paper walls because they make people feel more important.

The object in introducing this scheme was to ensure that people who could not afford to pay for services out of their own pockets should get such services by paying the £7 per year. It is wrong that anybody should introduce an element which would prevent such services being paid for by inserting some small print which says in effect: "This is one fellow we can prevent from getting the free service." I ask the Minister to ensure that people who go to hospital for treatment shall have their bills paid, provided they do not go to a hospital which has much higher costs than those of the local hospital. Very often no beds are available in the patients' own area. Such people should be entitled to go where they can get beds for treatment because when a person is ill it is much more effective to get early treatment than to wait three or four months for a bed to become available.

I am wondering about the amount of money which the new contributions will produce. How much will be produced up to the end of March? The Minister mentioned £5 million as the amount for a full year, made up of the 15p and £7 contributions. I assume that the grants to assist the rates will come from that sum. If not, perhaps the Minister would tell us what will happen to the £5 million? Where will it go?

With regard to the assistance to the rates, while we are all glad that assistance is being given, we feel that there is something wrong with rates which have to be boosted so much by the State. In County Meath we have people who have been in charge of the health services for many years and they have been careful about overspending. This year our proposed expenditure, taking the county on its own, as part of the north-eastern region, was 42 or 44 new pence. The Minister does not allow it to go beyond 30 new pence so we get 14 new pence off. One of the neighbouring counties had 96 new pence and the Minister says it cannot go beyond 30 new pence, so they get 66 new pence. Is there something peculiar about this? Are some areas not doing their jobs as well as others? I would like to hear the Minister's comment on this.

I would like to know also about the cost of medicines and drugs which have to be bought. People who have to pay for these things say there is no point in going to a chemist's shop with less than £2. I am told that drugs and medicines have risen very much in price. It has been said that the cost of living has gone up, as has the cost of dying, and that the cost of getting better has also gone up dramatically. An effort should be made to find out whether excessive profits are being made on drugs. Up to a few years ago local authorities were supplying drugs at 48 per cent of their cost. They are now supplying them at 54 per cent of the price which is charged to people who buy these drugs across the counter in chemists' shops. Somebody is making excessive profits. An inquiry should be held into the costs of drugs and medicines. Some doctors feel that any new drug which comes out must be good. If a drug gets a good write-up they recommend it for their patients no matter what it costs. This makes it difficult for people without medical cards. The medical cards are very valuable.

I do not propose to delay the House for very long. I am standing-in for Deputy O'Connell. I would like to find out why private wards for patients cost so much in voluntary hospitals. I recently saw a five-bed children's ward. There was nothing luxurious about it. The five little beds were in one small room. I understand the cost per child is approximately £60 per week. That cost refers to the hospital alone and does not include the cost of specialists' treatment for the child. This figure cannot be justified by any standard. The costs of running a hospital are very high, but I cannot see why a room about 15 feet square with five little beds for five children should cost £300 a week. The children in it were small and were not eating much. The Minister may say that this has nothing to do with him, but all health matters concern him. If someone feels he would prefer to pay for treatment rather than wait for treatment at the expense of the State, it is wrong that he should be charged amounts like that.

I will cut across the FitzGerald Report here by saying that I believe that the Minister should make an effort to survey all the hospital beds available under every heading in each region. The regional officers could carry out such surveys. Old buildings which are in an excellent state of preservation should also be surveyed. Nobody wants to live in them because the rates are so high they cannot afford them.

We should find out if more hospitals can be made available at local level. This is a far better approach than talking in terms of getting £20 million or £30 million to build a couple of regional hospitals. When we talk about money like that, in view of the tremendous cost to get our services anywhere near like what they are in the North we are 20 or 25 years behind.

Deputy Carter will remember that the Minister's predecessor said it would possibly be 15 years or 20 years before any change could be made in Mullingar. I believe the situation has not changed, except for the worse, since then. In fact, the new regional hospitals we are talking about could be as far off as 15, 20 or 25 years, when many of us will be dead and will not be worrying about what type of hospitals will come after us. We should attempt to have a short-term, practical approach to this and with a relatively small amount of money these matters could be looked after.

I would like to pay a tribute to the staffs of the smaller hospitals throughout the country, many of whom are working under very primitive conditions. I was in a hospital recently where the operating theatre was so small that the anaesthetist had to stay in the passageway outside the theatre. There was no room for anything in that theatre. One or two people could fit by squeezing in. I am quite sure alternative accommodation could be found in the area if an effort was made.

One good thing the regional health boards did was to get people outside the area to have a look at these hospitals. As a result, there was a fresh approach. I disagree with Deputy Barry when he said that outsiders had been critical of areas because they were not looking at their own areas. People who come from outside an area are more likely to be critical of it than the people representing the area, people who have not done their job in the past and feel therefore that criticism of the particular hospital is criticism of themselves.

Mental hospitals present a big problem all over the country. I would like to congratulate whoever wa responsible for setting up clinics where people who are slightly mentally disturbed, instead of having to go into hospital every couple of months at tremendous expense, can attend regularly at those clinics, and get drugs which they can take when they need them. It is a great improvement to keep those people out of hospital. I know many people now living normal lives who were for years in and out of mental hospitals. This type of thing should be encouraged.

We do not seem to be able to segregate people in mental hospitals. There will have to be special wards for those who are seriously disturbed, slightly disturbed and particularly for the young. It is wrong that in some hospitals it is necessary to have young people in the same wards as old people who may not be in the same category as criminals but have been there all their lives and have an outlook on life which is entirely different to what we would like young people to have. There should be a more modern approach to people in mental hospitals.

Mental hospital staffs from the RMS down are dedicated people. We may criticise them but I do not believe we would like to do their jobs. We cannot give them enough credit for what they are doing. It may be said they are being paid for it, but so are we. Some of us do not do our jobs too well, but they have to do theirs all the time.

I want to refer now to the psychiatric nurses dispute. The Minister is not a man who is known to be unfair or to make intemperate statements, but he was very wrong when he commented the way he did on the agreement which was made at the settlement of that strike. I am a trade union official and nobody knows as well as I do how difficult it is when some type of grievance occurs to keep workers from going on strike to get something they cannot get any other way.

This situation was allowed to build up in the psychiatric service. Nobody regretted the necessity to take strike action as much as the people concerned. There was no vindictiveness and they were not trying to create hardship. When an agreement was reached at the end of the strike it was wrong for any Minister to say that he did not agree with the terms of the settlement. If he did not agree with the terms he should have said so before the settlement was made, not afterwards. This sowed in the minds of the people who were affected by it the idea that at the first opportunity the Department of Health would get their own back. It is unusual for the Minister for Health to be unfair in approaching difficulties but he was unfair in this case. If he got advice on this it was bad advice. I hope the matter will be finally settled and that an arrangement can be made which will prevent the necessity of ever having a strike again in that service or in any other hospital service. We must remember that the people concerned are human beings and if they cannot get their rights one way then they will attempt to get them by strike action.

I now want to talk about the ambulance drivers. Recently there have been discussions with the CEO's of the health boards regarding the ambulance service. The Minister must take an interest in this because it is a national problem. Nobody in this House or in the Civil Service would agree that their hours of work should start at 7.30 in the morning or earlier, should continue until 6, 7 or 8 in the evening, and that when they go off duty they should be on call. On call means that they do not leave the hospital or their homes during the night. If they are called out they must go. It is no use saying that they get time off the next day or they get paid for it. How many of us would agree after our day's work that we should be called back again and perhaps work during the night, then the next day be on second call which means if something happens you can be called out again. If we have the ambulances we have got to pay the drivers.

