The Department could be usefully employed in looking into this problem. Some hospitals have not got a sufficient number of nurses on duty at night. I am not having a "go" at the Minister. It is a matter of lives being at stake. This is serious. The Minister would have to take the rap if anything went wrong. He might not know about it because the Department might not have told him about it. So the Minister must not take the rap. Let them get the information and see what can be done. The Minister should tell them to do it.
The question of nurses' training was mentioned by rural Deputies. Listening to them makes me realise that what I suggested to the Minister two years ago should be brought into effect. Many girls in the country want to take up nursing as a career. They write to almost every hospital. They are called for interview. They might go to one hospital in Dublin on Thursday and come back the following Monday to another hospital. I suggested that a simple way out of this was for An Bord Altranais to set up an interview board comprised of the matrons of different hospitals and that a questionnaire be sent to the applicants. The applicants could state in order of their choice, the particular hospitals that they wanted to join. Having regard to their eligibility and suitability for the profession, An Bord Altranais could then recommend them to a hospital, or assign them to a hospital. It is very simple to centralise this whole question of allocating or assigning nurses to different hospitals. It should not be difficult.
If An Bord Altranais tell the Minister it is difficult he is worse to take that from them. It is a simple thing. It would simplify life for these girls who are frustrated at having to try so many different hospitals and having to write to each one individually. It is so stupid when we could centralise it at the drop of a hat. This could be the national interview board for all hospitals run by Bord Altranais. Rural Deputies ask me if I can do anything about Dublin hospitals. This is not fair to the girls. We should all press to have this done. Two years ago I asked for it and it has not been done yet. It should be done. I hope that by this summer we will hear that it has been implemented. The Minister should not take that sort of nonsense from An Bord Altranais if they try to put obstacles in his way.
No matter what Minister is in office my approach is the same. I must confess that I made life impossible for the late Mr. Childers but it is the only way to get something done. My abrasive approach may not be the most acceptable but at least it gets across what I have in mind.
I feel strongly about the question of medical cards. We succeeded in getting the previous Minister to establish a national system of guidelines of eligibility. I cannot for the life of me see why the Department cannot issue a directive to health boards to make a list of these guidelines available to the public. It would save a lot of money, because people who could look at this, who know their income, know they are outside the limit, would not apply. Each application must cost a bit of money, because officials must assess it. In the Eastern Health Board alone, the officials are not able to cope. People are told that they did not make application and many applications are being mislaid. These guidelines should be made available to the public, through information centres, public libraries and so on, and every application should be acknowledged with a copy of a guideline.
The Minister's answer to me during the Estimate debate in November last was that the public representatives know. That is a very poor answer. The public should know—not the public representatives. Why can we not? I have a motion down for next week's meeting of our health board to ask that these be made available to the public. I do not think it is good enough for one health board. I would hope to get support for it and I would like to see a directive from the Department of Health, again as the body responsible for the health services, to all the health boards to make these available, because they are uniform now. We should not be trying to hide the fact that certain people might be entitled to the health services, might be entitled to the medical cards, we should make them available. It would serve a great purpose and would save a lot of money for health boards.
The other big problem with the Department is the over-visiting of patients by doctors under the medical card scheme. This is a problem that needs looking at. Patients do not know the system; they do not know how it operates or that the doctor gets paid each time or that they can only have a certain number of visits in a year on average. There is therefore a situation where the public are not informed. If they have a medical card, they feel entitled to visit the doctors they like and they will do so. It is not pure "cussedness" on their part that they want to do it. They feel that it is a service and they should avail of it. If the doctor says to a patient: "Sorry, you cannot visit me—you had better change your doctor", he goes to another doctor and the whole thing becomes a vicious circle.
Would it not seem again that the Department of Health should take the initiative? The word "initiative" is not very popular in the Department, but would they not take the initiative and start a type of an education process by way of ordinary discussion programmes on television and radio, telling them what the cost of this service is, how patients need not go to a doctor so many times, how they are better off not going to a doctor in many cases, and to leave the place there for those who must go to a doctor. This would be a good idea and would seem a logical approach to it. The doctors would not become involved in having to tell the patients they cannot visit them. There is concern about many dedicated doctors who feel, that for social reasons they should visit the old patients on their lists because these patients wish to be reassured. That is a costly business. again for the State. We must consider other ways to stop it.
