Dáil Éireann díospóireacht -
Tuesday, 27 May 1975

Vol. 281 No. 5

Vote 49: Health (Resumed).

Debate resumed on the following motion:

That a sum not exceeding £177,022,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1975, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that office, including grants to Health Boards, miscellaneous grants. and certain grants-in-aid.

—(Minister for Health.)

Mr. Power

I am very pleased to speak on this Estimate, which gives us the opportunity of pointing out the fundamental differences between our policies and the policy pursued by the Coalition. In his speech the Minister said that he had determined some major priorities. Among those priorities he lists the provision of free hospital care for all. This is a socialistic pipedream catering for a concept rather than for the nation.

In the face of last year's difficulties he must now agree that this is neither attainable nor desirable. To pursue this any further can only be termed ministerial madness. Perhaps this is not entirely the Minister's fault. Perhaps some of the blame can be laid at the door of the officials in his Department but that is hardly likely. In my view this blame can only rest on the Minister because this is one of his priorities and I am sure his officials have been told to bring it about, if possible.

It is hardly necessary to point out the even tenor and the results obtained during the term of office of his predecessor and the good relations which existed at that time between the nursing staff and all involved in medicine and the Department. Much of that has been lost. Needless to say much of the fault of the present impasse must rest with the Minister. We must compare the certainty and guidelines laid down by the late Erskine Childers, the setting up of the health boards and the fact that people knew where they were going and how they would get there, with the uncertainty that exists today.

I do not wish to belabour the Minister personally for I have always found him approachable, human and helpful. The policy at present pursued in the face of difficulties, the frightful expense it would involve and the experience gained from other countries, where a free-for-all medical scheme is available, should be a salutary lesson for any Minister. We should pursue not what other countries have tried and failed but what will suit the needs and pockets of this country.

We realise that there is a limit to the amount of money available and hope that the best possible use will be made of it. Maybe the services we are now giving to our GMS cardholders are not all we would like but the people who are not so well off and those just outside the limit of the GMS card who suffer hardship and anxiety trying to make provision for the rainy day from scarce resources are the people we should help first. Why should we provide free hospital treatment for even the very rich, if they do not want it? The Government's priorities are seen to be wrong here. When I wished to point out to people the difference between the Government and Fianna Fáil, this is one of the items I point to as a glaring example of the defects in the Government's priorities. I am positive the Irish people feel the same.

Deputy Haughey had a Private Members' motion and many Deputies spoke on it. I am confident that the pleas we made then had the support of the Irish people in this matter. When people's GMS cards come up for review, in many cases they are cancelled and when the matter is brought to the notice of public representatives and when pleas are made to have the thing re-examined, it is frequently found that card holders have been on short time and have not the same earning power as they had, and they get their cards back. The point is that the cards should never have been cancelled.

According to the Eastern Health Board's guidelines, even agricultural labourers and county council road workers could be left out. I am sure this is something nobody intended when the free GMS scheme was introduced. It is possible that a husband, wife and child, with total earnings of not more than £27 per week, would find themselves outside the category. All will agree that £27 does not go very far. It is, therefore, essential that the Minister would extend the scope of the service. I could quote many examples of hardship. The hallmark of a good Government is sometimes their willingness to admit a mistake or an error in judgment and rectify it. They should be prepared to admit that a policy they were pursuing was not right and they would correct it.

There is another frightful anomaly to which I wish to draw attention. It is the gap between national school leavers—children are now leaving national schools at 12 years—and post-primary pupils at the age of 16 in the matter of free medical and dental treatment. Children leaving the national school at 12 cease to be qualified and do not again qualify until they are 16 years, when they are able to get medical cards. Many pupils between the ages of 12 and 16 years are denied treatment, particularly dental, at a time in their young lives when they are most vulnerable and when caries are most rampant. It is madness that such an anomaly should exist.

Since the arrival of free post-primary education and automatic blanket promotion in national schools, the age of primary leaving has been reduced by at least two years. Pupils who formerly would have stayed in national schools until 13½ or 14 years now leave those schools for secondary and vocational courses as young as 12 years and sometimes even 11. At that age they are most vulnerable, as I said earlier, and because of this hiatus between the ages of 12 and 16 they are denied dental examination and treatment—they are cut off from such services for four years. This could damage their health in the future. Dentists and others to whom I have spoken feel that this four years of neglect can undermine the health of our children, that the damage done in those years can never be repaired. I raised this anomaly by way of parliamentary question and pointed out that this gap should be bridged immediately.

While on the subject of dentists, the Minister will have to look into the scarcity of dentists in the public service. It is very difficult to recruit dentists and because of that, dental examinations of children which should be held at least yearly in the national schools are sometimes not held at all until after many children have left those schools. There is, therefore, no preventive treatment for those children, the only work apparently being carried out is extractions. It is essential that an all-out effort be made to recruit dentists into the public service. The dental schools are turning out a sufficient number of dentists but many of them go abroad for experience. It is hard to blame them because any town to which a young dentist might go to seek to earn a living seems to be full of people in private practice.

In County Kildare there are 15,000 national school children and it is estimated that six dental surgeons would be needed to give them adequate service. In fact, we have one dental officer for the county and three assistants. There are 15,000 medical card holders in the county and as well there are 1,000 students from Maynooth University who have now been included in the dental programme. In other words, four dental officers are endeavouring to take care of 31,000 people when 12 would be needed. The result is that children are being neglected. If children are to be looked after properly, extra dental surgeons will have to be appointed and the conditions will have to be made right for them. If it were the case that electricians, plumbers or stenographers were not available we would get them from outside the country, as we have done, if there was special need. It is just because this is a soft area, an area which is not of great political consequence, that the matter is being neglected. If a similar situation existed in any other branch of the public service or private service there would be an outcry. The need exists for more dentists. The present conditions are not conducive to attracting dentists into the public service. The idea that he would be able only to touch the tip of the iceberg and would never be able to get down to fundamentals would be intolerable to anyone who wished to do his job well and to fulfil himself in it.

Anyone who enlists as a dentist in the public service must feel a frightful sense of frustration. No dentist would like to spend his life in such frustrating circumstances, where he would have to confine himself to doing extractions and to dealing with cases that should never have been allowed to deteriorate to the extent that they have, never having any hope of carrying out preventive treatment because of the huge waiting list for treatment. I hope the Minister will take note of what I have said in regard to this matter. It is time that a change was brought about in the dental service.

I am pleased to note that the Minister has taken notice of a recommendation from the recent IMA seminar in Waterford to the effect that the Dentists Act, 1929, be amended to provide for the use of trained dental auxiliaries in community dentistry. The Minister should adopt this suggestion. Trained auxiliaries are employed in the dental service in England and New Zealand. Auxiliaries would be trained to apply procedures which would reduce the incidence of dental decay. This is a very important aspect. In view of the unsatisfactory position in regard to the dental service and the shortage of dentists, I hope the Minister will ensure that this amending legislation will be introduced. The usefulness of dental auxiliaries has been proved in those countries where they are employed. Their employment here would mean that there would be more personnel helping to prevent tooth decay.

The Minister stressed that one of his priorities is the training of handicapped persons for employment. I am glad that he is aware of the problem. Many people have become increasingly aware of it within the last few years. I would hope that the Minister would lay great stress on the employment of the handicapped. His priority should be altered somewhat to include employment as well as training. It is a good thing to train handicapped persons for employment but it is vital that when they are trained they would be placed in jobs. My experience is that it is not easy for handicapped persons to secure employment. I quoted some time ago the case of a boy who was blind from birth and who had passed the Leaving Certificate examination, which must have involved very great work. Because the Department of Posts and Telegraphs had changed their switchboard system from bells to lights it was impossible for that boy to obtain a position as telephonist in that Department. As a result, that young boy was very frustrated. He had to wait a long time before getting a job.