Ambulance drivers are dedicated people. Anybody who has gone with an ambulance driver can see the care and attention that is given to the patient, no matter how ill or how contrary the person is. We all know how well they look after people involved in a road accident. Advantage has been taken of those people by trying to make them Jacks of all trades, not very important people who can be called out and should be prepared to do duty 24 hours a day. We should not forget that the old slogan "They also serve who only stand and wait" applies to ambulance drivers as well as everybody else. They are on duty when they are waiting to be called out. Even in the Army a man who is on stand-by for a night gets the next night off.

The rates of pay they are getting are not commensurate with the job they are doing. The compensation they are getting for this type of stand-to is not adequate.

In one or two counties before the new health boards were established arrangements were made that they would be paid overtime for hours of work. They did not get time-and-a-half, which is the normal overtime; they were paid an overtime rate which was slightly more than the ordinary time rate. When the new arrangement was made it had to be changed because it was found they were earning as much in overtime as they were in normal wages. Why was this? It was simply because they were on the road night and day. It was definite proof that when they were being paid for it they had to be out all night. Therefore a nice arrangement was made whereby instead of getting £24 or £25 payment for overtime, it was agreed that they would get an extra £2.50 per week, and they would get that whether they went out or not. The man who earned £20 in overtime would do the same amount of work for £2.50. Can you blame him if he is discontented with what he is offered? The whole service must be examined and a new approach made to it.

Would the Minister, for goodness sake, find some way of bringing the dental service back to normal? I believe—and this is a personal and not a party point of view—that, until we can make an agreement with the ordinary dentist in the towns and villages and in this city for a fee per service, no progress will be made. A dentist told me recently he was doing work for the county council clinic. Normally he did a two-hour stint and six people were listed to him and notified to turn up. The average number that turned up was three. If the service they required was small he just sat down for the remainder of the time. He said to me: "If I were given a fee per service I could take about ten and it would not cost the local authority as much as it is costing them now." If that is true or even half true an effort should be made to hammer out an agreement.

Another group of people who are not appreciated as much as they should be are those who are responsible for the care of the aged. No matter what we may say about this being a great Christian country, we treat our old people shamefully. How many of them do we find in old folks' homes? They are just put in there and forgotten. Nobody visits them. Old people may have a farm or a house which they want to give to some of their relatives, and they will be looked after for the rest of their lives. There was a time when I recommended to these people that they should transfer their property and apply for the pension. I do not do it any longer, because a number of victims of that transaction found their way into the old folks' home. It is not that they are not being well cared for. The staff there do everything they possibly can to help them; there are people who go in to visit them and try to entertain them. However, all of us admit there is a vast difference between the comfort of a person sitting at his own fire and having to go miles and miles away where he does not know anyone. These old people may make new friends and they may not. Maybe they turn out to be contrary old men and old women, as I suppose we all will as time goes by.

I do not think that old people who cannot afford to stay at home should be put into this position. Because of the cost of their upkeep would it not be much better to give some assistance to them at local level which would enable them to live at home? Many of them are very independent people who like to be able to live their own lives and look after themselves. Many of them can do so, but some of them are living with a son or a daughter and when they get old or get ill and the family are coming along, the daughter-in-law is not able to look after the children and the mother-in-law as well, and the result is that the poor mother-in-law finishes up in the county home. I have made a comparison with a number of other countries and, as I said on more than one occasion, we have a worse record than they have in that we do not treat the aged with as much tenderness or consideration as those other countries that have not got our tradition of christianity.

The drug problem has been mentioned by other Deputies and I do not want to detain the House, but let me say that it does appear as if the drug problem is growing. When one looks for an explanation of some rather stupid act done by a person, if there is no other explanation, usually we find that drugs are responsible. The decision not to have hard drugs or indeed any drugs in a number of lock-up dispensaries was a good one. It was far too easy to get drugs in this way. I remember going into a dispensary with a doctor on one occasion; it was in bad condition and he wanted to show it to me. The first thing I found was that, although a new door had been put on, there was no lock, so we just pushed the door and walked in and everything in the dispensary was there open. He has since retired. I pointed out to him that I thought he was a very irresponsible man. He was rather angry and wanted to know if I expected him to put a lock on the door when the county council would not do it. Maybe he had a point, but I considered the drugs were left in his custody and he should not have left them so that any hobo could walk in off the street, push the door and pick up anything he wanted. The doctor subsequently said that nobody stole anything around that part of the country, and maybe he was right.

If we are really serious about the health service and particularly if we are really serious about attracting our Northern brethren in with us, we must with the problems involved.

I know there are a number of Deputies who wish to speak, so let me finish on a personal note. On a number of occasions I raised in this House with him the question of the validity of certain marriages which take place outside this country. Some people were surprised that I raised it with the Minister for Health, but it is the responsibility of his Department. The Minister pointed out that it was difficult to get the matter cleared up and that he proposed to introduce legislation as soon as possible to try to regularise it.

The simple facts are that some years ago it was the practice for some young couples to go with a Lourdes pilgrimage and when in Paris or in Lourdes to get married, have their honeymoon there and return. The idea was a very nice one, but the snag in it was that unless you were 21 days living in France you could not have a civil marriage and a marriage in France is not recognised unless there is a civil as well as a religious ceremony. In this country the religious ceremony is recognised as a civil one as well, so the matter is very easy to deal with. I suggested at the time that legislation should be introduced for the purpose of having it officially recognised here and the Minister pointed out that he could see snags in it, that he would see what he could do and that he proposed to introduce legislation.

That is 12 months ago and the position now is that people who go and get married in Lourdes are not married according to the laws of this State. They are married according to the church but the plain fact is they are not legally married according to the State, and if they die intestate the next of kin are not their wives or their children but the relatives they have on their own side of the family. There is the case of a wife who was dispossessed by her husband's relatives because she did not go through a civil ceremony here.

Mr. MacEntee when he was Minister introduced a Bill ten years ago but when it was almost ready for debate in the House it disappeared. People talk about belts of croziers. There is no question of anybody being in the wrong in this matter. I have discussed it with a bishop and those in the church are as anxious as anybody to get this thing rectified. It is unfair to mothers of families growing up because as far as the State here is concerned they are not married. Do not let us put our hands together and say that according to the church they are married. The fact is they cannot go into court and say they are married because the law says they are not.

To many people the spiritual aspect of marriage is more important than the civil but all will agree that we require the legislation I have been appealing for. I know the Minister is terribly busy but I appeal to him, nevertheless, to have this situation rectified. He wanted to know if many are involved. I estimate there are between 200 and 300 couples. I have as much respect for the clergy as anybody has but it is said that the clergy are preventing legislation by saying they do not think it is a good idea. That happened a certain number of years ago. If the French Government are prepared to agree, it should be a very simple matter for us. The Minister need not say to me that it is all right to go and have a civil marriage here. There is the problem of the children, and children already there are not covered by the marriage. Therefore, I ask the Minister to introduce the necessary legislation at the earliest possible opportunity.

I have listened to a number of speakers during the morning and, apart from certain detailed criticism here and there, the general trend has been a recognition of the comprehensiveness of the Minister's statement. I regard it as one of the most comprehensive I have heard in the House since I came into it. I think it is the first time a Ministerial statement has covered all aspects of health from birth to the phasing out of life. This is welcome. Of course some Deputies tried to pick holes in it. That is natural. There will always be criticism, some legitimate, some not so legitimate, but as a Deputy of some little experience of matters appertaining to health, I welcome this statement. Regrettably, I have not had the time to read the statement in full so as to be able to assimilate all the items under the different subheads.

During the past year, since the setting up of the regional health board system, certain attempts have been made by certain people with a mission in health, as it were, some of them medicos, others politicians. No later than last week we had such an attempt at our county council meeting. It was an attempt by members of the Westmeath County Council. I was appalled at the role the Westmeath County Council adopted. They are represented by four members on the Midland Regional Health Board and it appalled me that they could stoop so low as to suggest that we should scrap the regional system and go back to what we had.

