We had a very interesting, prolonged debate on the health and hospital services in which a great deal of the comment was constructive and some of the criticism was quite fair in that there is no Minister for Health I know of who could make the progress he would like to make at the speed which would satisfy either his own ideas or those in the Parliament where he sits.
I notice that there was no speaker in the debate who in any way criticised the abbreviated statement of health and hospital policy which I put in at the very end of my Estimates speech. I think this is the first time that I know of for a number of years where a general statement of policy was made indicating the priorities and there was no general criticism or even no detailed criticism of what constituted the national health policy as devised by me as Minister for Health for the time being and as approved in the Oireachtas as a result of Health Estimates being passed during the last two years. I was glad that no one, therefore, challenged the general type of policy which should be developed.
I would have hoped that more Deputies would have spoken about the development of community services and would have, perhaps, by their speeches advertised the necessity for encouraging voluntary organisations throughout the country to come together, not to lose their identity, but to work together as participants in social service councils with a view to collaboration with the statutory authorities and the health boards, in respect of the ways by means of which people can be kept out of hospital, and people in distress of any kind assisted. Whether the reason for failure to comment on this was that the Deputies feel that in my Department we are doing our best to encourage the social service councils, or whether their interest has not been sufficiently aroused, would be difficult for me to know.
It is true that the social workers in my Department have helped to establish no less than 16 social service councils in the course of the last two years. More councils are in progress of formation. We now have a national council for social services on which there are experts of every kind. The council will give me advice on the development of community services and on matters that arise in connection with the formation, growth and pursuit of social service councils.
I want to say that we have a very long way to go in this regard. The domiciliary services which were referred to by a number of Deputies cannot be fully implemented without a great deal of voluntary help and through the work of voluntary organisations supported by voluntary funds, in addition to the funds donated by the health boards. Above all, a type of organisation which permits the appointment of more social workers in every social service area is needed, not only because of the valuable service they provide but also so that they can help to train voluntary workers to look after those in distress.
This also relates to the provision of youth services and to the very great importance of providing community centres and recreational facilities for youth. These matters are not my responsibility. They relate to the work of the Minister for Local Government and also, ultimately, to the development of more cultural facilities and adult educational facilities in every area. The social service councils can promote these activities in conjunction with the local authorities and with all those working in these fields.
I will deal now with the financial question, which arose. I am quite aware that the health services impose a very heavy burden on the ratepayers and the taxpayers. This is found in every country in the world. It is true to say that the richer the country the heavier the burdens of health and hospital costs seems to appear. I foresee that the costs here will increase still more. I foresee an increase in the cost of providing hospital services over the next ten years as techniques become more expensive and specialisation grows, and more and more people are saved from death and brought back to health through advanced techniques. The hospital services will become more expensive and involve us in considerable financial difficulties.
If one examines the position in a country like Sweden, the second richest country in the world, one will find that the Minister for Health there stated that he did not know how he was going to find the finance for the kind of health services which were being sought by the Swedish people. Sweden is a country where a married man with £3,000 per annum and two children pays £1,300 income tax. It is no use for Deputies to get up and make the bald statement that the health charges should be removed from the rates. This would involve the transfer of £35 million in the present year from the rates to the Exchequer. It would impose impossible problems on the Minister for Finance and on the Members of this House if such action was taken.
The following increases in taxation would produce approximately £35 million:
A 7p increase in the standard rate of income tax, or
A 17½p increase on 1 gallon of petrol, or
A 23p increase in the price of a packet of 20 cigarettes.
I do not think that such a transfer of taxation on property to taxation on incomes or expenditure is really feasible. We have limited the increase on the rates this year to 30p in the £ and we will continue, so far as possible, to give this kind of assistance in future.
Deputies have made various suggestions for some new kind of insurance scheme. I regard myself as looking pragmatically on all proposals for insurance schemes which are intended to limit the necessity for paying rates or income tax. It is almost impossible to devise any kind of insurance scheme that would be truly equitable. In Europe there are a number of countries which, through the growth of the co-operative societies and the co-operative principle applied on a very large scale, began their health schemes through the introduction of an insurance principle. Schemes varied from country to country. All those countries have found that it is quite impossible to charge on a pay-related basis, or on any other basis, the full cost of health and hospital services, because the cost of hospital services have grown so tremendously. If we look at the position in Denmark or the Netherlands, we will see that they have schemes on an insurance principle, but there are enormous subventions for hospital services from the State.
