Dáil Éireann díospóireacht -
Tuesday, 14 Mar 1972

Vol. 259 No. 10

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

Debate resumed on the following motion:

That the Vote be referred back for reconsideration.

—(Deputy R. Barry.)

Sir Anthony Esmonde

Before reporting progress on Thursday afternoon I had made suggestions to the Minister as to how charges could be taken off the rates and more equitably distributed over the public as a whole. There is no need to go further into that matter except to say that the real trouble now is that the regional hospital boards are spending the money and the county councils are asked to vote that money although they no longer have any say in the expenditure of the money. Therefore, we put down the motion referred to by Deputy Richard Barry in which we suggest that the charge should be transferred to the Central Government. If the Minister adopts the suggestions I made on Thursday afternoon he will be able to do that; he will be able to collect sufficient money and remove from the county councils the odium of having to increase the rates to meet ever-escalating charges. I shall not deal with that matter any further at this stage as I do not want to hold up the debate unnecessarily. I am sure that Deputies who will follow me in the debate will have some comments to make along the same lines.

I want to say a word or two about the FitzGerald Report. The Minister did not clarify in his long opening speech what decision he would take about the regionalisation of hospitals. There is considerable concern in a great many counties because of the suggested closure of hospitals. I want again to advert to the position in Wexford. For many years we have been awaiting the provision of a new hospital in Wexford. All we get is an indication that not only will we not get a new hospital but that the existing hospital will be closed. Sufficient Deputies have spoken of their particular problems for the Minister to realise that different circumstances exist in different areas. The Minister would be ill-advised to proceed in toto with the suggestions made in the FitzGerald Report because, while they may be applicable in some circumstances, they are not applicable in the majority of cases. The Minister should keep an open mind on this matter. He should examine the matter very thoroughly before arriving at any decision. I understand that he has not as yet taken any decision and is not likely to take a decision in the immediate future. He should evaluate all the facts and should allow the present situation to continue. I can certainly say that as far as County Wexford is concerned we will use all the force we can command, political and otherwise, in an effort to maintain our hospital and until we get the service we require.

I want to put one point to the Minister. Before tourism from the United Kingdom was destroyed due to the political circumstances obtaining today there was a very heavy influx of people into Wexford during the summer. They included not only persons coming on holidays but also Irish nationals living in Britain who came back to obtain maternity service. It is a very easy matter to get from Wales and other places to Wexford. Persons also came for the purpose of surgical operations. The idea of transferring our general hospital is unadulterated nonsense. I hope the Minister will do some deep thinking on that matter.

I notice that in his opening speech the Minister still allies coronary thrombosis and lung cancer or other cancer conditions as the two leading causes of death in this country, as they are in most other countries. There are three causes contributing towards these two conditions. Two of them certainly apply in the case of lung cancer. Air pollution is much more injurious to health than anybody in this country seems yet to have realised. In 1968, the United States of America realised the adverse effect of air pollution on the health of the community. It was found that the pollutant emission from cars and other mechanically propelled vehicles consisted of carbon monoxide, a deadly poison if consumed in sufficient quantity, hydrocarbon gases and nitrogenous gases. In the United States of America the volume of the emission was considerably above that in other countries. Anti-pollutant emission devices were produced. Regulations were introduced in 1968 which had the effect of reducing the pollutant emissions, in the case of hydrocarbon gases, by 40 per cent and in the case of nitrogenous gases by 25 per cent. No European country seems to have made any study in depth of this matter, with the exception of Sweden. Sweden has devised a scheme along the lines of that introduced in the United States of America and as a result pollutant emissions in that country have been reduced.

Pollutant gases, with all the noxious ingredients they contain, are a contributory cause of lung cancer and of chronic bronchitis. They are also extremely injurious to the heart. An extra load is imposed on the vascular system and that in itself is a contributory cause of coronary thrombosis.

A second cause is cigarette smoking. Some people think that cigarette smoking is the sole cause of lung cancer. I would draw attention to the fact that cases of lung cancer occurred long ago. In considering the increase in the incidence of lung cancer one must bear in mind the fact that cases occurred long before pollutant gases became as prevalent as they are now. That is understandable. Exhaustive tests have been carried out in the US and in Sweden and it has been discovered that there are carcinogenic materials in polluted air. Cigarette smoking is one cause of cancer and pollution is another. They are both irritants to the lungs. If people smoke in a heated atmosphere their smoking is certainly a contributory cause of cancer. I would not agree with those who say that it is a direct cause but it is a contributory cause by virtue of its being an irritant. It is also the cause of many chest ailments. The Minister should direct attention to both cigarette smoking and pollution.

Cigarette smoking has been highlighted in this country as a cause of cancer but pollution has not. The country is aware of the dangerous situation which we face. A hydrological expert has said that pollution of the air is so great that it finds its way into the water and that in 25 years time all marine life will be destroyed. We should look intelligently at this problem.

The three causes of coronary thrombosis, which is taking a big toll of middle-aged people, are faulty diet, weight and the lack of exercise. Many breadwinners have been struck down with this disease with consequential suffering to the families involved and a considerable charge on the State. I suggest to the Minister that he bears a responsibility to the public to highlight this issue. Television is a good advertising medium. Talks should be given by people who are competent to deal with diet and factors which lead to coronary thrombosis. Research has been carried out and it has been found that fat is one of the major causes of clotting. The fat of meat is the most injurious of all fats. Butter is harmful to a lesser extent. The public should be advised of such things.

I have often seen men in restaurants eating fat meat. Generally they are very much overweight. Such people, in my opinion, would be incapable of walking a mile even though they may be in early middle life. Extensive investigations carried out in the US on the subject of coronary thrombosis have shown that butter is a contributory cause. The Americans have spent millions on research. They have been responsible for schemes to prohibit the sale of butter. People are inclined to heed advice for a short time and then to forget about it. The Minister should use RTE to highlight these facts and also to conduct a campaign against cigarette smoking and pollution. It should be shown that faulty diet and overweight are responsible for coronary thrombosis.