There is an old saying, and a true one, that you should never go back to what you left. I suggest this attempt was made from ulterior motives which I shall not go into here. Resolutions and motions of that type should get the wastepaper basket from all local authorities because that is all they deserve. Health is a continuous programme and we all know that even in a period of from five to 20 years one cannot improve the system to the pitch at which one would like to have it, but in the period since the Select Committee on Health Services was established by Mr. Sean MacEntee back in the sixties, the transition has been reasonable. The evidence tendered to that committee and the conclusions reached were the basis for the subsequent Health Act.

We hear a lot about the general medical services. Even under the old system, despite all the criticisms of it in the House and elsewhere, the benefits were very good in our circumstances. However, we must move away from that age and I think it can be truly said that we have moved away from it, particularly having read the Minister's statement. One has to look at the financial end of the matter, but before doing so one must bear in mind that the most important person in medicine is the patient. This has been recognised by the Minister and by Fianna Fail and I suspect it is possibly the reason for some of those screwy resolutions which have been coming from various interests who have a narrower view. The Minister has in detail given us an account of increased costs and of the manner in which expenditure on health has risen in the past two years. He has told us of the method he has used to deal with increasing costs and to relieve the pressure on local authorities.

The step taken by the Minister in making available £5.3 million towards the relief of rates took the wind out of the sails of many local critics who condemned the cost of health services in relation to the rates. I dislike to see them increasing, but we must not forget that the most important person in the health services is the patient and he is entitled to the highest standards of preventive medicine.

Deputies may disagree about the way the health services are operated but I doubt if any would disagree that the patient is the person who must get the utmost consideration. We know that costs have risen; we realise that there is a high labour content in our health services and that extra pay and allowances cannot be given without increasing costs. Deputy Tully spoke about ambulance drivers. In the past few years we have upgraded their status and Deputy Tully would like to see this practice continued. At the moment the Minister has a consultative committee working on this matter of health services and I welcome this step.

Staff relations are an important matter; it should be possible when problems crop up at local or central level to discuss them and to take measures to remedy them. Unfortunately, when we look at the size of our Budget and the money that is spent on health we can see that it takes, and will continue to take, a large slice of the national cake. Therefore, it behoves all of us when we look for money and when we get it, to ensure it is spent in a wise way. In this regard in relation to expenditure the Minister is wise in having the best advice available at local and central level.

We have improved the general medical services considerably, although there are many who will say that since we set up the regional boards there has not been an improvement in the services. I could point out many improvements but I shall not detail them now. The ancillary services can be of great help in promoting better health, especially among the upper age group. This is the group that is more liable to go to hospital. The Minister said not long ago that one person in ten spends some time in hospital each year. Hospital expenditure is the largest factor in health expenditure; in fact, it constitutes 75 per cent or 80 per cent of the entire expenditure on health. If we set out to achieve the best attention for the patient, the best pathology, the best surgery, and the best nursing care, who will say the patient is not entitled to this service? Therefore, our aim is to achieve better hospital services.

If we think the one-man unit will last in the 1980s we are only fooling ourselves. In this context, when the Minister implemented the scheme in the Eastern Health Board, when he asked the Western and Southern Health Boards to proceed on a Eastern Health Board to provide on a planned basis for better hospitalisation, he was met with some criticisms. In addition to criticism from politicians there was criticism from some of the medical profession. However, despite that criticism, the Minister was right to proceed with the scheme in the university cities. These areas will give the lead with regard to hospital services and if we cannot promote the scheme in the university cities we will not be able to proceed in the five regional areas.

If we do not proceed in the eastern, western and southern areas we will fall behind in our aim to provide better hospitalisation. Young people leaving medical schools now do not want to work in small units. They cannot be blamed for this attitude; it is happening in other countries, and why not in Ireland? The Minister should not be deflected in any way from proceeding with this work, although knowing his attitude towards matters relating to health I am sure he will not be deflected. In going ahead I believe he will benefit surgery and health in a way that has not been done heretofore.

It has been said that it may be a long time before we are able to build all the units we would like to see, and this may be true; but it should not stop us from embarking on the scheme which was proposed in the Health Act passed by this House and erecting all the hospitals we can, siting them in areas where the best laboratory services and all the staff necessary are available so that these hospitals will be able to provide training centres not only for surgery but for nursing also. I would welcome this trend.

I heard severe criticism in the past of the FitzGerald Report. That was the work of an 18-man team drawn from the highest posts in medicine. They gauged the position properly. They looked to the future but, unfortunately, sometimes when we discuss matters we are inclined to look to the past. The future is often made in the past and this should be so in our case. We have sufficient experience of the past to make better headway and spend more wisely in the future. Therefore, let us not waste time or money in talking of units that will be obsolete in the eighties. Let us provide medical aids to support the surgery which we expect in the future: let us have medical units to receive the patients but we should not indulge in idle speculation as to what might happen in regard to the one-man unit because I believe that is something of the past. No doubt, on the other hands, criticism will be levelled at the rise in expenditure of about £13 million in two years. We have something to show for it. Somebody said lately, and it is now recorded here, that the cost of the health services is roughly £28 per head per year. I say: What about it if we get the service for it, if we are able to cut down on disease, provide better surgery and better nursing services? What about it if we can prolong life? The expenditure would be well worth while if we can achieve those aims.

In his report the Minister referred to the basis of a programme designed to achieve defined objectives, and to my mind this is very necessary if we are to ensure that we shall not lose time or duplicate services. The Minister spoke of community care, general hospital care and special hospital care in those programmes and above all, about preventive medicine, where targets would be set for dealing with certain diseases in children and old people. In support of this we can do a good deal on a voluntary basis. Strangely, in this House when we are discussing health in terms of spending we always seem to call for higher spending and the criticism is usually that we are not doing enough no matter how high rates or taxes may be. We could do much more to help the auxiliary services if each of us did a little voluntarily. I submit that the units set up for the care of the aged could be helped and expanded if we spent a little less time walking around with placards and protesting and more time doing something positive. We would have more for our work and thought if we devoted more time to the aged on a voluntary basis and, in terms of comfort, the aged would benefit.

I think it was Deputy Barry who said he was in favour of early marriage and the surrendering by the aged of rights and the making of suitable family arrangements. So am I, because I think we can neutralise the tendency to get rid of the aged. We have housing legislation to provide extra room so that the aged people in a house by making a family arrangement, will have their own apartments and I think in that way conflict between young and old can be avoided. By voluntary effort we could do a great deal more, but somehow we are not good at that. It is not for want of sympathy; rather, we have too much sympathy and not enough practical help. If we could encourage the voluntary end of the auxiliary arms of the scheme we would be doing a good day's work. For instance people could devote part of a day each week to helping to take hot meals to aged people who might live in isolated places and who would welcome comforts in kind rather than cash. Often it is a little thing that makes the difference in a person's life. I commend this aspect of the programme.

There was reference in the Minister's speech, too, to preventive medicine. We all know that preventive medicine is much less costly than hospitalisation and we must encourage our people to co-operate with their family doctors and to report any symptoms that they have and which they might associate with disease. There are many illnesses or diseases that could be prevented if detected and treated in time. The programme mentioned by the Minister here is a means of helping in this regard.

There is the prospect also of programme budgeting. Of course, the Minister's Department are not the only Department that will be indulging in programme budgeting. This is to be welcomed because it will provide a more steady system in relation to spending. It will help to make people more aware of the expenditure involved.