Firstly, we should start an education programme telling the people about the cost of this service. It is costing every working person in the State £180 a year for the health service: that is something that is not known. That is a lot of money and that has never been spelled out. We must therefore talk to the people about it, about the utilisation of this service. If we do so, we will reduce enormously the cost of this service. We should tackle it and get moving on it quickly
The question of drugs arises and again we should start the education process. Why not start with women's clubs throughout the country? The Department's inspectors could visit them to give general talks on drugs and their adverse effects and that they need not be used. This should be part of an ongoing programme of the Department to change the whole picture about health.
With regard to eligibility for medical cards, it is not good enough that it should be left to a junior official to make a decision as to whether or not a person is eligible. It is a dangerous thing. The Minister constantly says in replies in the House that the CEO has power in special hardship cases. I know that that power is not being exercised in the Eastern Health Board area. It is a cut and dried issue. There is no grey area: it is a black and white issue—one is either eligible or not. There are many grey areas, where people have unnecessary expenses. These are not spelled out enough on these application forms, and a junior official makes a decision. I say "junior" knowing that a CEO with a committee should make the decision. There should be a committee set up in the health board to consider that. It should include a doctor working in the board, or an independent doctor who would examine these borderline cases and make decisions. This is the way it should operate—a committee should do it, not an individual.
I should like to see the Department of Health examining these suggestions for reform and innovation and doing something about them.
I know that the Fianna Fáil Party are committed to the concept of regionalisation of the health service with the health boards. When the Minister came into office and found this a fait accompli, he said “How does one unscramble the scrambled egg?” He was right, but I say: “Discard it, and put another egg on the pan”. They are not operating properly. There are numerous complaints and criticisms by people who are involved in the operation of health services and by public representatives, who find them ponderous bodies with unnecessary duplication of services. They have become very much removed from the public and the old system of the local health authorities was much more efficient. All that these big ponderous health boards are doing is providing extra jobs for certain people, but certainly not streamlining the service.
If the Minister doubts what I am saying, let him have a study into the cost benefit analysis of the health boards vis-à-vis the health authorities. If he does that, I shall be convinced. It is the only way. The present way is operating with public representatives having little or no say on them. Policy is not determined by the public representatives. If anyone examines the present representation on these boards, it will be seen that it is not quite what it should be, and is in fact far from it. I have asked—and I think it is necessary, though I believe the Southern Health Board have such a situation— that the health board splits up into functioning committees. We, in the corporation split into committees and have this power and are able to get changes and to get policy implemented. On the health boards, one cannot. It does not operate properly and as a public representative one is a mere rubber stamp. Bureaucracy organises, manages and dictates the policy of these boards. I will not tolerate it: I will not accept it and I shall constantly campaign against it until we get a proper structure. They do need to be restructured and the sooner the better in the interests of the health services. The concept might have been good but the operation is not.
I am glad that a recommendation came from the seminar in Waterford that the hospital boards be abolished, because they were serving no purpose. The Minister should look carefully at the powers being conferred on Comhairle na nOspidéal because it has unlimited powers, dictatorial powers and powers greater than those of the Minister. That might be all right but if there is a board to decide for the country; having it too Dublin-orientated is dangerous. It is not good. The Fitzgerald report was prepared by a group of people who were Dublin-oriented and did not understand the problems of rural areas.
Decisions may be made in Dublin which are at variance with feelings, views and problems in rural areas. The Minister must set up an appeals body against decisions of Comhairle na nOspidéal. This is the only way he can get it working so that people will have some confidence in this body. They have too much power and no body like this should have powers greater than those of the Minister. The Minister would be well advised to look at this.
Dental services is an area I know the Minister feels strongly about but he feels almost impotent to deal with the problem. In 1969 a report was prepared by Professor Kaim-Caudle on dental services in Ireland and if ever there was an indictment of a service it was contained in that report. I should like to read some passages from it:
All children attending national schools are entitled to free dental services. These are provided mainly by public dental officers and are of a fairly rudimentary nature. Fillings of deciduous teeth are rare, one filling per 10 extractions.
Of course, that is appalling, it is disgraceful. In the case of adults, those who are eligible in the social welfare benefit class, he says that these are of a most rudimentary kind. He goes on to say:
Even for expectant and nursing mothers in this group the service was minimal.
That is a terrible indictment. Six years ago that was published and the service has not improved since. In fact, having regard to the expenditure in other areas this has deteriorated. We have got to look earnestly at this and see what we can do about it. I suggest to the Minister that he look into the costing of a proper service. The public would not be adverse to paying for a proper service. We have got to look at this in conjunction with the health services. We should cost a proper national health service, talk about it and have discussions with the public. The public would be prepared to pay if we had a proper service introduced.
