There seems to have been a fair amount of sound and fury in relation to this Bill providing for increased health contributions and one must, I think, look at the matter in the context in which it arises. One can see that the present contribution of £7 per year or 13p per week has been in existence since 1971 and there is no doubt that the cost of the health services has almost doubled since 1971-72. This has been partly due to increased costings and partly to improved services and I think we should take a realistic view of this contribution which is now asked for of 26p per week or £12 per annum. In effect, what these contributors are asked to pay is less than the price of 20 cigarettes per week and bearing in mind the increased and better services, it is a small amount to ask people to pay. I know that times are difficult and costs have risen right across the board but for people to get excited about the fact that they are being asked to pay less than the price of 20 cigarettes per week just does not seem sensible, having regard to the excitement that is being generated from the Opposition benches.
The health contribution to date brought in £5 million per year and this will bring in £3½ million, and if one estimated it, one would probably find that the actual benefit which people in this category receive when related to what they are asked to contribute is something like 10 per cent, if even that. As the Minister rightly pointed out, the contributions to date bear very favourable comparison with those required in other voluntary insurance schemes, be they run by private institutions or by the Voluntary Health Board. I personally have always been an advocate of contributions towards mental services and I think that viewpoint is gaining strength in the country. One hears a lot of criticism about people wastefully and unnecessarily availing of medical services. If there is this situation, it means that unnecessary and increased costs are being visited on the nation and this ultimately has the effect of restricting the availability of health services, institutional or otherwise, which could be made for the rest of the nation and preventing other categories being brought in for what one might call subsidised benefits.
One must look at this Bill in the light of the Estimate for the Department. One sees that the Estimate shows a 40 per cent increase and this means that money has to be found. The average person today would not be prepared to accept the medical services and the medical treatment provided ten years ago. People now demand a better standard of treatment and they demand services on a much wider scale than were heretofore considered sufficient. I was glad to hear the Minister when introducing his Estimate refer to community care.
I can look at medicine from what is a slightly privileged position being the son of a family doctor. I can see the tremendous improvements that have occurred in medical science. Cases that were utterly hopeless and untreatable, except in a palliative sense, are now treatable; conditions that would have incapacitated people years ago can now be corrected and those treated can live normal lives. I was very impressed on visiting a hospital outside the city environment to see people well over 70 years of age undergoing major bone surgery, people who prior to treatment were hardly able to move. They had every guarantee that, if they underwent major surgery, they would be vastly improved physically but, even more important, they had every guarantee they would survive the surgery. This is just one piece of evidence of the improvement in medical care and medical surgery. Many of my constituents have availed of the service in the hospital to which I refer. They pay the contribution of £7 a year under the Health Act. In return they are provided with a truly wonderful service for this very small sum. I am a contributor to the VHI because I do not come within the £7 a year category. I do not begrudge the money I pay to the VHI though the contributions are a great deal higher per capita than would be the case if I were in the category paying £7 a year. This bears out what the Minister said; the requirements of this Bill compare very favourably with the payments under the voluntary health insurance scheme.
It is becoming very apparent that re-thinking will be required in the implementation of the health services at all levels. One has only to walk through the corridors of this House and discover for oneself how many Deputies are carrying antibiotics in their pockets. We are living in an antibiotic age. If a person develops a sniffle he runs to the doctor and asks for an antibiotic. He does not wait for the doctor to prescribe. I am told by doctors that patients actually name the medicine they require. The doctor is in a difficult position because he has got to keep the confidence of his patient. This is vital in all aspects of medicine. There is wide and wholesale abuse of antibiotics and one now actually hears people inveighing against antibiotics and their abuse. Over-usage is amply demonstrated in the huge range of antibiotic drugs available and in the enormous sums of money made by chemical firms churning out antibiotics. I do not know what the figures are but it would be a useful exercise—it is information the Minister might be able to obtain for the House—to make a comparison of the quantity used and the money spent on antibiotics today as against ten years ago. Even making allowance for inflation and increased costs I believe there would be a very large figure as a multiplier to explain the difference in the figures.
The Minister, when introducing his Estimate, referred to his ambitions in respect of general surgical hospitals and general surgical treatment. I assume that includes physician treatment. This is a vital service that must be provided. I know there are difficulties. I know there are competing interests. I know that people want hospitals. I know this is under investigation. It is a thorny problem because one is dealing with humans, with local loyalties and local history. The service is a vital one. It is one that must be maintained at the highest possible level and it is in relation to this service that this payment is required to provide some sort of subvention towards the service.
I have been told over and over again by constituents that they regard the £7 a year as very, very cheap indeed. When one bears in mind the cost of a fully paid patient in a general hospital at today's prices, this payment is minute in relation to the actual cost. One does not need to produce statistics to prove that. Every family is aware of it, particularly those families which have had to bear the cost of surgical medical treatment in a general hospital, not to talk about a specialist hospital. On many occasions, in my capacity as a public representative, I have had to make representations on behalf of constituents because they were not in a position to meet the bill presented and a system of instalment payments had to be arranged.