There was reference in the Minister's speech, too, to the management structure of health boards. The health boards are only new establishments and we must give them a chance during their transitional period. Therefore, I do not think we should have had so much criticism of them at this stage. In our circumstances planning should be based on a unit such as a health board where the Minister has available to him all the advice and technical help which should be available to any Ministry of Health. The personnel to spearhead the various aspects that come within the ambit of the boards should be established by the health boards.

If one reads page 11 of the Minister's statement he will probably agree that the information given is a justification for general medical services. From the statistics given one can see that the marriage rate and birth rate are on the increase while the number of deaths is decreasing. We are told also that there were no deaths last year from highly infectious diseases and that there were no cases of poliomyelitis or diphtheria in 1970. That is a great step forward. I remember a time here when those two diseases were mentioned here regularly at Question Time and on Estimates. There was one stage when there was a serious threat of poliomyelitis. The virtual disappearance of these diseases is a great advance in preventive medicine.

I would like to refer now to one matter which concerns my area. Some time ago tenders were issued for the building of an additional unit to St. Joseph's Nursing Home, but so far I see no sign of any building begining there. I want to impress on the Minister the desirability of development in this direction. Before the building of St. Joseph's the accommodation available was poor. We used what was formerly the old county home. The addition of a new unit to St. Joseph's is badly needed. I do not think the delay in building this unit has been caused by the Department but I would request that the CEO of the Midland Health Board would exert some pressure so that the unit may be commenced at once.

Unlike Deputy Barry I would agree with the Minister giving priority to the development of social services throughout the country. I have dealt with this matter to some extent during the course of my remarks when I referred to the care-of-the-aged programme, but of course there are many other sides to it. If the community would participate in a measure of voluntary health it would be more effective than anything we could do by voting money because we are being accused of overspending in this regard while not spending enough in other quarters. However, we try to provide what we believe to be a realistic sum to ensure that the best services are available to patients and, in the field of medicine, the patients are the most important people.

Deputy Carter referred to the comprehensive review of the health services given to us by the Minister when introducing this Estimate. Certainly, the Minister covered the entire field, but Deputy Carter referred also to the difficulty of studying all this material. Of course, the information supplied is very interesting but each of us receives so much documentation that it is very difficult to get through it all.

In dealing with the Health Estimate there are two main considerations, namely, the quality and the cost of the services. Of course the quality of the health services is all important but cost is very important, too, as has been said by Deputy Barry and others. I believe the general view, both inside and outside the House, to be that the payment of a large portion of the cost of health services through the rates is an inequitable system of providing the necessary finance. This should be changed. I agree with this view because the householder is, I believe, being called upon to carry far too great a proportion of the total burden. It would be much more equitable if the total cost were transferred to the Exchequer, especially if tax evasion could be tightened up to the point at which everybody would have to pay his or her fair share. The general experience is that in many households all the family do not contribute what they should and the main burden of the rates, for instance, falls on the head of the house, a very hardworking individual generally, and I doubt if any of us want to see this sort of situation continue. All of us want health services improved and standards maintained. Money will have to be found for that purpose, but the present method of financing the health services is not the way in which they should be financed.

The money provided must, of course, be spent to the best advantage and we must at all times ensure that we get the best possible value for the money spent. There is a possibility that we are retaining services which have outlived their usefulness. There is need for review and reassessment. Deputy Carter says the heaviest burden of cost is in the institutional services. Approximately 75 per cent goes towards providing hospital care and treatment or institutional treatment of one kind or another.

I question whether the mass X-ray scheme is worth retaining. Has it not outlived its usefulness? It was introduced for early detection of tuberculosis. It was a very valuable service initially. It must now be costing thousands of pounds. Is this expenditure justified for the sake of finding, perhaps, one person suffering from a chest ailment? This is not money well spent, in my opinion. I think, too, that people have been given a wrong impression about this mas X-ray. It is described as a health X-ray and foolish people imagine that when they are X-rayed under this scheme they are all right for the next 12 months because they have a clean bill of health. Tuberculosis can, of course, set in during that period and be gone beyond cure almost at the end of the year. So can lung cancer. But people have this foolish idea. This is a service that should be reviewed and reassessed with a view to seeing whether or not continued expenditure on the service is justified. This money would be better spent advising people to see a doctor when they do not feel well.

Another service of doubtful value is the BCG vaccination service. It had its place in its day, but that day is now past. That is not to say that there will not be in the future some groups at risk, but the wholesale BCG vaccination of all infants has outlived its usefulness. This money is not wisely spent and there should be some reassessment of the position.

As has been said, the main consumer of expenditure from the health point of view is the hospital or the institution. What can be done to minimise requirements where hospital beds are concerned? What can be done to limit the period in hospital to the shortest possible time? What can be done to streamline hospitals to ensure that the best value possible is got for the money? These are areas in which economies could be effected, areas in which the quality of the service could be improved.

The concept now is that of the total health and illness needs. It is not just the provision of beds in hospitals and treatment. Community care is a matter of much greater concern to those engaged in the provision of health services. This is a very important change. If we had better community care services, we would have fewer people in hospital. No doubt it will cost something to keep people in the community, particularly the old people, but it is the community they should be kept. In the long run it will be cheaper to keep them there because they will be happier than they would be in institutions.

Deputy Tully referred to his experience in this field. All of us who have any contact with health, with hospitals and the care of the aged have had the same experience. I know excellent geriatric institutions where old people get every possible care. Conditions are exceedingly comfortable and they are kept spotlessly clean, but the only impression one gets is that they are just waiting there to die. They do not belong. As few as possible should be put into geriatric institutions. When our services are developed to the point at which the aged can be catered for in the community as a whole the number who will have to go into geriatric institutions will be very much reduced.

A tribute must be paid to the Minister here because of his interest in this particular aspect of health services. I know he is pressing very hard to get these services under way and to ensure that these people are well cared for, but if possible they should be cared for at home. This will require the setting up of good organisations and the employment of trained people to direct the services and carry them out. They do not all have to be qualified nurses or qualified social workers. In many cases people who have the time at their disposal and who are able to look after people in the ordinary way in their homes are quite capable of providing many of the aids most of these people will need. It is a question of organising this service and ensuring that it works continuously.

Quite a good start has been made, and I may say in passing that the religious orders have, over the years, been doing an excellent job quietly. Every effort must be made to co-operate with them and to assist them in what they are doing because they are doing it better and perhaps more cheaply than it could be done by other people. They do not always get the financial assistance they should get simply because of rules or regulations in the order which prevent them from meeting the absolute letter of the requirement of the Department. We should close our eyes to those conditions appertaining to grants and assistance of one sort or another because over the years religious orders have been providing a valuable service and the laying down of conditions on paper requiring signatures and bonds should be dispensed with. Let them get on with the job and assist them to give the best possible service.

This whole idea of dealing with overall health and illness needs is a good one. The further it is pursued the better. The more work done in this field the less people we will have in hospital. That will reduce expenses. Many people must go into institutions for overhauls. These should be short overhauls to get them back on their feet and into a frame of mind and physical condition to go out again and live for a period in the community. It is all wrong to concentrate this in any one institution. More and more the care and treatment of the aged will become a problem and hospitals generally will have to accept part of this problem. Attached to each general hospital there should be a geriatric unit. This is necessary even for the teaching of doctors, nurses and everybody else. Each general hospital should bear its portion of the geriatric load. Otherwise, it will be impossible to maintain a nursing staff in an institution that is wholly geriatric. We must get them down to small numbers and get them out into the community and look for some of the voluntary service that Deputy Carter spoke about. It should be possible to harness that. The voluntary people can serve them in their own homes rather than in local institutions. I think institutional care should be part of the general hospital work. If these people require operations or some complicated treatment then they have it on the spot and the people there can decide when they are able to move out into the community to recuperate.