The advent of the mechanically-propelled vehicle has meant that there are people who never take any exercise. Going along the street one sees people who have too much avoirdupois and some of them would not be able to walk two or three miles. I know of people who would get into a car to go to the nearest corner shop for cigarettes. Lack of exercise is one of the causes of early death. The public should be awakened to the facts of this dangerous situation. Until they heed the warnings the heavy mortality rate, with all its suffering and unhappiness and the hardships imposed in a great many cases on young widows, will continue.

The rush and bustle of life today is another contributory cause of heart disease. Everyone is in a hurry everywhere. People are worried about their financial position and taxation. People are worried about the state of the world, feeling that there will be a world conflagration or a civil war in this country. The only advice I can give is to tell people not to worry. If something is going to happen it will happen anyway. Worry is certainly a contributory cause because it constricts the arteries and coronary thrombosis is a blockade of the main artery to the heart. If it is totally blocked the person dies.

I wish to refer to speech therapy. This is something relatively new. Speech therapy is something which is quite different from elocution. Elocution is aimed at enabling people to articulate properly. Many people require elocution. Speech therapy is something that is necessary for many children. It is a distinct science for training vocal muscles and the proper emission of sound. I am associated with mentally handicapped children. Speech therapy is absolutely essential for such children if we are to tackle their problems properly. There should be a speech therapist in every county. I have been present at the discussions of a committee concerned with mentally handicapped children. There are a considerable number of teachers on this committee. The teachers expressed the opinion that not only was speech therapy needed by handicapped children but that it is also needed in every primary school in the country.

There is a small school of speech therapy at the entrance to St. Vincent's Hospital. It is run by the Irish Sisters of Charity and there is a very skilled nun in charge of the school. The Minister has been concerned with this school and has helped it in every way. The school turned out 15 graduates in June. That is not sufficient. We should try to expand considerably in regard to speech therapy. The British have also been very much behind in speech therapy but they are in a position to pay higher salaries than we are. Most of the girls who qualify in speech therapy will probably emigrate because they would be able to obtain better salaries in the United Kingdom than they would here. In County Wexford we have even gone to the extent of putting up a voluntary fund to sponsor a girl through the college on the understanding that she will stay with us for three years. The intention of the person we have in mind, who has agreed to stay with us, was that she would emigrate as soon as she could.

Speech therapy is a comparatively new thing all over the world and I suggest to the Minister that we should have an institution here which would be responsible for training at least 30 people per annum. If we could turn out 30 speech therapists a year we would clear off the backlog which we have at the moment. I do not believe there is any speech therapist in the South Eastern Regional Health Board of Carlow, Kilkenny, South Tipperary, Wicklow, Wexford and Waterford. There may be a couple in the Dublin North Eastern Health Board area but there certainly are not many all over the country.

They are very anxious in the small colleges to obtain university status when they would be able to expand and could have available to them some of the educational grants which are made available to universities. They would thus be able to carry on their work. Perhaps the Minister would see his way to giving us double the amount we are getting for the coming year. It is a three-year course and we all hope that in a few years time we will have in this country the number of speech therapists it is necessary for us to have.

Dr. O'Connell

This Estimate gives us an opportunity of discussing the progress made by the Minister in his Department over the past year. It is right that we should pay tribute to him for his conscientious approach. Perhaps we expect too much of him but he certainly has tried to do his best in regard to our health services. He has been described as an arch-conservative. His speeches have indicated that he is very conservative in his approach but despite this he has gone a long way to try to make something of our health services. It is no credit to his predecessors, with the exception of the late Donogh O'Malley, who was, unfortunately, too short a time in this Department, that the present Minister was left with so much on his plate and so short a time in which to deal with it.

The Minister has been trying to cope as best he can. There are a few things about him which puzzle me. I wonder why he did not consider extending the health services we have. Reunification of our country is in everybody's mind at present, North and South. I have been in the North on many occasions recently. One of the obstacles to which the extreme Unionists refer—those who say they will have nothing to do with us—is the fact that we have deplorable health services, that it costs so much to get medical services in the South.

It is very hard to answer that especially when in the North of Ireland any man, woman or child can be assured of full and adequate health services free. We are not doing anything in the South to put our health services on a par with those in Northern Ireland. If we are sincere in our statements about the reunification of our country we should be making every attempt possible to produce national health services covering every person, to ensure that our health services are as good, if not better, than those in Northern Ireland.

I have told the medical profession in Ireland that they may have to submerge any selfish interests they may have in this and they may have to look at the bigger interest at stake and say that we will have national health services for our people in the interest of the entire country.

I do not know how long the Minister will remain in the Department of Health but I should like to see him there for quite a while. I would ask him not to set his sights on Europe but to see if he could produce national health services for our country. It should not be impossible. The cost would not be that much. It was said that we could not produce a free choice of doctor for the lower income group. A former Minister, Mr. MacEntee, said that the care of the aged was the responsibility of their relatives. Now we realise he was wrong. I ask the Minister to see if he could make an estimate of the cost of national health services for the country and how they could be implemented.

The 15p per week provides security for the middle income group who must seek hospitalisation from time to time. It is a great relief to them to know when they enter hospital that they have not to face a large bill when leaving. It should be possible to go one step further, because the administrative costs could not be that much greater. The Minister has put a figure on the cost of providing a choice of doctor for the lower income group. I should like to remind him that the cost of this need not necessarily be multiplied by the remaining 70 per cent because it is the lower income group who make most calls on a doctor's time. Therefore extending it further does not necessarily mean a proportionately greater cost. The Minister should grasp this nettle. He should see what he can do about extending this facility and providing a national health service for this country, and having regard to our aspirations and our wishes in regard to reunification, I believe he would have the support of the medical profession.