We have got to talk about this urgently. We cannot forget about it, hide our heads in the sand and say, it is there and we are doing the best we can. That is not good enough in this age. We have got to talk to the Irish Dental Association and say to them: "We are going to change it whether you like it or not because we have to account to the public, not vested interests in any particular area; the public are suffering." We have got to provide the best service we can. The dental association have to be prepared to permit the training, recruitment and employment of dental therapists, those who would deal with fillings and periodontal disease—problems of that kind. We have got to get these. It is a costly service, but it need not be that costly. We can produce a first-class service with these dental auxiliaries and dental therapists as is happening in New Zealand and as has been recommended by the World Health Organisation and the International Dental Association. Those two powerful bodies are in favour of this.
The Irish Dental Association would not be averse once they are assured that their status would not be endangered and they would be more than happy. These talks should be initiated as soon as possible to see what we can do and to introduce a training programme for these dental therapists who could be brought into the service quickly and improve it. The present services are appalling and we should not be allowed leave them as they are. The Minister must have the power to make regulations regarding the qualifications of these people and no one else. The Minister must exercise this power.
Similar problems would arise in the psychiatric service. The top personnel in the psychiatric nursing service must not be employed in doing work not befitting them and this is the way we should be talking about it. In an age when we were not so enlightened we had so many people committed to our mental hospitals but that is all over now. We now see the error of our ways but we have inherited a problem and that is as a result of the institutionalisation which occurred of our mental patients. We, the doctors, are to blame; we are the culprits; we have institutionalised these people in our ignorance. We have these people institutionalised and we cannot close down these places and throw these people on the scrap heap because we have this revolving door syndrome; they go back in again or end up in prison.
It is important to discuss this. Three suicides occurred among people who were psychiatrically deranged and found themselves in prison, people who may have come out of institutions who should not have. The Minister for Health is responsible for ensuring that these people—a report has been produced that up to one-third of the people admitted to prisons are psychiatrically abnormal—get psychiatric help and we should be aiming to give it to them. These deaths might not have happened if we had a proper psychiatric service in our prisons. We should be aiming to do this. A psychiatric service is needed. It should have been provided but it is not being provided and I do not care if the Minister for Justice says it is tomorrow. I will say he is wrong; it is not being provided. If we get such a high proportion of our prisoners who are psychiatrically abnormal, deranged, or with psychiatric disorder we must aim to help them.
It is not good enough that we, as public representatives, are not allowed to visit our prisons to see what is happening. We should be allowed. We vote the moneys for the prisons. There should be a parliamentary committee to visit the prisons regularly to see what is happening. I should like the Minister for Health to see that it comes within the ambit of his responsibility. These people in prison who need psychiatric treatment should have it. It is not good enough to give this treatment to an occasional person. We will have further suicides and this is what we should be aiming to prevent.
On the question of mentally handicapped, I know great progress has been made and the Minister can say the situation was worse before he came into office. It was worse but the situation is still far from satisfactory. As public representatives, we often meet people who have the burden of mentally handicapped children in need of hospitalisation and residential care. The waiting list is long. I had a letter from the Minister this morning with reference to a letter sent two years ago when I was promised that a patient would get a place soon. Two years later we are still awaiting a place. I know we cannot work miracles overnight but this is where we may be misusing funds, not channelling them into where they are badly needed. This is what is wrong with our health services. It might be said with justification that the pressure groups get things done in the health services, as they do in other areas. As the Minister pointed out, the people who are not vocal about their complaints are frequently neglected, and this applies particularly to the case of health. We should divert funds so that people can get their rightful dues.
The question of the cost of the health services arises. There will be advanced technological and surgical techniques and we will find that people who have been bed-fast for long periods may be rendered ambulatory and mobile within a few days with sophisticated modern operations. The question arises: can we afford to provide these services? I do not know how we are going to solve it. We will have to work out whether we should spend £1,000 on a kidney machine at the expense of somebody who needs a very important hip operation.
Perhaps ten people need a hip operation where one person requires a kidney machine but the kidney machine is doing a vital job. The demand on the services will be so great we will have to know what we are going to do. This is the big problem and we are going to have to sit down and study it. We will all have to take responsibility, not just the Minister for Health. The public also will have to look at it.