The FitzGerald Report has been talked about. I would say it has its good points, but I think it would be wrong to regard it as a bible to be followed in every detail. The people who were associated with the drawing up of that report were eminent people in their own field but they were mainly top-level consultants. Their considerations would mainly hinge on providing top-level institutional care and treatment. They would also be extremely concerned with the availability of teaching material for the medical schools and for the nursing schools. Of course these are matters of very serious concern, but there might be a danger that we would too readily overlook the importance and value of a good local service.

I think the vast bulk of the work required can be provided locally and only the complicated cases need go to these institutions or hospitals that were described, unfortunately, as regional hospitals. It would be far better if the regional aspect were left out and if they were described as good, general hospitals. We need this local service. There are many institutions at a lower level that can provide and should be asked to provide a good, local, limited service. That is what people want. It is only when cases become a bit more complicated they should be sent to the other hospitals.

Assessment is extremely important and also good out-patient services. For too long too little was done about good out-patient and diagnostic services. If people could be screened at local level many of them could be held at local level and looked after adequately there rather than sending them to the more expensive hospitals. I am sure this is the aim but we are in such a hurry to deal with regional hospitals that there is a danger the local possibilities might be overlooked and allowed to run down. I do not think this should be allowed to happen.

I am connected with a number of institutions in the Dublin region and I am naturally concerned about that region. I have been a member of the Federated Hospitals almost since the beginning. That is the seven Dublin hospitals. There is a welcome move for the federated hospitals to move into what is now known as St. James's, the former St. Kevin's Hospital, to come together there and have a big, comprehensive, first-class teaching hospital. The medical schools will be able to get all the material they required there when this idea is fully developed. We are still talking about seven hospitals being accommodated in St. James's Seven hospitals will not be accommodated there and the sooner we get this into our heads the better. I visualise only four hospitals being accommodated in St. James's and the Meath Hospital and Steeven's Hospital remaining in existence for the next 30 years. We ought to be realistic. For other reasons, the Adelaide Hospital is unlikely to become very closely associated with St. James's.

It is wrong to continue to tell the other institutions that they cannot do this, that or the other thing, simply because this development is to take place in St. James's. I am chairman of the Meath Hospital Board and if we are not seen as remaining in existence for 30 years that will have some effect on Steevens' Hospital. I hope Steevens' Hospital will be connected very closely with St. James's in the outpatients department. The outpatients department in St. James's should also provide outpatient service for Steevens' Hospital, thus being a valuable link and providing valuable joint service but other developments in these hospitals should not be held up.

There is also the question for places like the Meath Hospital of whether it is to continue to give accident and casualty service. If that is the case, then adequate provision must be made. Nobody is satisfied with the present situation. There must be suitable developments if that service is to be retained. It is desirable that it should be retained. Access to the Meath Hospital is very easy and, therefore, accident cases are brought there to a large extent. The same applies in the case of Steevens' Hospital. In addition, there is a specialised urological unit in the Meath Hospital and other specialist units. The Department should accept the fact that these institutions will continue in existence for, possibly, the next 30 years. The contribution they are expected to make during that period should be stated clearly. They should be informed now as to what is expected of them and the assessment should come from the Department.

The members of the board, in particular the medical members, have a fair idea as to the service they can provide on the basis of the necessary expenditure being sanctioned by the Department but they are not prepared to continue to provide a service which in their view is not good enough in critical circumstances. I should like to direct the Minister's attention to the importance of this matter being considered. References to the seven hospitals being incorporated in St. James's should cease.

It is very important that there should be the most rapid progress possible in outlining exactly what is required by way of new hospital accommodation at St. James's. I should like to see the outpatients department and the diagnostic facilities provided as soon as possible. That cannot be done until a decision is made as to the outline of the hospital block and the siting. We are also awaiting the establishment of a physical therapy school at St. James's. The decision is being held up in the Department. It is very important that a decision should be made on that matter and I hope the Minister will soon find it possible to make that decision.

The James Connolly Memorial Hospital is another institution in which very extensive changes are taking place, also arising out of the FitzGerald Report. Very shortly, the nucleus, at least, of a good general hospital will be in operation there. Top level personnel in the medical and surgical spheres are already working there and are prepared to work there. There are decisions in relation to the hospital that must be made as soon as possible because, without them, it is not possible to get the total picture.

As the Minister knows, there is considerable pressure on the north side of the city and county for maternity beds. At one stage the question of setting up a maternity unit at the James Connolly Memorial Hospital was mooted. I do not know whether that matter is still under active consideration or not. A maternity service in that locality would be very useful. There is an enormous population growing up in that general area. A comprehensive school catering for 1,600 pupils is being built. There is need in the Blanchardstown area for a maternity service and it should be provided. At least two units of the existing hospital could be joined, making 80 maternity beds available without much trouble. I would ask the Minister to have an assessment made of this matter because it is not easy for the board to make decisions about the future developments at the hospital in the absence of these departmental decisions.

At an early stage it had been decided to provide an active treatment psychiatric unit at that hospital. There does not seem to be any move in this direction now. I do not know where the matter is held up or to what extent the Minister's Department is responsible for holding it up. If we are to get the shape of the hospital and to get the machinery working we must know what specialist units are to be provided there.

It is generally accepted, and it is certainly accepted by the board, that the treatment of TB should be phased out of the James Connolly Memorial Hospital as soon as there is a demand for beds for other purpose there and as soon as it is possible to provide the alternative accommodation in Peamount. This matter has been discussed by the board. It has been accepted that Peamount should be the TB centre for the eastern region and that, perhaps, later on it will be big enough to provide this service on a national basis but that the major thoracic surgery should continue to be carried out at the James Connolly Memorial Hospital. It is desirable that decisions on these matters should be taken as soon as possible. Nothing can stand still. People become disinterested if there is no movement. At the moment a start is being made. The outpatients department has begun to operate there. We are awaiting X-ray equipment, which is due to arrive shortly, and that will facilitate the development of the general hospital.

There are building projects in relation to the Meath Hospital awaiting sanction by the Department. I hope planning permission will be available in the near future.

Reference was made by a number of speakers to the drug problem. I suppose everybody is concerned about this matter. Again, positive progress has been made is the last year in dealing with the problem. The Dundrum unit was set up and other steps were taken to provide a service. The drug squad has been strengthened. The main problem is tracking down the drug pedlars. It is a shocking crime to peddle drugs. There was an account in the paper recently of a tragedy concerned with a number of students trafficking in drugs. The problem has now been measured and progress is being made.

Co-operation is necessary between the voluntary hospitals and the health boards. Co-operation between them has been lacking for too long. A good start has now been made. There is a better understanding between the health boards and the voluntary hospitals generally. Anything that can be done to strengthen that link should be done. A comprehensive view is being taken of the accommodation required and the part that every institution and organisation can play. The managers under the various health boards should be able to advance to a point where we can make full use of the potential in an area by providing better service at a lower cost. This is what we all want. The Board of Peamount Hospital have invited one of the managers of the Eastern Health Board on to the Board of Peamount Hospital so as to establish a link. They wished to give an example to other institutions in this matter.

The Health Act is open to criticism and has been criticised. It has been necessary to bring in consultants and to have them working full-time since the Health Act came into force in order to show us how the Act should work. This is an indication in itself that something is wrong. It should not be so difficult that we should require special consultants to show us how the Act should work, but it may be a good thing generally. All the health boards will operate in a similar manner in order to make the Act work. There will be desirable uniformity. Something must be wrong somewhere. We have the hospital boards, the health boards and Comhairle na nOspidéal all working semi-independently. Overlapping should be avoided. Community care, hospital care and treatment are inseparable. The health boards would have been quite capable of doing the total job without the hospital boards at all. They only introduce a new complication. This particular aspect of health services could have been provided by a subgroup of the health boards. It is very difficult to see how they will work without having unnecessary expense and overlapping.