The Minister is anxious to make this health service a model service, but he has not broken through a number of restrictions that are on him. It has been said by other Deputies that the biggest worry and complaint of the people is the impossible burden of health charges on rates. It should be possible to take this burden off rates completely and make health a charge on the Exchequer. The Minister may put up all kinds of arguments against this and say we cannot possibly do it. We have got to do it. We have got to follow Britain in this. By making health a charge on the Central Exchequer, at least we shall know that those who can afford to pay will pay. It is morally wrong that people on fixed incomes who happen to own a house, and who would be glad to dispose of the house but they cannot get alternative accommodation, should be crippled with rates due to the enormous health charges. I know many who are in this position but who cannot dispose of their houses because they would be left homeless and would not be granted accommodation.

Something must be done about this before there is a public outcry. I believe the Minister knows it is a crushing burden, but there is a stranglehold there from which he cannot free himself. I have heard the Minister speak and I know how he feels about this. He will have to get someone working on this and convince his colleagues in the Government that action must be taken in this regard.

If we had a national health service we could get rid of the indignity and humiliation of the medical card system. It is perhaps the most degrading system that was ever devised. There is a great disparity between the different counties. I jotted them down last week as one Deputy was speaking. How can it be that 50 per cent in Galway have the medical card while only 12 per cent in Dublin have it? There is something radically wrong with a system that permits a public servant to decide whether a person is entitled to a medical card or not. We cannot have public officials asking the most intimate details about a person's means before they will decide to give a medical card, or politicians using it as a political gimmick, which is happening regularly, in order to get votes.

I have said over and over again that this system must be abolished, because there is no uniformity about it. I have tried to find out what qualifies a person for a medical card, but I cannot get the answer. I got such a vague, ambiguous statement from the CEO in the Eastern Health Board that I just could not understand it. Having made representations over and over again, I have found that on the fourth or fifth occasion a medical card has come. I am wondering what has happened to the Minister's earnest and sincere intentions, as announced by him some months ago, that there would be some uniformity. He found it impossible to work it in practice. He found he would upset many people; selfish interests would be interfered with. It is a bad system under which if you are friendly with the CEO you will get a medical card for a person and, if you do not know him, the person suffers.

I do not think the Minister would contradict me on these points. He knows they are true. He must tackle this problem and tackle it fast. There is only one way to tackle it and that is to get rid of the medical card system completely. The whole concept of the system is wrong. It is degrading and humiliating and it is used for so many things. It is even used to obtain free books for school children. People apply for the medical card for that purpose alone, in order that they can show the medical card to a superior in a school to get free books for their children.

There certainly is not the disparity in incomes between Kerry, Galway, Roscommon and Dublin that would justify the disparity in the numbers holding medical cards in those counties. There is something wrong with a system that can provide 50 per cent of the people in Galway and only 12 per cent of the people in Dublin with medical cards. I do not think the incidence of poverty in Galway can equal the incidence of poverty I have seen in Dublin. I should like the Minister to be courageous in this matter and to persuade his colleagues to rid us of this terrible system of the medical card, this poor law system that we should have shed long ago. I do not think the answer is in the choice of doctor scheme for the lower income group. The scheme must be extended so that there will be no discrimination, so that people do not have to keep writing in, keep sending in forms, getting their employers to state that they are paupers and that they are, therefore, applying for medical cards.

The system here is such that the income of sons and daughters is taken into account. They must go to their employers to get them to fill in certificates saying their incomes are so-and-so. Some of them will not do that for their parents and accordingly many invalid fathers and mothers are unable to get treated medically. The Minister knows that. I have written to him about it dozens of times. The time has come for him to be courageous about it. I ask him as a matter of urgency, pending a complete reappraisal of the system and the complete elimination of such an iniquitous set-up, to call the CEOs together and get them to issue some standard so that the public will have some idea of who is and who is not entitled to a medical card in each region.

Last September the Minister promised to do that. I ask him to do it now as a matter of urgency. It is appalling that it should be left to individual CEOs with one assistant each who do not understand prescriptions. It is dangerous that they should have to consider prescriptions and medical histories of applicants. It is wrong that they should be called on to make decisions on the basis of prescriptions submitted. That is why I ask the Minister, as an immediate step, to call the CEOs together to arrive at a standard for the entire country. I do not know what is stopping him from doing this. I know he has the best intentions and he is on record as having told this House that he intended to do it. This is one of the enigmas of the Minister for Health.

Another enigma is the spectacle of the Minister for Health going into the Division Lobbies to vote against giving a First Reading to the Contraception Bill and at the same time approving of the two family planning clinics in Dublin. He saw the booklet they issued and said it was a great service. His voting against the Contraception Bill was the most disgraceful thing I have seen any Minister do. I know he did not vote from conviction and this makes me say that he was a coward on that occasion. He speaks about medical education but why has he not got facilities for family planning as well? Ireland was a signatory to the UN Convention on family planning yet if it were not for those voluntary organisations we would not have any family planning facilities here.

If the Minister is sincere and believes that these clinics should not exist, let him stand up here and say so. He cannot have it both ways. He praised their booklet and yet he voted against the Bill. The time has come for the Minister to display his courage, to stand up and be counted no matter what his colleagues say. I am surprised that a Minister of his religion should speak as he did, knowing the importance of this to the country. We have doubts about the Minister for Health, we wonder if he acts according to his convictions. I ask him now if he has had consultations with the Minister for Justice about the right of our citizens to education in family planning, or has he decided to turn a blind eye to this whole matter? Is he prepared financially to support those organisations who are having a difficult time? Does he know of the increasing demand for this service? Has he considered the importance of it in the context of a united Ireland? I hope he will have the courage to stand up here and reply to all these questions.