Do we spend £2,000 on a machine? Will we have to take into account the benefit to the community of a person of 60 years as opposed to a person of 80 years? We will have to face serious ethical problems unless we are prepared to provide unlimited finance for the health service. An orthopaedic surgeon mentioned to me the number of people who are awaiting orthopaedic operations. Many of them could be rendered mobile and wonderful jobs could be done on them. Are we prepared to pay for this?
Many of the problems that will arise will not be just political problems. We will all have responsibility in deciding. We will have to examine what the services are worth to a patient and to the community before we decide to give a person a kidney machine or whether to take a person into hospital and give him a new hip joint. There will be big problems. Are the public prepared to finance all this because techniques are becoming more and more advanced in kidney and heart operations? Are we prepared to spend £10,000 on a special pacemaker for a patient? Who will decide? Will it be the surgical or medical profession or a committee who will say what is best for that patient? If you are putting a sophisticated instrument into a persons body, will it make him so much more mobile and active that the expenditure is worthwhile or should the money be spent on another patient? We will have to have an ethical committee to study these problems and to assess the priorities.
An 80-year old man was taken into hospital to have a hip replacement operation but the operation did not go quite right. He spent seven months in hospital at £120 a week. Was this hip operation justified as the man was 80 years of age? Was he going to become mobile in which case the operation would have been worthwhile? As it happens he is worse. No one man should have to make these vital decisions. There are several important things to be examined in a matter like this. Who picks up the chits for this £120 in a hospital? That man would probably have been better off without such an operation. He is not going to run the mile in four minutes.
The Minister for Health will have to consider such matters seriously. He will have to decide in conjunction with a team, who makes the vital decision and what factors are taken into consideration. It should not be left to the surgeon, the technician. Many factors will have to be considered—the man's home, his background, his employment, and aftercare. This is a problem that will have to be faced more and more often and we will have to make decisions.
We had a Bill before the House—I have almost forgotten the name of it— the Misuse of Drugs Bill. I reported progress on it some months ago and I will be expected to resume when it appears again on the Order Paper. Even though I have amendments down I have forgotten the provisions of the Bill and what I said on it. I wonder if it will appear again or has it been decided that there is no misuse of drugs, there is no problem, the whole thing was in vain and that it is wrong that it should ever have been brought in? I know that the Bill was not taken during the week when I was absent from the Dáil but that was a long time ago. If we are serious about tackling the drug problem, we should discuss the Bill and put it through the Houses of the Oireachtas. It is not good enough to say a Bill is before the House unless we do something about it. I had hoped we could have the Committee Stage before the recess and I would ask the Minister to see if anything can be done about this.
Many Deputies spoke about drugs, smoking, alcohol and advertising. I have a few words to say on alcoholism. Rightly we look upon this as a disease but we cannot allow alcoholics to destroy and kill themselves. It is not enough to feel sorry for them. They can be helped to pull themselves out of it; we cannot just let them kill themselves. We may reach the stage where there will be compulsory detention in hospital and I think this is the way we will have to do it. We will have to provide hospitalisation but if they refuse treatment there will have to be compulsory treatment. I would be prepared to adopt a very rigid line on this matter.
There is a lot of alcoholism. Many people have the will-power to make their minds up about curing themselves. We should not adopt such a lenient attitude towards them that will make them helpless. We should encourage them; we should exercise certain restraints and these restraints will have to be set out so that we can look at this problem seriously. I think alcoholics are getting too much sympathy which convinces them they can never do anything for themselves. They feel there will always be someone to be sorry for them and that they cannot help themselves. This does not assist them and restraints have to be imposed on them. We could deprive them of certain benefits and certain rights if they are not prepared to conform. This attitude is at variance with the general attitude but it must be admitted that the general attitude has not exactly succeeded in overcoming the problem. We should be prepared to look for more positive methods of solving the problem. It is easy for us to say: "Take all the ads off television" but, when it comes to paying the licence fee, we all throw up our hands in horror and say "No." I realise that the public, when they are screaming for the ads to be taken off, must be told what the cost to them will be. If they are prepared to pay the ads can be taken off. We should spell this out to them.
My last point is in relation to the opthalmic services. The Eye and Ear Hospital is not able to cope with the situation. It is badly in need of extension. It is not good enough that people should have to wait six months for an appointment. People who are paying for an ophthalmic service in their social welfare benefits should get it. The service has been ignored for too long. We must take all the necessary steps to improve it.
I hope the points raised, and there have been some very constructive points, will be examined, analysed and assessed by the Minister and that he will put his Department to work on how best the suggested improvements could be implemented.