The involvement of general practitioners in hospital work is very desirable. The general practitioner should keep himself up to date. He has been working in isolation up to the present. I do not know whether the Department have been working on a scheme whereby general practitioners could be brought into the work of the local hospitals and be kept up-to-date, as well as have available to them all the diagnostic facilities which should be available at local level to help them to do a better job and to place people in proper surroundings. I have my own ideas and I am trying to make a start in the James Connolly Memorial Hospital with local practitioners in that area. I hope the scheme works well.

When speaking about ways and means of keeping people out of hospital it seems to me that there is something wrong with the VHI and with the schemes connected with the middle-income group. These schemes are designed to put people into hospital. The patients get things practically free in hospital, whereas if they get the same things at home they have to pay for them themselves. A critical look should be taken at the VHI and also at the limited services being provided for the middle-income group. The tendency is to hospitalise people instead of keeping them outside, which is what we should be trying to do.

Deputy Tully talked about the improvement in the accommodation of psychiatric patients. Very considerable improvements have taken place, but much work remains to be done. Overcrowding has been reduced considerably. The setting up of occupational therapy and production units in these hospitals has done much to take away the old stigma of custodial care. Much remains to be done. Most of these institutions are too big. It is not possible to sort out the patients and see what can be done for them individually. It is not possible to know them as people. In most institutions the patients are merely numbers.

Credit must be given to the Minister for the stride which has been made in making provision for the mentally retarded. These people were neglected for too long. In recent years places for them are being provided fairly quickly. The various ancillary services are also being provided. There has been a move away from the institutional type of place for mentally retarded. They are being accommodated in chalets. This is all right for a certain number of mentally retarded people, but we can go too far too quickly on this. The cost is prohibitive and prevents us from providing places for people simply because we are spending so much money on chalet type buildings. It will not be easy to staff these buildings. The idea is that they should resemble homes and that eight or ten people should be living in a chalet with a house-mother and father. Such people may be difficult to get and staffing difficulties may arise. They will have just as comfortable surroundings, and you can have as well the usual recreational facilities. They can go out to work in the normal way. It does not make much difference to me whether they go out from chalets or from larger units if the facilities are there and they are treated as normal people. The opinion was held for far too long that this type of work could not be carried on except there were specially trained people to look after the mentally retarded. I am glad it has been shown that first-class accommodation and occupation can be provided for those people in institutions without specially trained people to look after them. They only need people to provide occasional medical care and treatment. The important thing is to provide work which they can do on a continuous basis. It is good to know that such institutions have been set up in recent times.

Deputy Tully spoke about the present system of dealing with medical cards. A few years ago every agricultural worker had a medical card. Now, because their wages have gone up a little, even though the cost of living has kept step with any increase given, many agricultural labourers with families are deprived of medical cards. This position should be reviewed quickly because people with three or four children should not be deprived of medical cards when they are earning £17 or £18 a week. It should be accepted that such people cannot afford to pay for a doctor.

One thing which increases hospital costs is the length of time people have to wait for an X-ray or some test which has to be carried out. This is caused by shortage of equipment, or because nobody is available to carry out the test. There should be a check-up in hospitals to see what keeps people there for a few weeks when they are not seriously ill. I know the Minister is interested in a work study to see how the hospital services can be streamlined and how the drudgery can be eliminated. He has stated that a section has been set up in his Department to provide specialist advice on this. Have we to get outside consultants to come in or can we employ work-study experts on a whole-time basis? A number of work-study people could go around the various hospitals. They could do a job in one, then go on to others and later come back to each hospital to review the situation. Doctors and nurses feel they could co-operate with this type of effort.

Consultants charge a fantastic fee for the service they give but it is almost impossible to measure the results. Such people will not give you a yardstick by which you can test what you have got. It would be better to employ a trained person on a whole-time basis. This would be something you could measure. I would like, when the Minister is replying, if he would spell out in more detail how he thinks this sort of service could be started and what would be the best approach to it.

Health is the most important thing in a nation because if we have not healthy minds in healthy bodies we have no nation. There is an old Latin proverb which says mens sana in corpore sano and this should be the foundation on which we should talk about health. We are coming nearer to the tragedy of centralising our health services. Any Deputy who has been associated with the health services for a considerable time knows what it is to run a health organisation.

I started off on the old Limerick Mental Hospital Committee, then we had the Limerick Health Authority and now we have the Mid-Western Regional Health Board. This new health board came into operation on 1st April last year. While we can associate it, in our humorous moments, with the particular date in question we must realise that it has been an unnecessarily tragic event in the health history of the nation.

I am in as close contact as anybody else in my area with the everyday working of the Mid-Western Regional Health Board. I cannot see any improvement in the health services under this new system. We are now one awkward conglomeration, with each individual trying to plough his own furrow. That is only to be expected when people from different counties with their own administrative methods are brought together. We were lucky in the Limerick Health Authority, which combined the city and county. We were a very united group. We knew what administration was because we served our time to it. We all put the patient before every other consideration.

In a 12-month period the Limerick Health Authority did a great deal more than has been done in a similar period under the Mid-Western Health Board, and unfortunately it is costing I do not know how many times more. Were it not for the subvention we got in Limerick city the rates estimate for health would have been 60p in the £. Nobody would mind whatever expense was involved in providing every facility for the patient, but it is not happening under the new health board. Administration costs have gone mad. There are too many administrators and there are committees for this, that and the other. The old Limerick Health Authority, with the city manager and the dozen or two dozen officials he had, was the most efficient health authority in the country because it had a good administrative board. The case of each individual was put before the authority and the executive concerned, and each case was treated on its merits. Our last consideration was the rateable valuation or the income of the particular household. These things are only details when you consider a person's expenses for hospitalisation and specialist treatment. Yet the line is drawn because a person has £x valuation or £x income and he is told: "You are out." I know from my experience over 20 years in administering health that people with large incomes and high rateable valuation can be very badly off because of the expense incurred when a member of the family is stricken with some disease.

We welcome advice from administrators but they must be efficient. In any organisation, from the boy scouts up, unless there is administrative ability the whole organisation collapses. There are so many administrators in the health board that we do not know where we are. The numbers should be pruned.

My remarks apply not only to health but to social welfare, education and all the other fields where Fianna Fáil administration is concerned. They have forgotten what it means to be human. People have to be brought into one campus and there will be groups A, B, C and D. Everything has to be administered from one place. In regard to health boards we are setting up regions in Cork, Galway and in Dublin. We forget about the small units of 20, 30 and 40 beds. People are shepherded into vast domains where they are just numbers on a chart in a ward without any regard for their family position or their individuality. Never was this inhuman approach more visible than in the working of the Department of Health.

Now I want to deal with the grandiose schemes which the Minister has put before us in his 50-page speech. It is a beautiful dream. It is about time he woke up and told us how he intends to go about the implementation of most of the things he has suggested here.

Most of them are going on now.

Everywhere.

I hope the Minister is right.

I do not want to interrupt the Deputy, but nearly all of them are going on now.

I do not know what experience the Minister has, but I want to tell him that the reverse is the position. We have sent you urgent matters from the old mental hospital, from the Limerick Health Authority and the Mid-Western Health Board, but not one brick has been laid, not a spade has been put in the ground, and yet you tell me work is going on. It is going on all right, in Dublin. This is the centralisation of Fianna Fáil. I have not gone into the details of the Minister's speech but I would say that three-quarters of it is devoted to Dublin and its outskirts. If you call that health administration the sooner you check up on it the better.