What is the reason for this? Even though it might be possible for the Minister for Finance to try to work out what the impact would be on the total expenditure of everyone concerned in an insurance scheme and charge the employers, the employees and self-employed persons compulsorily with an insurance premium the premium would either be so high that it would come to look like nothing more than a tax, or else it would be of a form that one could not be certain whether the relief of taxation that might be afforded would impinge on the various sections of the community in a fair and equitable way.
I am not saying this in order to give an easy or cheap answer to the Deputies in the Dáil. Deputies who have been a long time in this House and who have studied the reports of committees on taxation in general will know the difficulties of coming to sound conclusions on these matters. I do not know how to describe the means by which one arrives at a conclusion. You cannot tax a person more in relation to income tax without causing political difficulties and resentment and you cannot tax a person more in expenditure without going beyond a crisis point. We, as the Danes and the Dutch found, cannot charge insurance beyond a certain point by itself sufficient to pay for the health and hospital services without again causing a defence mechanism to arise whereby you know that you cannot go on with the proposition. If anybody could suggest to me a form of insurance that would really be equitable, that would really work, and that would have any very large effect in reducing rates and taxation in an equitable manner for the persons who pay the insurance, I should like to hear of it. I shall not go into detail about the Fine Gael scheme. It would not be worth while to apply that scheme in our present circumstances.
As I said, we shall go on thinking about the subject of whether some insurance scheme to replace the present system can be formulated. I do not know how it can be done. One of the difficulties is that if you substitute for rates a very considerable insurance scheme, it is very difficult to say whether simply relieving certain householders from rates as a result would be fair to people who do not pay rates. We would like to be certain of that. There might be some case for doing it, because everybody knows the rating system is imperfect in certain respects. It applies fairly in certain respects, but in relation to people with permanent incomes it applies unfairly. Provision has been made by the Minister for Local Government whereby rates can be remitted, through striking an extra rate by the county council, for those persons who are burdened by an excessive rate in relation to their unchanging incomes, incomes that have not altered through the passage of time and the growth of inflation. As I have said, it is very difficult to change the system we have.
Some Deputies have asked about the cost of our having the same system as can be found in Northern Ireland in relation to payment for the health services. The position here is that 90 per cent of our people get hospital services, drug assistance and out-patient facilities either free or for the very small sum of £7 a year, and only 10 per cent of the people are obliged to pay for most of their health and hospital services. The extra £30 million would add another £10 a year on taxation or rates to the £30 a year which is roughly being spent this year for that purpose. No doubt if the time came when we had to consider the co-ordination of the health and hospital services as between ourselves and our kinsmen in the North, we would have to go into the question of altering the service. However, I want to say with absolute frankness to the House that I cannot get a single statistic or fact in relation to the Northern Ireland health and hospital services which suggests that we have less good health here than could be found in the North before the terrible events took place which began in 1969. I can find no evidence to this effect in relation to expectancy of life, the death rate, the infant mortality rate or the perinatal death rate; I cannot find any evidence from looking at figures of deaths from various diseases. If deaths or afflictions from one particular malady are slightly higher down here we find they are lower in respect of others. Therefore, although it is true we shall have to consider this whole question of the method of financing our health services if we reach the point where a reunification measure comes into operation, I still say that our system has been greatly praised by doctors who came from Great Britain and from America and that we are not criticised by experts who come from outside in respect of our three-tiered system. Inevitably there will be defects in any three-tiered system, but I do not think it works so badly and I doubt if there are many people who are deprived of medical services to which they are entitled through the establishment of the three-tiered system which we have today.
Some Deputies made observations on the implementation of the FitzGerald Report. Let me repeat for the nth time that there will be no change in the function of the main hospitals of this country without, first of all, there being a study undertaken by the regional hospital boards, by the regional health boards and, in so far as the matter applies to the working of Comhairle na nOspidéal, by Comhairle na nOspidéal; and that before any change would be made I have agreed to consult the county advisory committees for health wherever there is a dispute on the future functions of a particular hospital. No hospital can be closed without my consent as Minister for Health, and under certain circumstances there must be a public inquiry held in relation to changes in the functioning of a hospital.