We should be realistic in our approach to this Bill. We should realise what it means and what it will provide for those who come within the ambit of the scheme.
In relation to general hospital costs and expenses I believe, and many other people believe, that sometimes there is an undue demand on the hospital services, a demand which need not necessarily be made and, if not made, would not harm the patients. There is an undue demand on the X-ray service for comparatively minor injuries which could be diagnosed and dealt with clinically in the doctor's surgery. I also believe that a great deal more minor surgery could be done by ordinary practitioners instead of referring the patients to hospital.
I have in mind in particular the suturing of patients after accidents. It seems to have become a regular procedure that, if a person has a would, he is referred to hospital for suturing. That used not to be the case years ago and many doctors still do their own normal suturing in accident cases. A tremendous number of the medical profession are referring these patients to general hospitals. Very often the suturing which is carried out in these hospitals is done by young doctors who have just qualified. I cannot see why general practitioners with years of experience behind them cannot do this work themselves. If they did, they would be taking a fairly substantial load off the expenses involved in the running of general hospitals and particularly out-patients' departments.
We are all aware of the congestion in the out-patients' departments of general hospitals. Many of the patients in the out-patients' department need not be there and should not have been sent there by doctors. I know the general public have direct access to the out-patients' department after accidents. When they have gone to a suitably qualified doctor, an able doctor, I do not see why that doctor cannot carry out minor surgery himself in the nature of suturing and ordinary repair work of that kind.
I have already said that I regard the too free dispensation of antibiotics as a bad thing. We are going through this period at the moment. It is world wide. It is rather frightening to see the difference in the prices of antibiotics. A first-class book is available to every medical practitioner. It is freely availed of and freely used by practitioners. It is a little book called Mims. I understand that a Deputy of this House is responsible for its production, its design and up-dating. It is a most efficient publication. General practitioners, public health officers and doctors avail of this book. It is produced regularly.
If you look at this book you will find that it puts the various drugs and antibiotics under various headings, says what they are used for, also gives their contra-indications.
It also states—and this is where I take issue with the medical profession in the use of modern drugs—the price of the drugs at retail level to a patient. I have seen a difference of from £1.20 to £5 in the price of antibiotics used for exactly the same condition. Just because one happened to be the most recent one it was being used as the new thing. It was not called penicillin; it was called something else. It was a new name. There is a sort of game of keeping up with the Joneses, keeping up with the new stuff.
I take issue with certain doctors who say they want to do clinical trials on a new drug to satisfy themselves that it is the right one for the purpose. Surely these drugs were tested before they were put on the market. Surely there is information in medical literature on what they can and cannot be used for. Why should a general practitioner indulge in this sort of clinical trial? The main offenders are the younger brigade of general practitioners. I am not saying they are necessarily doing wrong, but they are increasing the cost of the medical services unnecessarily. They are doing work they may not be fully qualified to do. If the drugs have been passed for a certain purpose, they should be used for that. They should not just pick the expensive drug.
Where there is a difference of from £1 to £5 for pills or antibiotics for a certain condition, the doctor should stop and think and have regard to the cost and, if the cheaper medicine can do the job, it should be availed of. There might be a tendency where medical card cases are involved, and where there is free medicine, for doctors to avail all too freely of these expensive drugs which are not necessarily required for the condition being treated. Unfortunately all of us are being made to pay for that.
I know I would be severely criticised in medical circles for suggesting this, but it is time that we started to think about a national formulary. If a booklet of 100 pages or so can be produced by a private concern which is regularly availed of and used by the medical profession, I do not see why something cannot be done at national level and only certain drugs made available for free medicines. This can be done. It would help to control the situation.
It is very hard for the Government in a small country like this to control the price the manufacturer puts on a new drug. It could be controlled by the process of exclusion and inclusion in a national formulary. This message should be brought home to the doctors. I mentioned this at a public meeting recently and a certain medical man took issue with me and said it was not feasble. He did not give any reason. I should like to know why it is not feasible to introduce a national formulary. Under the old dispensary system a code of that nature was used. Doctors have told me that was the position. Even making allowance for difficult and rare conditions that can occur, when a special drug has to be used the doctor can prescribe it and a claim for reimbursement can be made. It must be justified in the circumstances of the case. This loose prescribing in the sense of not having regard to the costings involved has in large measure increased the costs of the health services.
I know the Minister is very keen on the community care programme. I should like to see something being done in conjunction with the community care programme in relation to education on health. Many of us have been reared on the basis that to talk about health is being neurotic, that one is a hypochondriac if one takes an interest in health. The view has been: leave it to the doctor on a sort of witch doctor basis. It is about time that our education should bear in some way on the fundamental of physiology, on normal good health and on how people can manage themselves.