In the past year we have seen headlines about our psychiatric services and I am aware that attempts have been made to improve them, but only after extreme public pressure. A year ago I asked the Minister to set up an inquiry into our mental hospitals. Despite all we hear, despite the lovely facades of some of our new out-patient clinics, intolerable conditions exist in our mental hospitals. I had one of the most depressing experiences of my life recently when I visited St. Ita's in Portrane. It is a beautiful place with beautiful surroundings, but then I asked about the temporary buildings which 87 years ago were erected as temporary accommodation for the workmen. I saw those temporary buildings and I never want to see them again. There, 96 people were herded into a ward with two open toilets. I should like to see television cameras out there to show up the intolerable conditions We have no right to treat people like that. Of course, the Minister will say we have plans, but they are not plans for this year, next year or the year after. This is an urgent problem. We would not dare treat cattle as we treat those people. These poor innocent people are herded, worse than cattle, in intolerable conditions. I had to demand that another toilet be provided for them.

Television should highlight these facts and let the public know what is happening. It is not the fault of the doctors that such conditions exist but I do not like doctors to defend the system. I do not think any doctor should be afraid to speak out on this matter; fear of losing his job or anything else should not be a deterrent. If they find that such conditions exist they have a duty and a right to speak about them in public.

The Minister has admitted that bad conditions exist in Our Lady's Hospital in Cork. That made the headlines some time ago but there are many other places that do not get any publicity because people have not the courage to speak out. Perhaps we should have an independent body to investigate this problem and to decide the number of hospitals that need replacement or improvement.

We should be ashamed of our mental services. It is nice to see the new St. Brendan's building but there are parts of St. Brendan's that nobody would like. The Minister may stand up and say that we are doing very well, but I say it is not good enough when 96 women are herded into a place with two open toilets. When such conditions exist it is obvious that we have our priorities wrong. The Minister's first priority should be to go out to Portrane and see the conditions. If he does this I would defy him to stand up here and say that he is satisfied with them. Will the Minister do this?

I admit that the Minister tries, but he must have more courage. I realise that he cannot do everything himself and that he must convince the Minister for Finance that the money is required. If he is courageous or persuasive enough he will get the money. The Minister cannot leave it to the health boards. Our mental health services are not good enough and we must do something about them. There is a moral obligation on us to provide the necessary money. If the public knew the facts they would support us in allocating the necessary funds. We must let the public know the situation.

Minister for Health (Mr. Childers)

If I might interrupt the Deputy for a moment, I am glad to tell him that we have finance for the year 1972-73 to begin work at St. Ita's. The Deputy is absolutely right; the work is long overdue.

Dr. O'Connell

I thank the Minister. We have a problem with regard to the aged in our community and I realise that the Minister is sympathetic towards them. A former Minister for Health, Mr. MacEntee, said that the care of the elderly was the responsibility of the relatives and that the State was not to be bothered with them. I regard this as a most callous attitude. All of us, if we survive the coronaries and other hazards, will get old. I agree with many of the statements made by the Minister about what the community can do for the elderly.

However, there are geriatric cases who need medical and surgical attention and who cannot get admitted to hospitals. I must confess that, as a doctor, I have had to tell lies in order to get people into hospital. If a man is 73 years I have to say he is over 60 years; 65 years is regarded as very old by hospital standards and if a person is said to be more than 65 years he has no hope of being admitted. Geriatric cases suffer from medical and surgical problems as do any other section of the community; in fact, a geriatric can get an acute appendix. However, there is a reluctance on the part of hospitals to accept these patients.

We should insist on general hospitals having a certain number of beds for geriatric patients. Geriatrics is part of hospital teaching and I do not know how a teaching hospital can give instruction on this subject if they have not geriatric patients. I hope the Minister will say to the general hospitals that they must have a ward for these patients or a geriatric unit. If this is done many of the geriatric cases can get proper attention.

There is nothing more depressing or frustrating for a doctor than to try to get a case of terminal cancer into hospital. If a general hospital decides that a person has cancer, either they operate or they decide the person's condition cannot be helped by operation and he is sent home. That is the end of the matter so far as the hospital is concerned. They have not the right to write off a person in this fashion.

I would ask the Minister to insist that these general hospitals have terminal care units for such cases. There is nothing worse than to be forced to tell a person that you will try to get him a bed in Our Lady's Hospice or in the Hospital for Incurables. These units should be attached to general hospitals so that patients can get the complete medical and surgical care necessary. The units might even be prefabricated but they must be provided. People suffering from incurable diseases are in need of treatment and regular injections; they may even need emergency surgical treatment to relieve pain or obstruction. This is the thinking I should like to see in the Department of Health. We are paying for the general hospitals, voluntary and otherwise; we have a right to these services. It is a sad reflection on a city of 750,000 people that there are only five beds in Cabinteely for terminal cases. That is organised by the Irish Cancer Society but, having regard to the number of terminal cases that exist, there is urgent need for a number of units to be attached to hospitals.

There is need for a rationalisation of our hospitals. I should dispense with St. Luke's Cancer Hospital. No matter how enlightened our people are they do not like being sent to St. Luke's. One can see immediately the fear in a person who is told: "I should like you to be seen at St. Luke's." No matter how much one tries to allay this fear and anxiety one cannot do it. Personally I should want this removed. We should be able to site these facilities in a large hospital complex. I do not think you can isolate one service from the other. The facilities should be sited in a large hospital complex and we should get rid of the idea of St. Anne's for skin and cancer and so on. There is a lot of money wasted because of duplication and we could save a good deal by providing the services in a centralised hospital complex. The opportunity is there with St. James's. These relics of the past must be re-examined in the light of present day knowledge.

The same thing applies to the skin hospital in Hume Street. There is no reason why these hospital services should not all be included in a general hospital. I do not think it is right to isolate these cases. So many skin diseases are of a general systemic origin that you cannot just look at a skin condition and say: "That belongs to the skin." Its origin may be and indeed is invariably in the system. It then becomes a matter for consultation with a consulting physician and this can only take place properly in a vast hospital complex with a saving of money to the State. The Minister has done a great job in regard to the federation of the Dublin voluntary hospitals. He sees the need for it there with the vast hospital complex he is producing at St. James's. This is the right idea but I want to go one step further and do the same with these other institutions. He knows it will save money for the State and there are so many things on which the money saved can be used. I should like him to think along these lines because in that way we shall get answers to our problems, save money and get better services.