Having said that, I do want to point out to the House that the implications of the FitzGerald Report, not as applied to every recommendation they made but in general, are farseeing and, to my mind, must be pursued to the bitter end over a period of years. I am told by the experts in the field of consultant practice and by experts in the field of medical teaching that unless there should be some quite remarkable change in the general pattern of medical teaching, between eight and ten years from now it will not be possible to recruit surgeons for hospitals. Therefore, eight or ten years from now a number of recommendations made in the FitzGerald Report for the construction of certain general hospitals throughout the country and the closing of surgery in certain other hospitals will become absolutely inevitable.
This is not something which the relatives of people undergoing surgery like or appreciate, but it is always possible that, if a patient goes to a specialist hospital or a hospital where there are a number of surgeons and physicians working as a team with good paramedical facilities, the patients can return for convalescence, when they are regarded as out of danger, to a district hospital where they can be seen by their relatives more frequently. That is always a possibility in relation to the purely human problem, which is of great importance, that patients like to be as close as possible to their family.
Again, the FitzGerald Report must be seen in the light of the fact that there are health boards where already 22 to 25 per cent of patients go to Dublin hospitals in any event which, in many cases, are very far from where they live. Therefore, there is already a movement of patients from a local rural area to a regional hospital area and we want to examine the question of how many more regional hospital facilities we can provide which will reduce the number of people that need to go to Dublin. The extent to which we can do this will depend on the work of the regional hospital boards who, with the aid of competent staffs, would be analysing the results that will come from the in-patient survey of the Medico-Social Research Board. It may mean that in relation to some of the hospitals that will inevitably be developed in the country, such as Tralee, Castlebar and Letterkenny, and in relation to the more controversial proposals which have been made right through the midlands and on which there has been no decision, it may be found possible, if there is a sufficient patient workload for people living within a reasonable distance, to develop some specialties in these hospitals.
All this depends on very careful examination of the patient workload in each hospital and so there is no need for people to start marching or protesting on the future proposals in relation to the FitzGerald Report. Much of the FitzGerald Report is noncontroversial and can be pursued, even without waiting for the medical and social research board's findings because the facts are perfectly clear and evident, and this applies in particular to the development of the Cork Regional Hospital, the Tralee hospital, Castlebar, and the development, above all, of the great regional and general hospitals in Dublin where the population is increasing as in the case of other capital cities.
Deputy Burton referred to the position of Mallow County Hospital. I am going to see the county advisory committee for the north Cork rural area in order to explain to them why I refused to accept the proposition that not only should Mallow retain its surgeon but that it should be expanded. There is absolutely no case for the expansion of surgical or medical facilities there in a way that would go far beyond the population in the area and go beyond the inevitable results that would accrue from a very great modern regional hospital being built in Cork city. The action taken was to preserve the existing surgical facilities there.
I must say that I sometimes find it difficult to understand why people think that surgery is of such desperate importance in a local hospital. It is quite possible to imagine that in some hospitals where surgery, except perhaps for minor code surgery might cease, there could be expanded facilities for maternity cases, a better obstetrician—gynacological service, that some of the beds would be made available in order to conform with what I regard as one of the most correct decisions in the FitzGerald Report, that general practitioners should be allowed to take beds in county hospitals and to look after their patients. So you have the possibility of surgery stopping in a hospital but of there being better maternity facilities and above all, of general practitioners being able to find beds in the hospitals and to look after their patients there in ordinary medical cases. At the same time, if the FitzGerald Report is finally implemented one would expect more outpatient consultant services to be provided at the hospital.
This kind of service is growing, but all the emphasis seems to be on the retention of surgery as such, without looking at the whole picture of the developing services in the area concerned. If at the same time as a hospital changes its function, there is a great expansion of domiciliary services, if more people are being kept at home and looked after, more old people are being given meals on wheels and there is a whole community service made available to everybody in the area, while you may be centralising certain kinds of hospital treatment in one sense, you are decentralising the health services in another, so that no one could say that the Minister was a concentrator, a centraliser rather than a person who believed in a combination of inevitable concentration in relation to specialties and decentralisation in relation to the growth of community services.