Government Departments should give the lead in this matter. I am not blaming the Minister but it would appear that Government Departments have reduced the number of jobs available to handicapped persons. It might be necessary to introduce legislation which would make it obligatory that employers would employ a percentage of handicapped persons. This may not be the best time to make that suggestion in view of the current high rate of unemployment. The idea did seem more sensible when we were in power. This is an idea that may have to be shelved but it should be kept in mind when the economy is in a better position.

I should like to compliment the voluntary bodies who do such wonderful work for handicapped persons. The Rehabilitation Institute have a school in Naas where they train persons in upholstery and other work. The very fine training that is given represents a new lease of life to the handicapped persons and a sense of achievement. Without this training their lives would be dull and aimless.

I should like also to compliment AnCO on the progress they are making. A great deal more needs to be done. In one week recently representations were made to me on behalf of two boys in their late teens each of whom had lost an eye and each of whom could not get employment in either of the factories in the town because of the insurance requirements. We got in touch with AnCO on their behalf. The position must be improved. There should be more placement officers and other personnel to meet handicapped persons and to help to solve their difficulties.

According to the report on the handicapped there are 100,000 adults who have long-term physical or mental handicap of whom 15,000 might benefit from preparation and training for work. It is our long-term duty to identify these persons and then to train them in order to maximise their potential so that they could obtain employment. The facilities at present available are not adequate to deal with the problem as we would like it to be dealt with.

There is one matter in connection with the training of the handicapped which I have raised with the Department and with the Eastern Health Board but did not get a satisfactory answer. It concerns boys who travel to the workshop at St. Raphael's Celbridge. Excellent training is given at St. Raphael's. The boys travel from different parts of the city. Bus fares eat up the small allowance they get. The allowance is not given as payment for what they do but possibly to give them some sense of independence. In some cases the journey to Celbridge involves taking three buses. I would ask the Minister to interest himself in this matter and to assure me that these handicapped persons who are doing their best within their limitations will be recompensed for it and that the allowance they get will not be exhausted by way of bus fares to this special school.

The misuse of drugs is a problem that has not as yet affected us to the extent that it has affected other countries. Please God, it never will. I had contact during the year with the Eastern Health Board with regard to a request for a lecture on drugs to be given in Kildare town to a group of youth leaders and which would be open the the public. The attitude of the Department was that they would give lectures only to certain individuals, leaders, adults preferably, rather than young persons. Perhaps that attitude is the correct one. One of the recommendations in the report of the sub-committee that advised on the Misuse of Drugs Bill was that persons charged with illegal possession of drugs, peddlers or pushers, would be brought to trial speedily and dealt with within a specific time. I hope this will be pursued and that very stern measures will be adopted against these people. There is also provision that empowers the pharmaceutical society to inspect premises and appropriate records of all their members and any substances or drugs stored in their premises. I would agree that that is a very good provision, although I have heard that the other provisions have not met with unanimous approval when discussed at our local health board meeting.

There is a lot of verbiage and statistics in the Minister's speech indicating that he was providing more money this year. He informed us there would be no cut-back either in services or expenditure in real terms in relation to last year. If one pursued this, one would probably find it was statistically and clinically correct, but the reality is that the Minister has quoted many figures in order to bamboozle people. There is no new capital expenditure except to a very minor extent. During a discussion recently at our Eastern Health Board branch meeting we were informed that a very limited capital grant for the present financial year had been given and that no capital development in any of the hospitals in Kildare was envisaged this year.

We pointed out that we were dissatisfied with this lack of provision for capital development because there is a serious shortage of beds in St. Vincent's Hospital in Athy. We had asked some time ago that a geriatric unit be added to the county hospital in Naas. These two items are closely connected because, unfortunately, our county, which has so many main roads straddling it, has accident cases brought to the hospital in Naas at weekends out of proportion, I am sure, to its size as compared with any other county in Ireland. This geriatric unit we have looked for and which the county physician pointed out was so necessary will now have to be shelved. We had all the other facilities of staff, cooking and so forth. All we wanted was a building with beds in it to cater for geriatric patients, which would relieve the pressure on the hospital itself and also help to relieve the pressure on St Vincent's in Athy. I wish to place on record that we in Kildare are very disturbed that our efforts to improve the services there have been shelved.

I should like to pay tribute to our ambulance service in the county. They have always done their work efficiently and do it even more efficiently now as a result of the installation of the radio telephone communication system. We have many voluntary workers in Maynooth and other places that deal with all calls expeditiously and efficiently.

The greatest resource we have is the amount of voluntary effort available to the health services. I wish to quote what the Minister says at column 46, volume 281 of the Official Report of 20th May, 1975:

The Exchequer is now, therefore, almost the exclusive source of funds for our health services. This situation has been brought about within a very short period of time, due mainly to the need to remove health charges from the rates on grounds of equity. If we add to this the fact that health services, because of their labour-intensive nature among other factors, are particularly prone to rapid cost increases, we are faced, as a society, with the need to study in depth both the future financing of the services and the need to derive the best benefits from them.

Because of the rapidly rising costs, the increasing demand, and the rapidly changing technologies associated with health care, Governments all over the world are being forced to find vastly increased sums each year simply to maintain health services at their current levels. We are not unique in this respect. The richest countries in the world are faced with this problem and on a larger scale. We must carefully look at the resources available for health care, so that we may continue development in the future.

I would repeat to the Minister that the greatest resources we have are the dedication and unselfish devotion of the voluntary organisations many members of which are helping out through sheer love of the work they are doing. I do not think the Minister has laid sufficient stress on the need to use voluntary effort to the maximum. In my own county we have friends of the mentally handicapped in St. Raphael's and Moore Abbey; we have the people involved in CARE who have done such excellent work for the education of the mentally handicapped; we have the people involved with the blind and many other people who give of their services and talents free. The Minister continually suggests in his brief that it is necessary that big brother should deal with all the problems. I believe the work should be delegated to local communities as much as possible, and in this way much good could be done even before the harm happened. Our health services should be made a recognised part of community life. If we spend money on our community services and help people to get timely and preventive treatment at home, every pound we so spend will be repaid tenfold and possibly save us £10 later if institutional care is needed.

I have seen in a very small way what a local health centre can do in a town. We have such a centre in Naas which was built principally by people who each year organise a party for senior citizens with whom I was closely connected. They organised a waste paper collection and got the resources to build a health centre. It has not been very long in existence, but we have a social worker who arranges visits, and older people and people from outlying areas come there. There is a chiropodist and even a hair stylist for the ladies. People who had led the life of a recluse have a new lease of life.

It is essential that old and infirm people, people who are handicapped, in wheelchairs, or blind people, be given an opportunity to mix with one another, to move about in society. A health centre such as this has given them that opportunity. People in my own area have had their lives transformed and look forward to their visits each week to the health centre for the sake of the company they meet and the crafts they learn there. Something more should be done to help the community services and to integrate these services into our health scheme. More money should be channelled in that direction where it will be repaid a hundredfold.