I am all for rationalisation. We can get a better hospital and better specialised service in this way. I know the Minister is up against vested interests. People who are depending on votes do not like these changes but when I went to Athlone, I think it was, and spoke to the people there and told them the risks involved in small hospitals, that what was sent in as an appendix might not be an appendix, they fully understood and were not opposed to the idea. If the Minister wants to implement the FitzGerald Report and comes up against vested interests he must say: "They must be dealt with." This goes beyond politics. This is where trouble arises between Ministers and their colleagues. I do not think the Minister cares about votes in a matter like this. He is outspoken, but his colleagues are not and they have done him an injustice and hindered him. I should have thought he could have approached this matter by a process of education and by encouraging public meetings on it.

When there was an outcry in Athlone he should have brought down his experts, his doctors there and talked to the people. I found when I explained this to the people, they said: "What about an acute appendix?" I said: "Who says it is an acute appendix? Many a case of acute appendix sent in was not an acute appendix and needed more specialised treatment, but if you have a small hospital that has not got facilities and has not a few surgeons for consultation, a patient may die." The people saw the logic of this and were not opposed to it. This is where the Minister could break the resistance barrier and he should take account of what I say in this regard. We should not follow public opinion; we should lead it. You need not necessarily tell people what they would like to know but tell them what they need to know.

The Minister is very touchy on the McKinsey Report. I am not out to criticise him all the time; I think he honestly believes in the McKinsey Report and what it intends to do; I think he is sincere and I pay tribute to him in that he firmly believes in this report. While I do not agree with a man's views I must respect them and I respect the Minister's views on this. I do not think there was sufficient opportunity for discussion of the McKinsey Report, which is arousing much opposition, and this may be because it has not been properly explained. Perhaps I understand Americans having lived in America for a number of years. They have a way of putting things that is not too readily understood by Irish people. This is the whole crux of the McKinsey Report. We are not accustomed to the pattern that operates in American business and this is an American business approach to our services. This is obvious in the McKinsey Report, but it is not completely adaptable to the Irish system. I was interested to see that the agenda of the Irish Medical Association's annual meeting next month includes a resolution from the executive committee condemning the McKinsey Report. This is significant.

Mr. Childers

It contains in all four volumes and they have already, I hope, accepted three. Only volume IV is left. The other three have been largely and generally accepted with a good deal of adaptation.

Dr. O'Connell

I accept that, but I am beginning to think that they are only now realising that the McKinsey Report may not be quite applicable to the Irish scene. I think it is significant that this resolution should come from the executive of the IMA. They think the results may not warrant the cost. I should be interested in this debate because if this resolution is carried it indicates that the IMA oppose the McKinsey Report, and if that is so it will be an interesting situation. I suppose we were all in a hurry but I thought we should have given more time to discussing it; and a draft of it should have been available which should have been discussed at length. Certainly, the seminars did not achieve a great deal by way of explaining it sufficiently. Too many representatives on health boards are still very confused about the different posts that have been created and the purpose of them. Perhaps we will adjust to it now that it is in operation but I am dubious about it.

I have been watching the course of events in relation to the Mallow and Mount Alvernia Hospitals. Deputy Barry mentioned these hospitals during his contribution to the debate. In replying to Parliamentary questions the Minister has always told us that such matters are for the health boards and they are autonomous bodies. I wonder how, then, he can justify his decision to overrule the decision of the health board in the case of Mallow Hospital. The Minister is a man who moves around a lot. I read many of his speeches. He is a tremendous worker but I wonder how his Department could have had consultations before overruling the health board. This step was unprecedented and raises the question whether health boards are autonomous bodies at all. What is to happen in the future in respect of any resolutions passed by health boards? There is a peculiar dilemma in respect of the two hospitals I have mentioned.

I shall refer briefly to our dental health services. As the Minister must be aware, these services are very unsatisfactory but the problem is one that he inherited. The record of performance of the Department of Health in this respect has not been the best. Our health service has suffered. It is possible, I suppose, that we expect too much. Being so close to Britain, we expect to be as good as they are in relation to the various services but we must realise that we have not been able to be as good as them in this respect because the necessary finance has not been available to us. However, one can hardly be blamed for questioning the overall policy of the Government when we have a situation where 5 per cent of the people own 71 per cent of the wealth. We have had Ministers for Health who have been stymied because of lack of money. The Minister for Health cannot provide any service unless he receives the necessary moneys from the Department of Finance and, of course, when seeking money he must compete with the other Ministers. Perhaps it is taken into account, too, that health is not something that will win votes. I would say that our dental health services are the worst in Europe. Long before fluoridation was thought of, it was remarked constantly in America that the Irish people were among the worst off in the world as regards dental health. Our people did not take care of their teeth. They did not know how to do so and proper services were not available to them. Even now for certain orthodontic treatments there is a waiting list of up to 18 months. Pregnant women are very susceptible to tooth decay. Therefore, in their case in particular it is vital that the necessary dental services be available. There are many people who cannot afford to pay for treatment and, consequently, must continue to suffer.

Perhaps I am placing too much emphasis on the bad points of the service. The problem is one that has been tackled in so far as schoolchildren are concerned but it is not enough that school children only be looked after in this regard. We must admit that the Minister has done wonders in a short time in recruiting dental officers into the local authority health services, but he has inherited a bad system under which there was no consideration for people who could not afford to pay for dental care. Steps must be taken to provide proper services for everybody.

Mr. Childers

I admit it is a low priority but there is £250,000 extra provided this year for dental services. That should do something towards solving the problem.

Dr. O'Connell

I appreciate the difficulties experienced by the Minister in this regard.

Mr. Childers

The Deputy will find that a 4 per cent volume increase per year in social services is reasonably respectable when compared to the figure for other countries.