Having thus convinced the Minister, I will turn to another matter in relation to the Mid-Western Health Board. We have only one project going on at present and that is in Kilrush. I visited it, an excellent building, excellently laid out. My only complaint is that I want to see it restricted to the people of West Clare. I do not want to see old people being shunted there from North Clare, from Killaloe and from Tipperary. I want to see it confined to the local people because the only real comfort an old person can have is a visit from a near relative. All the drugs and medicines ever invented could not take the place of that because weariness and loneliness are terrible things.

Who in the name of God wants to die in a mansion or a castle? What old people want are the simple comforts of life, a vist from people near to them. That is more important than all the Minister has in his speech. Having been treated medically, the next most important thing is a visit from relatives or neighbours and a bit of talk and gossip by the bedside. It gives old people courage to get well and if they have any psychologist in the Department of Health, and my guess is they have not, they had better look into that aspect. At page five of his statement the Minister said:

This illustrates the broadly-based representation which has been achieved on the health boards and augurs well for our achieving the community involvement which I would hope to see carried right through the affairs of the health boards.

That is what I am objecting to. Unfortunately we have in specialised hospitals in Dublin people from all over the country. These things have to be done. I have in mind Saint Luke's and other such hospitals. Their relatives have to find their own modes of conveyance to visit them. Thanks be to God the "Great Train Robbery" helped in that it gave relatives of patients in Dublin a chance to come and visit them which they would not otherwise have been able to do, because health boards do not offer any kind of travel voucher unless the patient's doctor advises it. That means that many people in Limerick cannot go to see relatives in Saint Luke's unless the patients' doctors in St. Luke's authorises the issue of a travel voucher. That is an instance of the Minister's centralisation and specialisation. It is completely wrong. Futher on, the Minister states:

I have every reason to believe that the boards will be a success ...

I have every reason to believe they are not. I have 12 months experience as a member of the Mid-Western Board and I regard them as a complete and expensive failure. They were set up on 1st April last and whoever decided on that date played an expensive prank on the people. At page 7 the Minister states:

The modern health service administrator can no longer operate effectively and efficiently on hunches and guesstimates.

Surely the Minister cannot be serious when he refers to guesswork. Is not every estimate a guess, no matter how you go about it? Must not one estimate as near as possible, either up or down, in regard to any undertaking? Any businessman will tell you that. He must contract for a job and he must take a gamble hoping the wind will blow in his favour. He must work on a trial and error basis.

I consented reluctantly to go on a health board, saying I would give it a chance to see how it would get on. I now say, and this has been said by people with administrative ability on other boards, that we have achieved nothing more than we had under the old health authorities. In those days our communications were closer, we were nearer to the people whom we served. It is all right for me because I live in Limerick at the centre of the board's activities—I live only 200 yards from the board's headquarters and I visit them at least four times a week— but what about the people in West Clare and Tipperary? The Minister talks about community at work. There is only one community, and let us remember it. It is the family. Everything stands or falls on the family.

We have always provided free drugs and medicines for people who were not in a position to pay for them. We have always treated people in a humane fashion but when officials from outside come into our area they upset the smooth running of our organisation. Reference to the book or to regulations should never be a consideration where health is concerned. I realise we must abide by the law and regulations but when an emergency arises the first consideration must be to look after the patient. That was the position when we were a health authority but it no longer applies since we have become a health board.

The Minister referred to the important matter of staff relations. Everyone knows that if there are not good staff relations there will not be an efficient organisation and satisfactory results will not be achieved. In the matter of promotions consideration should be given to the staff on the board. These people were appointed on merit; they entered the service by way of examination or interview. Many of them were taken from the local authority on to the health board. These people know how the organisation operates and by their work they have ensured that it is run in an efficient manner. Although, generally, I am in favour of open competition in this context any promotions should be confined to the staff of the organisation.

So far as my area is concerned we have Clare County Council, North Tipperary County Council, Limerick County Council and Limerick Borough Council on our board. This unit is carrying out work efficiently and competition should be confined to members of the staff. I know from experience in public administration, and I am sure this knowledge is shared by other Deputies, that if a man from another area is taken on a board, because of the totally different objectives and outlook of the organisation from which he has come, he can make things very awkward for the people with whom he is dealing and frequently the result is that less progress is made. In other words, he can upset the applecart. On the other hand, those who have come into the organisation on merit and who have been promoted step-by-step, know how the organisation functions and they understand the local situation. We discussed this matter at our last health board meeting and I was told that in an open competition people from local authorities, health boards and county councils throughout the Twenty-six Counties can apply. This should not happen in the administration of health. I want to impress on the Minister that I was not alone in my views at our health board meeting last Friday.

The Minister in his speech mentioned psychiatric nurses. Last year we ran into a storm because something went wrong but the trouble could have been avoided. These nurses had been hammering at the door, not for weeks or months but for years, in an effort to get their complaints investigated and rectified. However, the door was banged in their faces and the people concerned refused to meet them. We were warned long before the strike took place that it would happen if action was not taken. The unfortunate nurses did not wish to take the action that was forced on them——

There was an open Labour Court hearing to be held seven days later.

When did these men first apply for a hearing? When did they apply to be received by the CEOs Association? How many times were they turned down? It was only because they threatened to strike that someone told the Labour Court to get involved in the matter. It was done as a last resort and the Minister need not tell me otherwise. Certain recommendations were made by the Labour Court and a working party was set up to resolve the difficulties, but what did the CEOs Association do? I am all in favour of people joining associations; I am a trade unionist and always will be. People are entitled to join an association but the CEOs are not entitled to take the action they are taking at the moment. Their action is completely dictatorial and I told our CEO so last Friday. If he does not take the action which we unanimously recommended at the board meeting last Friday, I will fire section 4 at him at our next meeting.

In our area we are involved with two hospitals—one at Ennis and the other at Limerick. Conditions were not similar in both hospitals, but this is understandable because they did not come under joint control until 12 months ago and I suppose people did not bother to clarify certain matters. They went to the Labour Court which made recommendations and a working party was set up. According to the arrangements, which applied in Limerick, the men worked a certain number of hours, sometimes irregular hours. Then they had two, three or four days due to them. That system had been agreed on and operated for years and everybody was happy. What did the CEOs do? These men had spent five days walking up and down outside the door — certainly many went in; they would all prefer to be in and it broke their hearts to be outside, and I know this. On resumption, the men who had four days due to them were docked or it was attempted to dock them of the four days even though this time was to their credit. Although they had these days due to them the CEO said their service was broken. I put the matter to the Minister and he said: "If the CEO agrees, send it up to me. That is a matter for the CEO." I raised this last Friday and to try and bring about good relations between staff and management I suggested that we make a blanket bargain and that whether a man had four or five days due to him, or only one or two, we would agree to take two-and-half-days in the case of everybody. I put that to men who were due more than that and they agreed to it because they are dedicated people, men and women, the psychiatric nurses.

When I put it to the CEO he said: "I shall have to consider this" even though it was unanimously agreed by the board that this should be done and even though they all agreed this was the fairest way out of the dilemma. I read out exactly what was said by the Minister in reply to the questions I put to him but yet I could not convince him because we all know he had to go back to the CEOs Association and put it up to the other health boards: "What are you going to do?" Then they would come back and say to us: "This is it." I am glad the Minister said what he did and I thanked him for his independent attitude.

We must get over this. No straight line can be drawn with any individual or authority. This is where the curse of the boards comes in. The working committee that was set up have not yet met or had not met up to last Friday. Some matters were left hanging fire and the workers went back on conditions. The Labour Court said they should all go back and they would consider these things. But the working committee had not met up to last Friday. I repeat what I said last Friday. "There is a limit to human endurance and the days of kicking people about are over." We go in now and discuss our problems around the table with the object of achieving a peaceful settlement by which men and women will have security in employment, something they had not got. The matters that have been left in the air have not yet been tackled. There is a limit to the patience of the workers. I would not expect them to accept being thrown about like this. I want the Minister to pay particular attention to this and give an order to the CEOs, however important and independent they think they are. I want to let them know that they have superiors and, as a public representative, I am one of them and I shall see that they do their bloody job and treat people as they should be treated and not wrap themselves in law and regulations. The quicker they realise those days are over the better. The Minister in his statement said that under the terms of settlement the position would be reviewed when the report was available of a working party which was examining the whole question of the psychiatric nursing service. They have not yet met. The Minister should take note of this and tell them to get moving. It is time something was done.