I wish to pay tribute to the Voluntary Health Insurance Board, a tribute that is all the more genuine when it is realised that it was the party that the Parliamentary Secretary represents that first introduced this board. It was unfortunate that the Government in which the Parliamentary Secretary is involved did a great deal of harm to the VHI board during the year. Voluntary health insurance is a great idea and a great help. I am involved in it myself and I have experience of the benefits of it. It relieves insured people of any worry about the future. At a time like the present when money value is deteriorating and living standards are being eroded daily, nobody is very anxious to provide for the future. But in this case people were very keen on taking out insurance so that they would be free from the worry and expense concerning problems that arise in every family. The VHI Board provided a wonderful opportunity of doing this at a reasonable cost but when the Minister spoke of his free for all scheme during the year there was great upset and people were considering cancelling their insurance proposals. People who had been happily insured knowing they were reasonably well covered began to doubt whether the insurance was a good thing.

The Minister's proposals never reached fruition and people's plans were again upset and they had to readjust to the situation. When the Minister discards his free for all idea —as I hope he will—I hope he realises that the voluntary health insurance is the very best scheme for all who want it.

Drink is generally considered to be one of the greatest social evils of the day. Whatever is in the Irish mentality it seems that we cannot approach drink—and possibly gambling and other matters—with any moderation; it seems to be the whole hog or nothing. In order to change our attitude to drink an educational programme is needed. In the present situation, apparently, all our social life centres around a lounge bar mentality and whatever we do is done either before we have a drink or after having a drink. There has been an increase in teenage and under-age drinking. This is an abuse which the Department must consider. I believe the education of children, provision of lectures and control of advertising are factors that must be examined. There is advertising of a very insidious nature that would tend to give people wrong ideas about drink and it is up to us to change that.

Closely allied to our drinking habits is the fact that we had 531 deaths on the road last year: there is a connection. This tremendous problem, after showing little change over a number of years, is generally seen to be increasing now and it must be examined. The Department are not giving any great lead in the matter.

The Minister's greatest mistake is that he has adopted this socialistic ideology. It is time for him to admit that the free for all which he envisaged is not on. He should get down to the ordinary work required to ensure that the very best results are obtained from the resources at our disposal. He should use and help the voluntary organisations to a greater extent. He should listen to the contributions from this side of the House which even, if he does not agree with them, he will find on examination indicate things that are wrong and the obvious shortcomings of the present system, the delay in dealing with dental and ophthalmic trouble and delay in getting appointments with consultants. The Minister must cut down this delay.

He should also look at the structure and working of the health boards. I realise now that the setting up of these health boards was a good thing although many on the opposite side of the House criticised them. It was only when we got the health board in Naas that we got improved facilities including two lifts in the county hospital—something our resources did not permit previously. Generally, our health boards have done and will continue to do good work. When the Minister talks of the huge expenditure that goes up each year he might well examine the structure and working of these boards. While I am confident that the work is good, I am also confident that it could be improved.

Again, I wish to thank the Minister for his courtesy on every occasion when I visited him during the year. He is very approachable. But in a year when he has been rowing with the doctors and other members of the medical profession there is grave need for him to review his own regime and give an account of his stewardship because, judging by the present political climate, it could well be that in the near future he might be steward no longer.

Dr. Thornley

My contribution will be brief. The problem of health and health organisation is one which has engaged my interest for a considerable time. As a teacher and a Deputy, I have had some personal experience about it. I echo the sentiments of Deputy Power in one respect although I shall take issue with him on another point later. I hope he does not object. The Minister has shown that he is one of the most courteous and approachable Ministers on the Government benches, always available to Deputies who wish to make complaints. I thank the Minister and his Parliamentary Secretary for that.

The point on which I take issue with Deputy Power is in regard to his references to the Minister's socialist ideology. After 25 years—ever since the ill-fated mother and child scheme —of observing the progress or lack of it on the health front, I must dissent from Deputy Power. To my mind what has bedevilled the administration of the health service in the past 25 years has been the continuance of a two-tier system of health service. I am speaking as a socialist and also from personal experience.

It is, I think, a fact which every Deputy knows that a person who goes for private treatment to a private hospital, paying for that treatment out of his own pocket or out of voluntary health insurance membership, receives a different form of treatment from what is received by the ordinary underprivileged person who goes to receive treatment as the holder of a general medical card. The Minister's efforts to abolish this discrimination between two kinds of patients for health services are to be commended and applauded and not criticised.

Once on a very unfortunate occasion in this House which I am just barely old enough to remember the late Deputy Norton used the same arguments as Deputy Power when he said that the equalisation of health services would mean the provision of free medical attention for ladies with fur collars living in Fitzwilliam Square. This was an argument which quite frankly I was unable to accept. I would like to see the time come when I personally, as a relatively wealthy and privileged member of the community, take my place in the queue along with everybody else for the same kind of health treatment and receive the treatment not in accordance with my means, my name, my accent or my background but simply in relation to my medical needs. I look forward to that day.

I am speaking not merely from a certain amount of study of medical services but from practical experience. I was working out with my wife the other day, if you will forgive the frivolity, Sir, that I hold the unique distinction of having been in 17 hospitals in my life. The bulk of these involvements were the result of sporting injuries, and I am not particularly ashamed of them, but in the course of these involvements I had practical experience of what it was like to be a relatively affluent member of society and what it was like to be an ordinary person queueing up on the wooden benches in some of the aged, broken-down and appalling hospitals which are a disgrace to Dublin. I have very little experience of rural practice in this regard. I have noticed the way in which, where the utmost courtesies are extended in hospitals to people like myself, general medical patients are used as virtual guinea pigs by the house doctors in hospitals in this country. I admit that this process may be medically necessary to add to the experience of the doctors in question, but I cannot again forbear to remark on the distinction between the treatment offered to people like myself and the inhuman manner in which these general medical patients are treated and any effort the Minister makes to end this discrimination will receive my support.

I want to make a further point with reference to the administration of Dublin hospitals. Some discussions of the conduct of the administration of health in this city are tinged with an aura of unreality. Anyone who for years has had experience of the administration of hospitals in this city will know that medical politics in this city are really ludicrous.

The hospitalisation of Dublin city is divided between at least three groups: the concentration centred on the Mater Hospital, the concentration centred on St. Vincent's Hospital and the concentration centred on what are known as the federated hospitals. This triad has no logic in medical terms, other than the inheritance of a century of religious and political divisions between the hospitals. I wonder if Deputies understand the problem of administration which the Minister faces in this regard. Personally, I look forward to the day when hospitalisation in Dublin will be rationalised to a point which will offend a great many members of the senior consultancy profession in Ireland. The Minister, in my view, has perhaps the most unpleasant nettle to grasp here and he is making great attempts to grasp it. I admire him for so trying.

There is one point here—and I echo the sentiments expressed by Deputy Power—that it is quite remarkable that, given the ramshackle nature of the administration of Dublin city hospitals, we have been able to attract staff of the calibre we do get for the salaries we pay. Some of the younger consultants in Dublin, with very high qualifications in the United Kingdom and America have returned to earn salaries which are a pittance by comparison with the salaries they earned abroad. Their retention in Ireland is only explained by their dedication to duty and their affection for this country, and I think the remarks about the row which the Minister has with the consultants must be taken in the context of the fact that we are competing on an international scale in Ireland for the services of really qualified doctors.

Reference was made by Deputy Power to drugs and drug addiction and this causes me to make one brief point. What is a drug? An American psychiatrist defined alcohol as the only sociably acceptable drug. It is a valid point. It is no exaggeration to say that a ridiculously large number of people are subsisting on librium and valium, tranquillisers of that kind, dispensed by doctors of all sorts in this city and I am sure the same is true of areas with which Deputy Power is more familiar than I am. If again I may be forgiven an aside which may appear for a moment to be irrelevant but which has a certain relevance, the other day I was staying in an extremely expensive London hotel and a group of young people came up to me and said "Are you staying there?" I said I was, and they said "Are the Osmonds staying there?" I said "I would not know really; I have not checked the guest list". They looked at me as if I were something out of the Dark Ages—I am only 39—and slowly the penny dropped. They were referring to a pop group and I said "I think I would just about recognise them if I saw them, but as far as I know they are not in the hotel", and I went on my way feeling about 70.