Dr. O'Connell

I accept what the Minister says and I believe him to be very sincere in the services he wishes to provide. Great credit is due to him for having made so much use of the money that was available to him, but there is much more to be done to bring the dental health services up to the level of other countries in western Europe. Perhaps we inherited a tradition of looking for everything without having to pay for it. I realise the expenditure involved in providing proper services and I know how high such costs are in the United States. Fluoridation is good but it will not solve the whole problem. A better service should be available to children after they leave the national school. There is much to be tackled and much money needed.

I omitted to mention one matter in respect of health education and that is that there is some provision in our legislation which prevents us from providing information on venereal disease. There should not be a repression of information relating to this subject. I believe the disease to be on the increase. The people must be informed about this disease. The problem will not be eliminated by pretending that it does not exist. One must face the fact that it is there and there must be a campaign of public education. That is not available. There is no education. I should like the Department to initiate such a campaign of public education about these diseases and the facilities provided for their treatment.

Mr. Childers

The number of cases notified is minimal.

Dr. O'Connell

I accept that.

Mr. Childers

If only the Deputy could get doctors to write to me privately, in which case I would not, perhaps, take the legal action I could; if I could get from a group of doctors the number of private cases I would then know whether or not these diseases are still minimal. The information I have is that they are minimal. If doctors would let me know the number of private cases then I would at least know where I was.

Dr. O'Connell

The way in which doctors are expected to notify the Department is not helpful. I know this. I would ask him to get his officials to look into this aspect because the incidence is very much higher than is reported. Venerologists agree on this. Perhaps we could improve the system of notification. Doctors are very busy men and they can be forgetful. If there were record cards we could have a better system of notification. This will have to be looked into to ensure that the Department will have an accurate picture of the incidence of the disease. There is need for education. As a medical student, I had the experience of seeing a patient refused treatment because he could not afford to pay. I thought that a deplorable situation.

Mr. Childers

Treatment is free.

Dr. O'Connell

He did not know that. People generally do not know treatment is free. Very few people knew there was a hospital in Townsend Street or what that hospital was for; it was a hospital for females. It was used to treat venereal diseases in females. Very few people know that St. Margaret's of Cortona, as it was called, is now transferred to the Mater Hospital. The danger of infection is serious. We are in an age now in which we can stop pretending these things do not exist and the Department must get to work on a programme of education. I would ask the Minister to look into the legal aspect because I think it is even illegal to have posters about these diseases. I should like to hear the Minister on this.

The work of the Department is very important and I am sure I will be excused if I spend some time on various aspects of health. There was a statement recently by Dr. Clinch, the Master of the Coombe Hospital, to the effect that the number of maternity beds in that hospital is inadequate. At the time the Coombe Hospital was opened I said to the then Minister, Deputy O'Malley, that I thought the Department were not looking ahead and were not aware of the trend away from domiciliary deliveries. What I said then has been amply born out with the passage of time. There is a shortage of maternity beds. There is a shortage in most of our major towns. The trend has changed. We no longer deliver three babies in their homes in one night. People now realise the risks involved in home deliveries. We will have to have prefabricated units erected in order to provide enough beds. I dislike the demarcation "north side" and "south side" and, if we had a proper system, we might do away with this demarcation. There is need for an investigation into the shortage of beds. There is need for a proper maternity unit on the north side and an extension on the south side to the existing Coombe Hospital. I was opposed to its erection on that particular site. It is a very impressive building and there are excellent facilities but not enough beds. We must, of course, weigh this against a possibly more enlightened Government which will allow contraception and family planning. In that event we may not need all the beds I am talking about now.

On the problem of drug abuse, I do not intend to set any scare headline. This is a problem of our society. It is a problem we must look at dispassionately and coolly in an effort to solve it. I do not think we are doing enough about it. There is need for more education. I do not believe such education would give rise to an unhealthy curiosity. I have been lecturing to youth groups for the last two years and I have found these groups very interested but not unhealthily curious. They appreciate the dangers. Proper facilities must be provided for drug addicts and those dependent on drugs. We are not doing this. It has been said that the Jervis Street clinic is merely a meeting place for drug abuses and that drugs are exchanged between them there. I believe this. I do not think we have the facilities there.

Mr. Childers

The social workers and the doctors do a lot of excellent work there, even though what the Deputy says may be partly true.

Dr. O'Connell

Of course, they do. I do not disagree with that. However, the doctors are there twice a week We do not have a registrar there. There is a house doctor, an intern, who looks in occasionally and who has no knowledge of drug dependence. We need a registrar there who has a full knowledge of this condition. How many doctors coming out of medical school know about drug abuse? Very, very few. How many doctors in active practice know about drug abuse? A doctor friend of mine, Dr. Davin Power, wrote a very enlightening article on this in a humorous vein. He wrote about a man coming into a doctor and using modern language about drugs and the doctor did not understand him. He was pointing to the fact that so many doctors are not aware of the facts and would not know a drug addict. I was fooled by drug addicts too often. I was fooled into giving them narcotics by injection although I had seen the problem in the United States.

Of course, the doctors in Jervis Street are working very hard but what is the use of counselling drug addicts if they are to be sent back to the same environment? This is what is wrong. The only way to cure a drug addict is to get him out of the environment and get him rehabilitated. For that, therapeutic beds are needed and they should have at least six such beds down there. We need hospitals to get these people away from the drug environment. The Minister knows this is how the problem must be approached and this must be done before the problem gets too big. As it is, it is escalating. I am being constructive in telling the Minister what we need. The facilities at Jervis Street are not good enough having regard to the magnitude of the problem.