If people were educated on health to a better extent than they are or could be by reading articles in newspapers or magazines many of them would not have to have recourse to doctors. If anyone asks the average family practitioner what percentage of his patients have a sort of nerve condition and are given tranquilisers or reassurance and yet have not got a physiological problem, one finds that the percentage is very high. That is largely born out of ignorance and fear. I am speaking from a slightly privileged position in this regard being the son of a doctor. I have seen cases, heard of cases and spoken to patients on this matter of health. I have come to the conclusion that if one can reassure such patients they are new people.
When one considers the contribution called for by this Bill one must bear in mind that in 1972-73 £36 million was provided out of the rates for our health services. In 1974 that figure was reduced to £13½ million. This has meant a tremendous load off the rates and that will be to the benefit of many people who are contributors under this scheme. However there is more to it than that, because certain counties are better off than others. Some counties have been able to find money easier for health services in their own administrative area. Putting the money on the Exchequer has meant an evening up of the general health service across the country. It has meant that there is no discrimination between the wealthy area and the poor area.
Deputy O'Malley referred to the fact that contributors to the Voluntary Health Insurance Scheme, in order to qualify for benefit, must spend 24 hours in hospital. I understand that is still the position. It was the position some years ago when I availed of the service. At that time I had to go into hospital for a test which could have been done in a matter of hours but, in order to avail of the scheme, I had to be booked into the hospital for 24 hours. I regarded this as unnecessary. The Voluntary Health Insurance Board would be doing a good service to medicine in general if they had another look at this aspect of their scheme because this means that people are unnecessarily occupying beds in general and other hospitals.
I know that an ENT specialist in order to save money for the parents of a young person who had had his tonsils removed arranged to have a taxi waiting outside the out-patient department of the hospital so that the child could be sent home immediately after the operation. When the parents sought recoupment from the Voluntary Health Insurance Board they were told they could not qualify because the child had not spent 24 hours in hospital.
I may have been critical in my contribution in relation to the use of antibiotics but I can plead a certain amount of bias because for things like the common cold and so on I do not avail of antibiotics, I use herbs. Many people consider that peculiar, but herbs were good enough for my grandparents and, because they give me the desired results and alleviate me of the aches or pains, they are good enough for me. The old and tried remedies can bring the same, if not better, results and in many cases a much quicker cure than the standard antibiotic type of treatment.
At the outset I said that I was in favour of contribution for a service but I believe also in involvement by the public in our health service. This has been very apparent in relation to mentally and physically handicapped people, particularly young people. There has been a wonderful surge of interest in this regard. The movement started on a purely voluntary basis and, although it has been only a few years in operation, a tremendous amount of voluntary work has been done in those fields. I do not think that the present care for handicapped people would be at the stage it is today were it not for the impetus given by voluntary workers. In this regard the State is a latecomer to treatment of these people but, even though the State has since become involved, those who worked in a voluntary capacity in this field have not backed out or sought to do less work. The contrary is the position. There has been an increase and ever growing interest in this field. There is a lesson to be learned from that and it is one that might be applied when we come to consider the community care programme the Minister has in mind.
If there was voluntary participation by people that scheme could be far more successful. When people are voluntarily involved in a scheme of this kind such a scheme tends to be more successful. I am certain that there are many married qualified nurses who would be prepared to assist in such a scheme on a purely voluntary part-time basis.
If these people were allowed participate in such a scheme, it would get off the ground much quicker and be far more successful. I know people will argue that one might be doing somebody out of a job. I do not think there is any fear whatever of that allegation being made in relation to community care services because, certainly at the beginning of this proposed scheme, there will be less than is required; the demands will be far more than can be met. There is plenty of room for voluntary involvement at that level. That, coupled with health education, could improve the general health of the nation and redound to everybody's benefit.
I see also that the Minister is taking a very keen interest in child health services. This is something that should be given the utmost support because a lot of illnesses have their seeds sown in the young age groups and, if not attended to at that age, can have very deleterious and serious effects on people in later life. We are aware of that in regard to heart cases. Modern heart surgery has brought a lot of light to bear in this regard. We are also aware that kidney complaints can ultimately result in a severe mental handicap. These are all recent developments in medicine. Therefore, the original child health service provided in national schools was insufficient in the light of present-day knowledge.
I am glad to note that the Minister is taking a particular interest in this field because children cannot protect or provide for themselves. It has got to be done by an outside agency. The all-seeing eye of a good health service is required in this regard. One could talk for a long time on the subject of health, which is a rather emotive one but I think I have said enough. I would ask the Opposition spokesman— I know Deputy G. Collins is full of fire and brimstone and will rise to his feet when I have concluded—to remember that there has been no increase in the charge to contributors since 1971 while wages, costs, everything has risen, the new charge called for is less than the price of 20 cigarettes.