The same thing applies with drugs. Deputy Power has inveighed against the use of drugs, but to people of 16 and 17, the smoking of cannabis is as harmless and as meaningful a pastime as for us the consumption of a gin and tonic or whiskey is the normality of life. This is something we have to face. It may be regrettable, and I think it is regrettable, but it is part of the generation gap.

Again on that subject, I should like to make a point which will make me unpopular, perhaps, with the medical profession. I have praised many members of that profession already but there is one sector of that profession for which I have a certain amount of contempt and that is the doctor who often works for a health board on the capitation grant system and spends his life writing prescriptions at the rate of one every three minutes. He prescribes so much librium and so much valium. That doctor can then come back to the taxpayer and demand recompense for his service for having attended so many patients in a morning. In my view he has not meaningfully attended them at all. Has that man dispensed drugs? Should we inveigh against him? I have the greatest respect for the more honourable doctor who spends perhaps 20 or 30 minutes with a patient investigating the problem and flatly refuses to give a prescription of the kind in question. That gets back to my point, what do we mean by drugs?

On the question of alcoholism, while Deputy Power has correctly praised voluntary workers in this field it is wrong that successive Governments have left the problem of alcoholism largely to the attention of voluntary workers. They have made ritual speeches saying that, "We have Alcoholics Anonymous; they are very good people and they do good work". When it comes to the finances of the Government very little is spent upon the curing of what is accepted to be the second major killer disease by the World Health Organisation. It is unfortunate that we should treat this appalling disease by more or less shrugging our shoulders, appointing a few social workers but otherwise leave it to the dedicated work of individual people.

The same problem applies with the care of geriatrics. It is unfortunate that we have an inflated numerical standard by world comparison of hospital in-bed attention which is largely the consequence, though not totally so, of the fact that the geriatric patient is automatically hospitalised. We have a reputation for our devotion to the family and our readiness to look after our aged but it is a reputation which in many cases we do not deserve. Very often we dispatch our aged towards hospitals with the result that we have inflated statistics and the deprivation of hospital beds for people who are in more need of them. The solution to this—this view is not solely held by me, it is held by many of my friends in the medical profession—is the extension of outside hospital home care. The Minister should give his attention to the ever-growing need for this. There are many people in hospital who need not be there, who could be at home if proper facilities in terms of visiting nurses were available for them.

I have said enough to draw attention to the tasks which the Minister faces. Health is perhaps the most difficult and controversial area of administration in the Government. Even the Minister for Education, to paraphrase the British Labour MP, Ray Gunter, lies on a less painful bed of nails than does the Minister for Health who must find it almost impossible to please all the people all the time. Too many Members, in this context, make pleas for the retention of medical services in their own constituencies, areas where they are involved. I look forward to the rationalisation of hospitalisation. We have far too many hospitals and a great number of them are ill-equipped. They will never be equipped to provide the kind of general medical attention which is needed in 1975 and in the final quarter of the 20th century.

I would draw the attention of the Minister to a final point. The only point on which I have to take the Minister to task is that he and his Department have not shown sufficient awareness towards the relatively costless financial involvement in unusual diseases which could be added to the category of free diseases. I am thinking of adding them to diseases in which case no payment is required for attention; ileostomy and colostomy, the subject of questions raised by Deputy McEllistrim and myself last week, could be included. It would cost very little to give special attention to diseases which cause people extraordinary pain, distress and inconvenience. Having made the rather jocular point about constituency references I should like to say that in my constituency the number of coeliac babies is quite remarkable. The number of complaints I get from unfortunate young mothers who have coeliac babies and who do not feel they are getting their rights from the State is remarkable.

The unfortunate Mr. Dubcek spoke of socialism with a human face and Mr. Edward Heath, who was comparably unfortunate in some ways, spoke of capitalism with a human face but one thing the Minister for Health did to his Department is to give a human face to that Department. I congratulate him on his work and I should like to add to that the Parliamentary Secretary to the Minister for Health and also the Parliamentary Secretary to the Minister for Social Welfare who has given a very good image to a previously rather abused Department.

Mr. Cronin

Previous speakers have covered the broad spectrum of health services but I should like to deal with one problem in my constituency even though Deputy Thornley thinks constituency interests are overdone and local problems are not of great importance. The Parliamentary Secretary will not be surprised to hear me refer to Mallow Hospital which has been the subject of debate for many years. I hope the Minister will be able to indicate his intention in regard to the national hospital plan when replying. I would be interested to hear that Mallow Hospital will be upgraded.

In view of references by the parties now comprising the Government it would be reasonable to expect that Mallow Hospital will be upgraded. The important point now is that a decision should be taken. In the present impasse an atmosphere of indifference and apathy could creep into the hospital and its services, the staff and amongst the public depending on the services at that hospital. I support the plea for continued services and an extension and upgrading of those services. The Minister should reach a decision shortly even if that decision has to be piecemeal and Mallow is decided on separately. There is a danger that the services and facilities which exist in Mallow Hospital could deteriorate further to the loss and inconvenience of all concerned.

Side by side with the plea for continued and improved general hospital services in Mallow comes the call for the provision of a full maternity unit. In years gone by there were two maternity centres in Mallow; one was at the county hospital and there was the Mount Alvernia private hospital, but neither of them exists now. As a result, the people in Mallow and the catchment area, which extends as far as the Limerick and Kerry boundaries, have to go for maternity services to Tralee, Limerick and Cork. A recent survey indicated there were approximately 1,500 births in the Mallow catchment area. This figure appears to reach the guideline set down by Comhairle na nOispidéal and, therefore, there does not appear to be any good reason why a full maternity unit should not be established in Mallow.

At present expectant mothers have to travel for ante-natal attention to centres in Cork, Limerick and Tralee. In many cases this treatment is not undertaken because of the inconvenience caused by a day's absence from home to receive this medical attention. However, this situation should not be allowed to continue. I cannot visualise any good argument against the establishment of a full maternity unit in Mallow. This centre caters for a population of 70,000 people, it is between Limerick, Cork and Tralee and there is justification for the provision of full services in Mallow.

I endorse some of the comments made by previous Deputies in relation to the availability of medical cards. The limit it too low; the bracket above the present income limit includes people who are committed to heavy medical charges. The medical services are costly by any assessment but there are people who are barely over the limit and I would ask the Minister to extend the figure. It is approximately £24.50 per individual, with suitable adjustment for children, and I would ask him to amend it to a more realistic figure in the light of present incomes. Formerly medical card incomes were related to the pay of a county council worker and if this were done now it would be of some help. At the moment there is an in-between category of people who are unable to meet their medical charges.

I am not a member of a health board but it has been brought to my attention that there is considerable delay in getting patients admitted to orthopaedic hospitals. It appears that people who can pay can jump the queue while those unable to pay must wait. This can drag on for several months. I know of a case recently in my constituency where a man had to go to another county in order to have a hip operation. I would ask the Minister to work with the health boards to endeavour to reduce this delay for patients who are awaiting admission to orthopaedic hospitals. There is a real need here and it should be attended to in the best way possible. I make this plea in the full knowledge of the problems of getting surgeons, but the problem is a real and urgent one and I would impress on the Minister how painful is the delay for patients who cannot get into these hospitals.