This whole question will take some very considerable time to deal with. As I have said already in the House the Minister for Health has to face the very embarrassing proposals for the location of the general hospitals from the north midlands down to Waterford, in which Ardkeen Hospital in Waterford, Tullamore and Cavan have been chosen; we could have, even when the study is being made by the regional hospital boards and the regional health boards, so many deputations from people looking for Tullamore, on the one hand, and Mullingar on the other, for Monaghan instead of Cavan, for the preservation of Kilkenny and of Wexford, with the permutations and combinations involved in examining the proposition of where the general hospitals should go, from the north midlands right down to Waterford, that it would be enough to drive any Minister almost mad particularly after he had received a very great number of dissentient representations from people, all of whom claimed that their particular town was a better centre for the general hospital than another.
However, as I say, this is going to take some time to process and I am going to continue to communicate, as I try to communicate with everybody in relation to the FitzGerald Report and the whole development of health and hospital services through the country, through the advisory committees who can co-opt people who feel particularly keenly about a particular proposition. For example, the Roscommon County Advisory Committee could co-opt people from the Roscommon Urban District Council or from some group in Roscommon who felt very keenly about the retention of Roscommon, which is not in issue at the moment and cannot be decided for a considerable period, and so I would be able to hear from the body which is set up for this purpose. The county advisory bodies have been set up for the general purpose of ensuring that a regional health board apply the general health and hospital programme equitably throughout the area, so that domiciliary services, community services, public health nursing, general medical and hospital services are applied in a way which ensures that every county receives the same kind of treatment and can see that the same general standard prevails there as in every other county in the regional health board area. These county advisory committees are obviously the bodies to discuss the matters that arise when it is proposed that a hospital changes its function.
Whoever may be Minister—I may still be Minister or some one else may replace me in the future—may have to get very tough on this subject and in the end when the Minister makes a decision in relation to the FitzGerald Report, if he can be absolutely certain that he is going to save human lives, and if all the expert opinion given to him shows that, or if he can be certain that more people will be restored to complete health by having all serious surgery cases go to a hospital where there is a team working, the Minister would be justified in defying all the public opinion that may protest. That will be the ultimate consideration, and the Minister will have to be trusted, as I hope he will, by the Members of the Oireachtas and those who have particular feelings about particular areas in relation to hospitalisation.
The Minister can get very good advice on this subject. The modern consultants, those who are concerned with modern medicine and hospitalisation are all absolutely convinced that the multi-consultant hospital, with the right kind of para-medical facilities, is the best for a great many maladies. This does not apply to simple appendicitis or hernia or simple fractures or maladies of that kind, but as we get to know more and more about the human body we all realise that the interconnection between the various organs of the human body, can be far closer than has ever been imagined. When a person is affected by some malady it is very often important not alone that more than one opinion should be secured but that there should be examination by more than one doctor or surgeon.
As I have said, this is universally agreed all over the world. The Bonham Carter Report, published in Britain, was similar to the FitzGerald Report, in so far as the general principle is concerned of concentration for serious surgery, concentration within reasonable limits, not asking people to travel unnecessarily. This has already been demonstrated in practice by the very great number of patients who leave all parts of this country to go to Dublin to receive very specialised treatment and care. If I remember rightly, 29 per cent of the patient bed days in the Dublin voluntary hospitals are in respect of persons who come from outside Dublin. This is already an admission of concentration by the medical world and by the political world that you do have to move in order to get really first-class treatment in a specialist hospital. The FitzGerald Report examined the problem at a lower level of specialisation.
Having said all that, I want to indicate that I sympathise with the natural feelings of people in relation to this whole matter but at least I have provided an intelligent system of examination, the regional hospital boards, the regional health boards, the county advisory committees, Comhairle na nOspidéal, and the Minister for Health ultimately will be responsible for the final decision because it is almost impossible to imagine a single case where a decision of a major kind can be made without some financial element being involved, either from expenditure in a hospital which is to change its function in the direction of receiving more patients or a change of expenditure in relation to consultants or staff. So that the Minister for Health cannot get out of the responsibility which will ultimately fall on him, whoever he may be, for the implementation of the very controversial parts of a magnificent report, of which a great many elements and a great many proposals can be steadily implemented, as they are now, without this controversy arising.