I earnestly appeal to the Minister to look into this and see what we can do about providing therapeutic beds and also how we can rehabilitate these people by means of hostels. We may have to look to voluntary sources for this but it must be done and very soon. The drug addicts are coming out worse than ever, going back to the same environment and spreading drug abuse like an infectious disease. If it were an infectious disease we would get it under control, but it is the very same and we are not getting it under control. Unfortunately it is on the increase. The only way to tackle the drug problem is by proper education. This is the preventive measure. The treatment is therapeutic beds attached to the clinics and the third requirement is hostels for the people we are trying to rehabilitate.

Alcoholism is a big problem which we are all trying to hide. People are stunned when they are told they are alcoholics. Alcoholism is the greatest curse in this country. We are not facing up to the problem nor providing the treatment. Doctors are not helping. Doctors do not want to treat alcoholics. I might as well be honest. This is my impression. It is time-consuming, frustrating and it calls for tremendous patience and understanding. It is a family problem. It calls for a joint effort of social worker and doctor. Perhaps the Minister would talk to our profession about this, talk to the medical schools, see how we could adjust our curriculum. Alcoholism is the curse of Ireland.

I glanced at the leaflet the other day. It is not adequate. There is much left out of it. It does not cover the full range of alcoholics. It does not mention the alcoholic who needs a drink to get through the day. There are many who cannot get through the day without a drink. I do not know who prepared the leaflet but I think it was hastily prepared and it is not good enough. I agree with the Minister that it is a step forward. It has made people think. We should have open discussion. Community associations should be encouraged to have seminars on alcoholism. Families have been almost destroyed by this problem.

Mr. Childers

It is included with drugs now in the new seminars for teachers and youth organisations. A lot more has to be done about it. First of all, we must take it out from under the carpet. It will take at least 12 months to do that.

Dr. O'Connell

I agree, and I know what the Minister is trying to do. I am not condemning him at all. Far be it from me to condemn the Minister. He knows it is a worse problem than drug abuse, but what is wrong is that we accept it as a social norm. Nobody wants to talk about alcoholism.

Is there any way in which we could have treatment of the alcoholic in hospital? The cost in one Dublin hospital is much higher to the alcoholic than to the psychiatric patient. Even the doctors and the hospital forget that it is a disease and they push up the price because he is an alcoholic. That is bad. The Minister should look into that and enlighten the doctors of the fact that it is a disease and that its treatment should not cost more. The alcoholic patient is occupying a bed the same as any other patient. He is as much in need of treatment. I deplore this approach by doctors who are experienced in the treatment of alcoholism. I found a reluctance on the part of hospitals to admit alcoholics. The Minister might have a talk with them about this. The Minister is correct in saying we must take this from under the carpet and he is correct in saying it is a worse problem than drug abuse. In a year's time, the Minister will probably be in a position to tell us how bad the problem is and then we will be really surprised. I could hazard a guess as to the incidence, which would not be far from the actual figure.

Mr. Childers

The nearest I can get to it is that one out of every 33 consumers of alcoholic liquor has a serious drinking problem. That is the nearest I can get and, God knows, that is bad enough.

Dr. O'Connell

I would put the figure at one in six. Watch what I say. The incidence among females is increasing and I am not saying anything new when I refer to the supermarkets and the vodka. There is nothing worse than a female alcoholic. Such a person is a very difficult patient.

Mr. Childers

I hope the Deputy is wrong. It is truly frightening if the figure he gives is correct.

Dr. O'Connell

The position about alcoholism in this country is very frightening. I will probably incur the wrath of all Deputies if I say that we could do without our bars here.

With regard to the choice of doctor scheme, a number of doctors have been precluded from entry. That is a little unfair.

It is time that the Minister, by regulation, implemented section 69 of the Health Act in relation to the disability allowance. Under this section only the person's income is taken into account, not that of his children. Again, the Minister comes up against a problem and I am sympathetic because I am aware of the problem. Disabled persons have to depend on the charity of their relatives. To a disabled person an independent income, no matter how small, is important. There should not be a means test. The Minister is a humane person. I would ask him to implement section 69 in these cases.

Mr. Childers

The Deputy is perfectly right. All the sections in the Health Act involving extensions of monetary assistance have been put into operation, save that one. That is the last one that we have to do and I could not afford to do it this year.

Dr. O'Connell

How much would it cost? The Minister is doing great.

Mr. Childers

It would cost £1.25 million. They have all been done except that.

Dr. O'Connell

The Minister will have to make the other section of our society pay a little more.

I hope the Minister will heed what I said about family planning and our contraception Bill.

Everything that I suggest involves more money. I have already brought up the point about old age pensioners who are medical card holders. The Minister should clarify this matter. The medical cards can be torn up when these people go into hospital for treatment. Their pension book is taken from them. We are discriminating against this section of our community. I do not think we have a right to do that. I do not understand why these persons should be classified differently from others. A person who is 73 years of age, who has a medical card and who becomes ill, does not get free medical treatment. At 37 years of age a man with a medical card will get free medical treatment. That is illogical. I want to see that these old age pensioners get their rights. It is a question of rights. I do not think it should be left to a public servant to decide this matter. We have to accept the fact that these persons must have the right to free medical service because they are holders of medical cards, irrespective of age. Neither the Minister nor the Department has any right to discriminate against this section of our community. I want the Minister to have the courage to stand up and answer me on that matter. What are we going to do about these people? I have fought time and time again for these people because they are being deprived of their basic rights. Otherwise, you can take the medical card from them and tell them that they are not entitled to a medical card. We had better make up our mind that if they are given a medical card they must be provided with the facilities the medical card entitles them to. At 37 years of age they get it; at 73 years of age, they do not. There is something radically wrong with that system. It will have to be challenged, unless the Minister now has the courage to say, yes, they are entitled to it. He and I and everyone else know that they are entitled to it but it is not being provided. This is not right, as the Minister knows. It is morally wrong to deprive these people of this service.

A public servant has not the right to say for six weeks that they are only sick because they are 73 and after six weeks that the pension book will be taken from them, although they may be receiving treatment for a heart ailment or surgical treatment or may have suffered a stroke that involves medical treatment. The medical treatment must be defined. I am not dealing with the case of persons who are receiving institutional care. I am talking about medical treatment. We must distinguish between the two.