Deputy Thornley referred to extension of the list of long-term diseases. I have no professional knowledge that would enable me to discuss these diseases but I am concerned that one particular disease might be fully investigated, namely, congenital heart disease. By its nature this disease remains with the patients when they reach adulthood. I know of a number of cases where these people have had to provide medicines and drugs on a continuous basis and, while there is some concession with regard to the purchase of drugs, I am convinced this disease should be included in the list of long-term diseases which have been drawn up by the Department of Health.

Many Deputies have commented on the over-use of alcohol and the use of drugs. From my ordinary knowledge and experience, I am convinced one of the greatest problems among school-leavers and students is that of boredom. These young people have just finished school and perhaps are looking for holiday work and it appears at this stage they are liable to become easily bored. The problem of drug-taking and the abuse of drink by young people should get special attention. The Departments of Health and Education should get together on this matter: they have much in common and they operate jointly on many health problems such as the treatment of deaf and handicapped children. More attention should be given in the schools to train young people to use their spare time in a useful way and this might go some way towards diverting young people who might otherwise develop the habit of drug-taking and other dangers.

Our nation as a whole needs to be taught and educated on how to use leisure time in a useful way. Many people on a five-day week have no interests or hobbies and they do not know what to do with their leisure time other than betting and gambling. We have a responsibility to pattern and fashion our teaching to cater for this kind of situation. People should be educated in the cultivation of hobbies or activities that would absorb their spare time.

I understand there is a shortage of social workers in the Southern Health Board area. In turn, this has the effect of burdening doctors with the work that should be done by social workers. Those employed in social work are doing an excellent job and the recognise it as a vocation rather than a task or a profession. They are doing wonderful work. I would like to see more social workers employed by the health boards to augment and expand the work of the boards.

Reference was made to the work of the voluntary bodies in many spheres of health activities. I want to put on record my endorsement of all that has been said and pay a special tribute to the nuns who quietly put in so many hours looking after people in their own homes. What occurs in North Cork constituency is, I am sure, common to the country as a whole; these very professional, dedicated people are doing wonderful work in a very quiet way. A tribute should be paid to them and I am taking this opportunity of paying that tribute to them now.

Health services generally have been fairly well covered by previous speakers but I would like, again, to emphasise the position of the handicapped. Many can get employment but others cannot. There is a selfish attitude being adopted by some employers where the handicapped are concerned. I know industries and factories in which a fair quota of handicapped people are employed. If this were the general practice, the problems of the handicapped would be greatly reduced, to say nothing of their being absorbed into normal community living.

I wish the Minister success. The Parliamentary Secretary is a constituency colleague of mine and so I have no trouble at any time in making contact with the Department. Both he and his Minister have been very considerate, sympathetic and helpful at all times. I make a special plea to them now to decide the future of Mallow hospital before the services there descend to a low level.

Mr. McDonald

I welcome this opportunity of complimenting the Minister, his Parliamentary Secretary and the Department for the progress that has been made. I particularly welcome the extension of the general medical services. Many more people now qualify for this service as a result of the raising of the ceiling. People are, of course, inclined to look at services from the point of view of what they do not find satisfactory and are inclined to lose sight of the benefits. This is frustrating for those who are operating the services.

I pay tribute to the Minister for the great pains he has taken to supply the House with very precise statistical information, including comparable figures with most of our European partners. From a statistical point of view it is quite obvious we compare very favourably with our European partners in regard to both personnel and services. Where the cost of health services is concerned, the price of drugs and medicines has escalated since the change in that particular part of the scheme. It is now more convenient for medical card holders to collect drugs and one wonders whether or not all these drugs are used. I have heard it said that there is a great deal of wastage of very expensive medicine and drugs. An all-out effort should be made to educate people into looking at this service from a national point of view. If medicines are prescribed, the patients should finish the course prescribed. Many people do themselves and their medical advisers a disservice in not following out prescriptions to the end. If they begin to feel better, they disregard the remainder of the medication prescribed. In this they are doing an injustice to themselves. As well as that, dangerous drugs are left lying around. There is a certain wastage and there is need for economy in this particular field.

I would appeal to the Minister to encourage the formation of general group practices. Difficulty is experienced in acquiring the services of a general practitioner at what might be described as unreasonable hours. Difficulty is certainly experienced over weekends. Group practices would resolve this problem. Another method of solving the problem would be casualty units attached to the county hospitals. It is not possible to be admitted to a hospital without a letter from a general practitioner and patients have had difficulty in getting this magic document. A casualty unit in county hospitals would be the answer when people are taken suddenly ill.

In some of the larger centres of population there is a maximum figure of 2,000 patients registered per practitioner. That is causing some difficulty particularly since the means test ceiling was raised. Those qualifying for inclusion in the general medical services register find that, because their private doctor already has 2,000 patients registered, he cannot take them on. This difficulty could be resolved if there was a little more flexibility in registration.

I should like to refer briefly to the midland region. Since regions were established some years ago the two counties I represent are part of a region that is left over after all the other natural regions are drawn. It is a difficult region to service because there is not a lot in common between some of the counties in it. Communications are from east to west because everything radiates from Dublin so communications in north and south of the region are very bad. I sympathise with the Minister in his responsibility in this regard.

I believe the Minister has been thinking about establishing a regional hospital for this area, which is quite small when compared with some of the others. I have given this matter a considerable amount of thought. I am a member of a number of regional boards and I have to travel long distances from where I live in the south of the region to meetings in the north of it, so I know the problems involved. The Minister should provide a service which will be convenient for the largest number of people. He must provide a general hospital convenient to both the north and south of the region. Instead of providing one regional hospital, he should provide a large general hospital based on the present county hospital in Portlaoise, which is a very fine hospital and is adjacent to a psychiatric hospital with 600 beds. The Minister should improve the facilities in both those hospitals. He should service the other half of the region from Mullingar, which has a large psychiatric hospital not far away. He has not spoken about this problem but because the lines of communication radiate towards Dublin it would be much more convenient if we had both those hospitals in the region instead of having one large hospital.

People who have not got their own transport and live in the south of the region, near Portlaoise, have to travel to Dublin by public transport in order to get to other parts of the region. It is much easier for those people to go to hospital in Dublin. A lot of time is involved for people who have not got their own transport in getting from one end of the region to the other. There is a special problem in this area because it has not been developed over the years. Other regions have hospitals located in large towns.

I should like to deal with one aspect of the social policy. Much has been said during the debate about the services provided for handicapped and retarded people. I should like to quote from the 1974 annual report of the Commission of the European Communities on social policy, paragraph 216. This is from the Eighth General Report on the Activities of the European Communities and states:

The social year has been dominated by the preparation of a number of concrete proposals for submission to the Council in accordance with the timetable set out in the Social Action Programme adopted by the Council in its Resolution of 21 January, 1974. The Council took its first opportunity to take decisions on these proposals at a meeting of Social Ministers in June. It was decided to approve three proposals relating to the opening up of Article 4 of the Social Fund for handicapped workers and migrant workers, the establishment of a General Safety Committee and the adoption of a programme aimed at the successful integration of handicapped workers into normal working life.

I should like to ask the Minister, who is presently president of the Council of Social Ministers in the Community, to continue to press vigorously for the inclusion of sheltered workshops in the categories of projects that warrant aid from the Social Fund. This is very important. It is not just a matter of having those sheltered workshops— there is a need for quite a number in this country—but they will give a very definite psychological boost to the hundreds of voluntary workers who, with the aid, assistance and co-operation of the Minister's Department, have brought the services available to handicapped people to a very fine standard, which compare more than favourably with those provided in many of the better developed countries in the Community. If they are qualified for benefit from the Social Fund they will be given the stamina to continue on in the wonderful work they are doing.