Deputy O'Connell referred to the care of the aged in various ways. I want to tell the House that a great number of hostels for the aged are being promoted and are in various stages of building. A number of Deputies referred to this matter, including Deputy Donegan. I circulated statistics in connection with the capital schemes in progress applying to homes for the aged. I think we are doing fairly well. There were 357 places for old people completed since 1st May, 1971. There were 931 places under construction on 1st May, 1972. There are at tender 375 places and there are in planning—and I think I am right in saying that those that have been planned can be put into operation in the year 1973-74—631 places—a total of 2,294 places for the aged and that includes 14 new 40-bed hostels of the most modern type which will be built for old people who are still ambulant but who need some care, who are not chronically sick. These will be built in places where we can be sure that these old people, if their families cannot visit them, will be visited by voluntary organisations who will help to bring a human friendly atmosphere to the place. Apart from that, old people can be cared for in homes of this kind which compare favourably with the county homes that we had, many of which have been or are being improved. All of this clearly indicates that the object of the Government is to improve the geriatric service.
A Deputy raised the question of home assistance in relation to the community service, As I think I told the House in reply to a question, there has been no final decision about the general future character of home assistance and the method of its administration. The Minister for Social Welfare has indicated that he is examining the problem but the Minister for Social Welfare will agree with me that, whatever decision is made, the home assistance officers must co-ordinate with the community services, with the voluntary organisations, with the public health nurses, with those in charge of the community service, the health boards, because in a great many cases persons need far more than money when they apply for home assistance. They frequently need help of one kind or another. Frequently help can be a substitute for cash because there are some kinds of help which may be more valuable in the circumstances of the person in trouble than actual cash. So, I can assure the Deputy who asked me about the future of home assistance that we will certainly have the form of co-ordination which already exists in relation to the home assistance officers, that that will continue.
Deputy Burke referred to the necessity of having social welfare officers and social workers. We hope that in regard to the community services administered by the health boards there will be considered the necessity of appointing the kind of supervisory staff which will mean more encouragement to the appointment of social workers, working with voluntary organisations, as I hope, in most cases, so that the whole field of social work can expand throughout the country.
Deputy Donegan referred to the position regarding geriatric accommodation in County Louth. The Deputy is no doubt aware that, while the present situation could not be described as satisfactory, there has been a considerable improvement in recent years. The situation in Drogheda was relieved by the transfer of some patients to Ardee, the former district hospital, and a new building is being made available in the Dundalk County Home for use as a sanatorium, and approval has been given in principle to the erection of homes for the aged in Drogheda and Dundalk.
In speaking of this whole problem of geriatric care I must, of course, make it clear that we are only at the beginning of the road, as was indicated to us by Deputy O'Connell, in regard to providing a full geriatric service. When I refer to geriatric service I refer to expert facilities for geriatric assessment, assessment of the capacity of an old person to live in the community or whether the person needs to be rehabilitated, whereafter he may or may not be able to live in the community, or whether a person must be regarded as chronically sick. This examination of old people at the optimum point so far as they are concerned is of great importance. This policy is gradually being developed and it involves the appointment of either physicians who are skilled in geriatrics or of geriatricians. It is not very easy to get geriatricians at the moment although we have been able to appoint some.
A number of Deputies referred to the disabled persons' maintenance allowances and the implementation of section 69 of the 1970 Health Act. I told people in reply to Parliamentary questions that this would cost about £1¼ million a year and that having provided the great majority of the new services that were recorded and reflected in the 1970 Health Act, I believed I would have to wait in order to be able to implement this scheme in which the incomes of persons other than the spouse are disregarded for the purpose of determining the disability allowance. Certain Deputies suggested that uncles and aunts were being deprived of allowances by virtue of the means of nephews and nieces who live with them. We have written to the CEOs of the health boards pointing out that section 50 of the Health Act, 1953, only allows cognisance to be taken of the relatives specified in section 7 (5):
any spouse, son, daughter or parent of a person, or any brother or sister of a person normally resident with that person...
We asked the CEOs whether there had been any departure from this practice and we also suggested to them that they should take a reasonably liberal approach to the assessment of the means of relatives other than the spouse pending the introduction of section 69 of the 1970 Act. Having done that, one can be certain that the vast majority of those who desperately need disability allowances are getting them. As I have said, we hope to implement section 69 at a later date.
The cost of the health and hospital services is mounting so rapidly that it is simply impossible to do everything in one year, and with the choice-of-doctor scheme and the provision of drug assistance for the middle income group and the abolition of outpatient charges and the special facilities for those with certain disabilities such as epilepsy and mental illnesses, we contribute quite a good deal to helping people who are partaking of the health services. We have made a very good contribution in the last three years. We are making such progress as we can and we will continue to do so.