I have had a resolution passed at the Eastern Health Board about this. I am wondering is it being implemented since I had it passed, despite the opposition from the chief executive officer, Mr. O'Keeffe, who has no right whatsoever to do it. I think he exceeded his authority in doing this and I denounce him for it.

An Leas-Cheann Comhairle

The Deputy is using the privilege of the House to denounce an individual who cannot defend himself in the House.

Dr. O'Connell

He will get an opportunity to defend himself because I will denounce him at the next meeting of the health board.

An Leas-Cheann Comhairle

If the Deputy would do that, rather than do it in the House.

Dr. O'Connell

I withdraw that because I do not want to mention his name until I go up there and meet him. Then I will talk to him.

Mr. Childers

I cannot change the present system, to be quite frank with the Deputy.

Dr. O'Connell

The Minister will not?

Mr. Childers

No.

Dr. O'Connell

Therefore, the Minister is discriminating against old age pensioners who are ill and who hold medical cards. We had better have a public outcry about this because I am going to make the Minister change his mind about it.

Mr. Childers

The Deputy will not succeed.

Dr. O'Connell

Now we come to a clash because I am now going to make the Minister change his mind about it because he is discriminating against these people and I shall not allow it. I tell the Minister that now, whether he likes it or not. I shall carry out a campaign against the Minister on this matter and the public will be informed. I do not care how it will be done but it will be done. The Minister has no right to do this. I tell the Minister frankly that I will have the case challenged. That is an interesting point for the Minister. I threatened this before with the health board when they would not dispense private doctors' prescriptions for medical card patients. I told them I would challenge it in the court and I will challenge this in the court and we will see whether the Minister is right or wrong. These people have a right as holders of medical cards. I will challenge it in the court. There is an interesting case. It will be a case against the Minister for Health. The Minister has admitted that he is not going to change. The Minister has no right to say that. He has no right at all to say what he has said. He has not the power to do that.

Mr. Childers

The health boards have the power.

Dr. O'Connell

No, they have not.

Mr. Childers

Health boards have powers to give allowances.

Dr. O'Connell

They have not the power to do that.

Mr. Childers

Health boards have power to give monetary allowances to old age pensioners in institutions and that is the way they do it.

Dr. O'Connell

Where a person is receiving medical or surgical treatment and is the holder of a medical card, that medical card provides for those facilities free. You have not the power or the right to do that. I am going to see that that is challenged. I come across these patients. The Minister has now admitted that my resolution has been overruled in the health board. That is exactly what he has admitted. That is very interesting. That will be on the agenda for the next meeting of the health board and I will see that it is challenged. The Minister is making a grave mistake and will regret it. I am very disappointed at his attitude on this subject. It is very clearly defined how it could have been done. I emphasised the fact that where a person was in receipt of medical or surgical treatment he is entitled to such attention free. The Minister has gone down in my estimation.

Mr. Childers

We can always argue about the eligibility of the person and the old age pension going towards the cost of the medical service. One can always argue about the length of time the patient is in an institution——

Dr. O'Connell

Could that not be left to the doctor to decide?

Mr. Childers

I have answered the Deputy.

Dr. O'Connell

I would suggest that a lot of complications could be avoided by leaving it to the doctor to decide on this point. It should not be left to the public servants. What do the public servants know about heart conditions or the complications of diabetes?

Mr. Childers

I am not going to change this to where the chief executive officer decides——

Dr. O'Connell

The Minister certainly will change it. I am challenging this. I have said that I will do this. The war is on. I am telling the Minister so, and when I decide on something, it is done. That is telling the Minister straight. I would like to refer to the question of Comhairle na nOspidéal. I should like to make my views on this known. Voluntary hospitals must accept recommendations about appointments that come from Comhairle na nOspidéal. The Minister knows my views on this. I have explained them before. If managers of voluntary hospitals will not accept the recommendations I say they are not entitled to the grants to cover their capital deficits. I do not think that anyone has the right to decide that the appointments suggested or approved by Comhairle na nOspidéal will not be acceptable to them, or that they have the right to decide. We will have to change. When we get a change of government we will have to look at the question of the voluntary hospitals. The Minister may not agree with me. I will be anxious to examine this question. I would hope to hear from our new archbishop on this point. I have a feeling that he will have an enlightened approach to this. I am anxiously awaiting the next annual general meeting which he attends in one of the hospitals of which he is manager.

The Minister in a statement last September did not assert himself sufficiently. He has not asserted the power or the function of Comhairle na nOspidéal sufficiently. I do not think the Minister should bend over backwards for the voluntary hospitals. On the question of family planning, if it is being taught in the medical schools there is a right to teach it in the hospitals.

I want to mention the measles vaccine. Too many complications follow measles. We should avail of this vaccine which is so successful. We should make it available to those most at risk—children under one and two years of age. We should carry out a national programme with this vaccine. Now is the time to do something about it. I welcome the programme of vaccination in connection with German measles. A few lives have been lost every year as a result of measles and the horrible complications which follow this disease. The question of vaccination should be carefully examined.

Last year I spoke about volunteers in hospitals. The Minister has spoken about the useful role which citizens could play in society. I agree with this. Many people have time on their hands and they would like to be gainfully employed helping their fellowmen. This can be done best in hospitals. Hospitals should appoint organisers and encourage the public to help. This could be done in mental hospitals. It is being done in Britain with great success. The Minister should consider sending a circular to the hospitals about this matter. People could do more than visit the sick. They could carry out duties as well as read, write, help with beds, et cetera. Such work could give people a great awareness of the problems in their midst. Such a scheme could be organised with a little help from the Department. A pilot scheme could be experimented with in certain hospitals in Dublin. It would be an eye-opener for people to visit St. Ita's. This plan should be seriously considered. The Minister might look at this point.

Debate adjourned.