There is need for more information on what is available in the social action programme in the Community. The Minister or the Institute for Public Administration should organise seminars for the personnel of health boards and voluntary organisations to give them an idea of the kind of projects that qualify for grants from the Social Fund. They should be given a grind on how to present applications which will get through the system of screening devices. Perhaps the NRB might take on this function. People from the Commission should be brought over to these seminars to answer questions, to explain the programme, and to give our people who are working in this field a closer insight into exactly what is available and what is not.

I sometimes think that our civil servants who are most conscientious are a little too respectful of the Community's rules, procedures, directives and articles. There should be scope for a little more bending of the regulations. They might drop the stiff-upper-lip attitude they always seem to adopt, and their high standards from the point of view of the confidentiality of documents. I had the experience of being refused a document by one Department, not the Department of Health. Without any trouble I got it in another language from one of my European colleagues. This put us at a disadvantage. We should have a full and frank discussion on what is available from the Social Fund. Even if it is not the intention to extend that type of service to this country, at least we should be allowed to know exactly what is available.

I could not agree with all the comments made by my colleague Deputy Thornley, especially with regard to the treatment of patients in our Dublin hospitals. It was unfair of him to say that different treatments were meted out and that some patients were treated as guinea pigs. Our hospitals provide an excellent service. People who are hospitalised in a training hospital, irrespective of whether they are in a private or a public ward, must expect to see students and interns doing their rounds. In all cases where people have raised objections, those objections have been respected.

I do not know whether the Minister has responsibility for the provision of detention centres for young offenders, and especially for young persons on remand. I remember reading some months ago that it was proposed to hand over this responsibility to the Minister. If he has assumed that responsibility, I would ask him to press ahead vigorously with the provision of these facilities. It caused disquiet that so many young people who are on remand, and allowed out on bail, seem to continue to commit crimes and cause a considerable amount of damage. There is a grave need for an improvement in the facilities available.

Some social workers should be made available in the principal centres in the United Kingdom where there are large numbers of Irish migrant workers.

I hope our Departments are not losing sight of the fact that, under the social action programme, a lot of work is being done to assist the migrant workers in the Community. With the large number of Irish migrant workers in the UK, many people are in need of counselling and aid which would normally come under the services provided by the Department of Health.

The public would not object if some staff were made available to work with the voluntary Irish organisations whether they be in Camden Town in London or in the other major centres where there are Irish organisations doing voluntary work. It is time they got support from the Department and from the people at home who are able to remain in their own country. I might have an opportunity of speaking privately to the Minister at some future date about how we can, in a very determined way, include our migrants in the new programme which is being provided and financed by the European social action programme not only for the retraining of migrant workers but also to extend many services to their families. It is true that our people in the United Kingdom have the benefit of all the social services in the United Kingdom but, if we could extend our service to them, it would be of solace and benefit to them.

Mr. MacSharry

I should like to say a few words in defence of the health boards system. Many people have criticised them and, on occasion, I have done so too. This is a new venture and it needs to be sold properly not only to the public but to the public representatives. The intention was to have the people involved in the administration of the health services as well as the elected representatives come together in the interests of the health services. Much more needs to be done in the future to make the system work as it was intended.

The Department of Health, perhaps to a larger extent than they should, use their influence on the health boards. Because of this the health boards feel they have not got the control they should have in their own areas. Many of the medical profession involved in the representation on the health boards have not yet played the role they were intended to play. I would urge on them to contribute in whatever way they can to the successful operation of the health boards system. Many of those involved in the administration of the health boards are doing tremendous work in the compilation of statistics and the organisation of the services generally in their own areas.

It is a pity the new system is subject to so much criticism. The public are not being given a chance to participate in it. Because it deals with a region the system seems removed from the man-in-the-street. That can be argued but, in my opinion, as a member of a health board, that is not the case because the health board administration is still available more or less on the county basis and there would be similar types of offices in the county as obtained under the older system, which are still as accessible to the public. The public are of the opinion that the health services have been taken further away from them by the establishment of the health boards. I do not feel that to be the case and perhaps an exercise in propaganda is necessary to sell the health boards even further to the public.

On the question of the overall administration of the health services by the Department of Health, Comhairle na nOspidéal, the regional hospital boards, the health boards and the local committees, it must be admitted that it is a fairly unwieldly system of administration but that all of those bodies have a role to play. It is a question of getting all of them to work together. The local health advisory committees have a major role to play because they are composed of people on the ground in the local areas who know of the difficulties obtaining there and who are best equipped to ensure that services are brought to those local areas. Unfortunately many of those local advisory committees, so far, have spent a lot of their time criticising the actual operation of the health boards. Because it is a new venture we have sections of the administration of the health services criticising each other when they should be working cooperatively together in the interests of providing a better health service. I am sure that in a couple of years' time the entire population will be satisfied that the health board system is the best way of administering the health services.

In the course of the Minister's speech he mentioned that the increase in non-capital moneys is £29 million, taking the figure from £169 million to £198 million. The Minister pointed out that that increase will not alone enable services to be maintained at the high level of last year but will allow further development and improvement. He might just as well have not said that because we all know that the increase of £29 million will hardly if at all, maintain the level of services of last year. If one looks at the estimate for the nine months' period, it will be seen that it took something like £36 million more than was estimated to maintain the services for that period. For this 12 months' period there is an increase of £29 million. I should like the Minister to give us some idea of what further developments and improvements are taking place because, while the level of service might be maintained the actual amount of service is diminishing.

I say that because, although the people involved in the implementation of that service are doing a fine job, they just have not the time to meet the demands on them. Rather than merely saying that further developments and improvements will take place, perhaps the Minister would tell us exactly what these might be, because from our experience of health boards all improvements and developments tend to show a slowing down. Even in the Department's circular letter issued to the health boards in November last, they were informed that no new posts were to be created after the date of that letter without specific approval by the Department and unless recruitment was covered by special allocation from development moneys provided for 1975. vided for 1975. That circular letter went on to say that the health boards should pay particular attention to the need to utilise present resources in the most economical manner possible and that they should examine the extent to which it might be feasible, without having adverse repercussions on the services, to release some funds from ongoing services to supplement the additional funds allocated by the Department for development. Therefore last November the Department of Health were telling the health boards not only that they were not to create new posts but that they should endeavour to see how they could, in effect, cut back ongoing services to make moneys available for development purposes. That is not possible because of the enormous demands being constantly made for improved health services. In my opinion £29 million increase in non-capital moneys this year will not do anything like what is required, and will not maintain the level of service throughout this 12-months' period.

The Minister says there are no cut-backs and that extension of the services will take place as rapidly as national economic circumstances allow. From what we read about the national economic circumstances we must conclude that there will not be any extension of the services but that there will be cutbacks. There is no point in beating around the bush about it; that is the position.

On the acute general hospitals plan that the Minister proposes to announce at the end of this debate— I feel he would have been better advised to announce it at the commencement of the debate so that the many interested parties would have had an opportunity of commenting on whatever might be the proposals involved—in the north-western region, where I come from, the acute general hospitals service would be second to none were it large enough. There was mention in the Minister's speech about approval of the extension of the hospital at Letterkenny. That approval is only in respect of the preparation of contract documents or of plans, which will mean that in 12 to 18 months' time all that will be approved will be the preparation of such plans and it will be some years hence before any acute general hospital beds are available in Letterkenny. There are two general hospitals in that area, Sligo and Letterkenny. Even though Sligo hospital was extended during the last six or seven years, we find now there is not anything like the space required for the services provided there. Letterkenny hospital caters for an equivalent population with half the number of beds. All that we can be assured of from the Minister for Health—and this was under pressure —was approval of the preparation of plans. When we speak about the level of services to be provided, that is not good enough. We must be serious; we must look around and ascertain where is the possibility of finding the money with which to provide such services.