The Minister also said in his statement that the action of the nurses was, in his view, indefensible. I do not blame the Minister. I know his job is a demanding one in the days in which we live, with tensions and worries of all kinds and people resorting to different treatments and tranquillisers but when he makes such a statement as that the strike was indefensible I know he did not know the facts or was not given them. The strike was forced on the workers.

I shall now deal with the capital building programme which the Minister says is going ahead. I want to know where. Limerick health authority, prior to 1st April last year, had its priorities arranged. These were sent to the Department and they went up and down and down and up and we pressed them as best we could. We were then called to a seminar in Killarney a couple of months ago and somebody—I think he was from the Department—came along to tell us all these things would be done by way of priority and how we should arrange our priorities. When I questioned the official he told me we would have to start all over again and that what we had sent up five or six years ago had all gone into the wastepaper basket, that we should send up what we wanted done and get our priorities right.

Killarney is something like 70 miles from Limerick and I said to myself that if ever I had wasted a day, that was the day. I went down there and heard a lot of balderdash from people who did not know what it was all about. They were talking to people, some of whom had 30 years experience. I myself have over 20 years experience. These fellows came to tell us how this business should be run. I do not know how I had patience not to say: "You fellows should get into class one at the bottom of the school and begin working your way up to our standards." This official had the cheek and presumption to tell me and other members of the board what to do. This was a united effort between the Southern Health Board and the Mid-Western Health Board. Other members of the southern board took up the matter.

Other members of the board took the matter up also and a case was prepared and sent to the Department. However, the whole thing was scrapped there. Yet we hear of capital building programmes. I would say that programme has been in the Department for more than five years. That is the case so far as Limerick is concerned anyway. The regional hospital in Limerick has a bed accommodation of 344. It is seven years since we applied to have an extension built to the hospital but the position now is that the plan must be placed on the priority list. At the moment there are 391 patients in that hospital, almost 50 more than there should be. The extra patients have had to be accommodated in corridors and various nooks and crannies. The River Shannon, in finding its level, will not meander as much as will the officials in the Department when they are dealing with this matter.

There is no use in the Minister presenting us with a 50-page dream. Three pages of this document are devoted to a building programme and apart from a reference to Cork and one to the regional hospital at Limerick these three pages concern Dublin. This indicates that unfortunate people who are ill have to be taken to Dublin from different parts of the country where they may not have a visit from any relative during their time there because very often relatives cannot afford the travelling expenses involved. The Minister is aware that there is nothing more consoling to a patient than to have his relatives sit by his side and talk to him. When a person is dying he would have nobody to talk to. This is the inhuman approach of the Department but it is the approach also in respect of education, social welfare and other matters. During my lifetime I will continue to pressurise the Government to ensure that people will be treated in a human manner.

Regarding psychiatry and its application to the young people, I am glad to see on page 24 of the Minister's speech and I quote:

With the advice of psychiatrists in my Department and outside I have decided to give priority to important schemes which will have the greatest impact on the younger age group. These schemes include short stay units at general hospitals, industrial therapy and workshops, the appointment of psychiatric social workers and the stepping up of social community services.

This is all very well but the Minister has not told us when the schemes will materialise. So far as our board are concerned I would say the schemes would rank about 20th on the list of priorities. Maybe they will be realised during the lifetime of my grandchildren but I doubt if it will be before then.

The position regarding the care and accommodation of the aged is tragic in some respects. Some of these unfortunate people who are put into hospitals could be cared for better by their own relatives. Very often their relatives do not bother to visit them in hospitals. More emphasis should be placed on keeping geriatrics at home and in this regard some help could be given towards their keep at home. Again, the Department are overlooking the human problems involved. I know they can be awkward and there can be certain disadvantages when there are young children in the house, but one must always remember that these people are human beings and should be treated as human beings instead of being thrown on the scrap-heap. That is something we must avoid when dealing with this section of our community.

Another important aspect is the care of the handicapped. Up to 15 or 20 years ago the handicapped child was known as the "cupboard child". As often as not, when one visited where there was a handicapped child, one would see him in a tea chest in a corner of the kitchen, screaming and jumping. The child could not help himself and the parents could do nothing. However, in the last 15 years the situation has changed and mental and physical handicaps are gradually receiving their due recognition. But we are still merely scratching at the surface of the problem. I am associated with a fund-raising committee in Limerick. Our object is to get the parents to realise that something can be done. We concentrate on the mildly mentally handicapped. There are institutions run by religious orders but the waiting list would stretch from here to where Nelson Pillar used to be. The bishop gave us a school and he had two of the Sisters of Mercy specially trained. At the beginning we had about 12 or 15 children scattered all over Limerick. The Department would not give us as much as a "bob" for transport. We had to have raffles, crazy football, flag days and church collections to enable us to buy a minibus. We get not so much as the price of a gallon of petrol from the Department for that minibus. The Minister and his officials were sitting in the Custom House while we were out collecting funds. It is costing £8,000 a year to run the school. There are 40 or 50 children in it now. They get speech therapy and occupational therapy and all the other therapies to enable them to take their place in the community as independent citizens. The Department gives us £2,000 a year and we ourselves have to find the other £6,000. We find it difficult to make ends meet. If we had the money and the co-operation of the Department, we could expand these services for the mildly mentally handicapped. Let it go on the record that Deputy Childers has been delinquent from the point of view of the approach to mental handicap.

I am sorry. The Minister. I hope what I have said will have its effect because it is more important than "the Minister", as far as I am concerned. I believe the majority of these children can be rehabilitated and placed in sheltered workshops, taking their place in society as independent human beings and treated, as they were never treated before, as human beings. The Minister and his Department deserve no credit, none.

As a result of our activities we induced the Brothers of Charity to come to Limerick three or four years ago and the health authority provided the Brothers with 40 acres of ground, completely free, in order to build an institution. This has been held up by the Department and by the Minister. Half an hour ago the Minister had the presumption to tell me everything was under way. Nothing at all has been done in all that five years of agitation. There have been no extensions to our institutions. Now we are told to send in our priorities once more and they will be dealt with by the health board and not, as it used to be, by the Limerick Health Authority. This is just sending the fool further. It is time the Minister woke up. I know his job is a responsible one. I know there are difficulties. But I also know the tensions and the worries people have to suffer.

The Department of Education are one of the main culprits here. Students now have to get four, five or six honours or they will be thrown on the scrapheap. Leaving certificates are ten a penny at the moment. These are the tensions which are filling our hospitals. Fianna Fáil want to bring people into bigger and bigger groups— education, health, social welfare and all the rest of it—and this is the root cause of a great many of our troubles. It is the cause of all the troubles, not alone where health is concerned, but also where education and justice are concerned. There is now no room in reformatory schools. So the Minister for Justice told me last week. The people are pushed and driven instead of being allowed to live their own lives in their own way. I want to impress on the Minister the urgency of the situation where treatment of mental handicap is concerned. Nothing is being done. This is a reflection on the Department of Health.

Will the Deputy move to report progress?

I will report, but it is not progress.

The Deputy talked it out for the last hour and a half apparently.

And I could go on for another five hours and it would not make any impression on the Department of Health.

Progress reported; Committee to sit again.
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