I come now to questions that relate mainly to health boards. The health boards are still in their formative stages. There are three programme manager posts vacant, in the East, North-East and the Western Boards. Some of the programme managers who have taken up office have done so only recently. There are some support staff posts that have not yet been filled in various areas. I have had a good deal of experience of administration of one kind or another—I have been in charge of eight State companies over a period of ten years and I have tried to learn as best I can modern methods of management—and I say that I could not expect health boards to be in full operation and revealing the potential for improving and making more efficient the health and hospital services until 1973-74, or perhaps the year after that.
I made it very clear to the House that the cost of the programme managers represented only a halfpenny in the £ on the rates and that the total cost of administration of the health and hospital services by the health boards in so far as health board expenditure is concerned is 3½ per cent. I do not think we need to be ashamed of that percentage. I doubt if there is a lower percentage to be found anywhere in Europe. All the remarks that were made in the Dáil that the health boards are enormously extravagant and expensive have not been shown to be correct by any evidence that I have. The increase in the total cost of the health and hospital services in the two years before the formation of the health boards is of a size which shows that whatever increase took place since then it certainly did not take place due to extravagance on the part of the health boards. Before the health boards were made operative, there were a good number of medical staff appointed. If I remember rightly, in the year 1970-71 something like 45 new consultants and psychiatrists were appointed all over the country either to do out-patient clinic work or to provide for the needs arising from a growth in the numbers of people attending hospital for one purpose or another.
The idea that the health boards in the first full year of their operation were recklessly extravagant in appointing more consultant staff, with a consequential increase in nursing and ancillary staffs, is totally without foundation and if anybody wants to ask a Parliamentary question the reply will show continuous progress is being made in relation to filling staff appointments of a medical kind and a para-medical kind that were absolutely inevitable.
A lot of people, like Deputy Coughlan, spoke in so loose and ignorant a way about the functions of the health boards and their purpose that I do not know whether I need to repeat the basis for their formation. It is quite simple. First of all, it was because of the growing specialisation in the hospital services, the fact that before the formation of the health boards there were a great many counties where virtually all the patients left the county to go to a hospital and a great many of them had to move throughout a larger regional area. In order to co-ordinate the hospital services within a health board area, the health boards were formed covering areas which for hospital purposes seemed to be reasonable in relation to the population and the number of hospitals in the respective areas and the purpose they served. The other reason was that if we are to get good health and hospital services where decentralisation is involved there must be expertise at the top, there must be opportunities for promotion for all kinds of expert staff dealing with the community services, and it was absolutely impossible to provide a system where there was expertise available in every one of the 27 health authorities which could be secured at a salary that could be afforded and where there were equally opportunities for promotion in those various fields.
So the area was enlarged with the idea of providing the right kind of headquarter staff, the secondary staff and the tertiary staff to do the best job possible in regard to all the services which should be decentralised and in order to ensure that the decentralised services would expand. This applies to the work of public health nurses, of the general practitioners and to the county medical officers of health, but it applies above all to the development of the domicialary services and the community services. If they are to be run in a first-class way, the staff at the top must have the facilities and the pay to ensure that the right kind of policy, the policy approved by the health boards, will be fully implemented.
I should like to say to certain Deputies who talked about the lack of information on the health services that I think this is true but I do not know how soon the health boards will be able to afford information offices for which provision was made in the Health Act. We are about to issue a new leaflet on the health services, or rather arrange for the health boards to publish a new leaflet, which will contain full particulars of all the health services available. I hope that if Members of the House find that local officers are slow in giving the necessary information to people about the health services they can get, they will make complaints to the health boards. I have not had many complaints on this matter.
There were a number of observations from various Deputies about the choice of doctor scheme. All I can say is that there will be a review after a period of operation and all the matters raised can then be examined. It has already been decided that, if the distance limit of seven miles is impracticable, it can then be extended.
Deputy Begley claimed that doctors must be resident at least two years in the country before being eligible to apply for appointment as a permanent or a temporary dispensary doctor. That is not so. The Deputy is presumably referring to the provision that, for official entry into the choice of doctor scheme, all doctors must have been in practice here for at least two years. A list of doctors wishing to participate in the scheme has been compiled on this basis and future vacancies will be filled on an open competitive basis without any residence qualification.