We are wasting our time saying that we are providing services when we are not, in effect, bringing them up to the standards required in a given area. The north-west, in particular, is an area which will not benefit in the overall plan for general hospitals because we are the poor relation of the country as a whole and we will be last on the list for any major financial investment in the general hospital programme. This is a tragedy because the people in Donegal, Sligo and Leitrim are entitled to exactly the same kind of service as the people of Dublin. The Minister said that free hospital care is to be extended to cover the entire population. It is time we took this kind of airy-fairy, high fallutin' statement out of speeches on what is a very important aspect of life—the provision of proper health services. In the area of the North-Western Health Board we have waiting lists for almost every service that is being provided. I want the Minister to be aware of the fact that until such time as he can assure the people who are entitled to these services that they will get them within a reasonable time he is talking nonsense when he talks of extending free hospital care to the entire population. It is just not on and he knows it.

The Minister mentioned his concern for the mentally ill and the mentally handicapped. I have no doubt that he is concerned and all of us are concerned about the care of those people. We have a long way to go before we can be satisfied that we are even scratching the surface of the problem. There are something like 3,000 mentally handicapped people in psychiatric hospitals who should not be there. God knows how many thousands of younger people, mainly boys in the north west, are at home because they cannot be admitted to any institution other than a psychiatirc hospital, which is not at all suitable for such people. A major problem that has to be solved in the very near future is the provision of sufficient places for the mentally handicapped particularly those who are at home and are causing tremendous difficulty for their parents and families. This should be of major concern to the people involved in the administration of the health services. I would urge the Minister to step up the programme of provision of places for the mentally handicapped, young children in particular. It is a terrible problem and all of us would do whatever is necessary to provide the fund to make such a service available. Even if this meant much more taxation, I believe the people would be willing to provide the funds for this purpose.

The Minister said:

I know that the central theme in the emerging health policy of the Opposition is that greater resources should be placed in community services and in preventive services generally. They do not need to convince me of the validity of this argument. I have held this belief since before I took office as Minister for Health, and I still hold it. All my efforts are directed towards this end . . .

We are focussing attention on this because we know it is emerging as exactly the kind of idea on which people require emphasis at this time. The Minister may criticise the Opposition for focussing attention on this and say that he cannot go as quickly as he would like to because of financial restrictions but community care, general hospitals, psychiatric hospitals and geriatric hospitals are all bound together. Each aspect of the health services is related to the others. If this were approached on the basis of providing a service within the community and, to as large an extent as possible, by the community it might be found that the financial requirements are not as great as one would think. If all aspects were working together, it could be arranged within the existing budget.

The Minister talked of a cost benefit analysis. This is something that cannot be done in relation to the health services. The Office of Public Works have been talking of doing it in regard to drainage for the last six years and it has not yet been published. There are schemes being operated by the Department of Social Welfare and similar schemes by the Department of Health. There is one Minister for both Departments and I am sure there is much that could be done in regard to people who, because they cannot make ends meet, have no alternative but to go into hospital. There are cases of old people who because the young family in the house cannot afford to keep them at home have to go into hospital. It costs the taxpayers and ratepayers £20 to £25 a week to keep such a person in hospital, whereas the relations might be glad to keep them at home.

A plan should be worked out between the Department of Social Welfare and the Department of Health whereby these people would be fairly reimbursed for such a service. That is the best way of solving the terrible problem that exists in geriatric hospitals. There are many people in those hospitals who could be kept at home if the people looking after them got a proper return for their services. This would save the State £20 or £25 a week.

According to the Minister's figures 35.2 per cent of our people have medical cards. He criticised the Opposition for introducing a motion to increase the guidelines for eligibility. He knows the hardships involved when people are just outside the limit. The limited eligibility scheme for medicines is working fairly well but much more still needs to be done in having proper guidelines set. I have heard the Minister say on a number of occasions in the Dáil that he has no control over the guidelines, which are a matter for the CEOs and the health boards. He talks of the £1 increase in the guidelines costing £1 million. Even on that basis eligibility all over the country cannot be the same. Different health boards will have different problems. I know the CEOs and programme managers for community care are very concerned about this. My point is this. Where the Minister states that it will cost so much to increase the guidelines, there should be a phased guideline rather than say that because a married person has two children and is earning £30 a week he is 50p over the limit for qualification for a medical card. That is neither right nor fair.

I urge the Minister to ask the CEOs in their next review to have some type of limited eligibility for medical cards operate for people who are marginally outside existing limits. There should be some way of helping this section of the community. If there is sickness in the family, these people will find the difference between having and not having a medical card unbearable and this can cause tremendous hardship. Even if it does cause hardship, the CEOs must stick to the guidelines until such time as the Minister does what this party asked him to do, that is urge the CEOs to have a limited medical card for people just outside the limit for the full medical card.

On the question of the health contribution, I understand that in the assessing of eligibility of farmers the valuation of buildings is taken into account. For all other assessment purposes the valuation of buildings is not included. Section 46 (c) of the Health Act, 1970, would need to be amended to have the valuation of buildings excluded for assessing eligibility. The Minister should look at this problem and see if there is anything he can do. Because of the inclusion of the valuation of buildings rather than the valuation of land only, many people in the farming community are outside the limit for eligibility for the health contribution section.

In his statement the Minister also said he was not satisfied with the dental service. He then made a startling statement when he said that he did not really know what the solution to this problem is. This is a very serious matter. One would expect the Minister or his advisers to have some type of solution to put forward. Because of the shortage of staff in the North-Western Health Board area they have established a priority rating. Only expectant mothers, TB patients and patients under treatment in hospitals will get priority treatment. In one county there are 600 people on the waiting list—non-priority patients. Some of them have been on that list for from one month to two years. This is not a service.

It was stated in a report of the dental services in the north-west that to cater for the population in that area it would be necessary to have 72 dentists. At the present time they have 23. They are 49 dentists short. The CEO was very anxious to point out that there was no shortage of money. They were not in a position to employ 49 more dentists because they could not get them. This is a terrible problem. I am sure, from listening to other contributions to this debate, that the same situation exists throughout the country. There must be something radically wrong with the terms of contract with public dentists working for health boards and the Department as against the position that obtains in the private sector.

I appeal to the Minister—this is a very important aspect of the service —to formulate some definite plan towards a solution. It is not good enough in any area. I speak particularly for the north-west, to have only 30 per cent of the staff required to provide a proper service. That will not be acceptable for very long. I urge the Minister to have the necessary discussions with the people concerned to ensure that many of our dentists will be encouraged to come home to practise either in the public or private sector. If he fails to get sufficient numbers of them into the public service I urge him to offer sufficient remuneration to those in the private sector to encourage them to participate in the public service. There are many ways to tackle the problem and I urge the Minister to take definite action. It is not good enough to ask what the solution can be. A solution will have to be found and the Minister for Health, the supreme authority in this respect, is the man who must ensure that every effort is made to improve the dental service, which is in a deplorable state.

I should like to pay a tribute to the information centres throughout the country. They are making citizens aware of their rights. This is a very important development. In the past people were not aware of their rights and had to go to their public representatives who, in turn, had to get the information for them. It is good to see these centres staffed with people qualified to inform the public of their rights. This service should be improved and expanded where necessary.

The welfare homes programme as laid down by the Department and implemented by the health boards has been the subject of expressions of fear that the thinking in the Department is they should be dropped or not expanded at the rate they might be. I appeal to the Minister not to have this programme slowed down in any way. It has been a most welcome development particularly in the north-west, where in Leitrim 17 per cent of the population are older than 65 years. In Dublin the percentage is five. One can see from these figures the necessity for having proper services for those elderly people rather than having them queuing to get into geriatric hospitals. The service provides self-contained homes for elderly people convenient to their own homes.

In addition, I should like to see much greater expansion in the day hospital services at all hospitals, whether psychiatric, geriatric or general. Many people if they can get treatment in a day hospital will not take up hospital beds and this will relieve the over-crowded conditions of nearly all our hospitals. In the north-west we had great progress under this heading and in St. Patrick's at Carrick-on-Shannon 130 day patients attended.

They would have had to be provided with accommodation in hospitals thereby aggravating already overcrowded conditions. This aspect of the medical service has proved to be a tremendous success in Carrick-on-Shannon and to a smaller extent elsewhere throughout the north-west. It should be vastly improved and the Minister should quickly provide equipment and money where they are required. This, too, would relieve pressure on hospital bed space.

I ask the Minister to consult with the Minister for Local Government to ensure that all water supplies, whether group or regional schemes, will be fluoridated. There are still many water supplies throughout the country which have not been so treated. It should be mandatory on all local authorities to have water supplies treated in this way. It is not an excuse that the cost would fall on the rates because health boards now pay the cost of this treatment.

There are a couple of other small points I wish to raise. I know the Minister and other Deputies have been concerned about paraquat poisoning and the sale of gramoxene. The manufacturers have added a foul-smelling substance to gramoxene but it has come to my notice in recent weeks that many of the ordinary weedkillers which do not contain paraquat are now being advertised as doing so. Most of the weedkillers which could have been described as harmless to humans are now advertised as containing paraquat and I urge the Minister to see if he can do anything in this respect. Many people now do not know whether a weedkiller is dangerous, and it is vitally important that the Minister has the whole matter examined.

There are many aspects of the health services which do not directly involve health but are incidental to the health services. For instance, there is the question of the telephone service in hospitals and such places. This is usually the last thing to be considered when funds are being allocated, but it is a very serious problem. One is aware of the problems that exist in relation to the telephone service generally but the problems become more acute in relation to the telephone service in major hospitals. In many cases where application was made for improved telephone service in hospitals an allocation was refused. It is just as important that a hospital should have a proper telephone service as it is that it should have a proper operating theatre. I would urge the Minister to have regard to this very serious problem.

Mr. J. Ryan

I should like to compliment the Minister on his introductory statement outlining the plans in regard to the health services for the coming year. In the two years in which he has been Minister I have found him to be very approachable despite the fact that his Department is a very difficult one to administer. In the last 12 months the Minister has been confronted with many difficulties by various sections of the medical profession. I am delighted that he is making headway in resolving the problems that arise between himself and the medical profession.

I would also compliment the Minister on the seminar that he arranged in Waterford. It was appropriate and welcome that after three or four years of operation of health boards there should be a meeting. I hope that cognisance will be taken of the many genuine recommendations made at the seminar as these public representatives are much more aware of the needs of the people than are the senior executives in the Custom House and in the health boards.

This brings me to the question of the operation of health boards. From my experience, both on a board and otherwise, the transfer of responsibility for health services from the county councils to these boards has been a retrograde step. Under the former system a public representative could approach the county manager in regard to an urgent problem and could be satisfied that the matter would be dealt with expeditiously. I want to put on record that despite the many criticisms of the county managerial system great credit is due to those senior executives in regard to the standard of hospitals and the level of attention given in those hospitals at the time they were handed over to the health boards.

The present system is unwieldly and remote from the ordinary people. The ultimate policymakers in the health boards, the CEOs, have too much power, much more power than the county managers and even more power than the Minister, from what I can gather from attending meetings. I would strongly recommend to the Minister that county health committees be given more responsibility and more say in their areas for the institutions for which prior to the inception of health boards they had responsibility. At the moment health committees are just talk shops and discussion groups. They have no power. The Minister might consider the suggestion that the system could be improved by the integration of the chairman of the health committee within the region into the health board. This would create better liaison and feed-back from the boards to the county advisory committees.

The provision of welfare homes is to be welcomed as being a happy relief to many elderly persons living in isolated rural areas. These people are cared for in these homes by staffs who are concerned for their comfort and wellbeing. I should like to compliment them on the work they do. I would appeal to the Minister to continue to provide funds to enable health boards to build more of these homes in the smaller towns and smaller areas of populations. This would bring contentment and happiness to elderly persons by ensuring that they would be cared for in their own locality.

Community care is an aspect of the health services which needs further financial assistance from the Minister. Within the limited resources, a fine service is being provided. My concern and the concern of rural Deputies is to ensure that regular care and attention is given to the chronically ill in their homes, especially in rural and isolated areas. Continued improvement of this service will involve the recruitment of social workers as a matter of urgency. I would ask the Minister to bear this in mind when he is considering the community care service.

One aspect of the health services which in my opinion is being too rigidly enforced is the home care allowance. There are many cases in my constituency which are in need of financial assistance. I can cite cases where married daughters have to surrender much needed part-time employment in order to look after parents and they do not qualify for the allowance. There should be more flexibility in the administration of the allowance. The matter should come within the ambit of the local health committees who are au fait with the needs of the people. I would ask the Minister to consider the transfer of this service to health committees.

There are the twin scourges of drug abuse and drinking. Persons in positions of responsibility are gravely concerned about the terrible evils that flow from these abuses. In the last couple of years the influence of drugs and drinking has reached alarming proportions, so that one must fear for the well-being of future generations. Surveys have been carried out in many parts of the country which reveal startling information as to the influence of these evils on school children from 15 years up. Every possible means of health education should be employed to enlighten young people about the terrible consequences of addiction to drugs or drink. I would appeal to the Minister to deal with this as a matter of grave urgency. If the situation is allowed to deteriorate the next generation will be affected.

I welcome the recent raising of the ceiling in regard to qualification for a medical card. The assessment of gross income may be unjust. The assessment should be based on take-home pay. There are borderline cases where it is impossible for the persons concerned to meet the prolonged cost of sickness in their homes.

There is a matter which I would ask the Minister to discuss with health board CEOs and members. Before the inception of health boards, members of county councils had power to issue temporary medical cards for a month or a little longer to cover emergency cases which they knew to be genuine. This ceased at the changeover, and I believe this special temporary authority should be reinstituted, because the temporary medical coverage can alleviate the hardship of serious illness.

Like many other Deputies, I am concerned for handicapped people. Greater efforts should be made to provide positions in State and semi-State bodies for them. Their present job opportunities are very limited. Steps should be taken by the Minister to ensure that they are properly trained to enable them to obtain suitable employment. I know some of these young people who have obtained such employment in my area and who are doing a great service to our community.

There is a scheme operated and supervised by the health board which is in need of revision and up-dating. It is termed the "refund of the cost of medicines", which is based on the monthly cost, and a refund is made by the board over a certain figure. This system is very unwieldly and there are very long delays in the refunding of these moneys. If there was better liaison between the chemists and the local health boards, a much better service could be provided. I know of people who are paying between £30 and £35 a month for medicines for sick people. They cannot afford such payments but have to find means to obtain this money to meet these costs and wait excessive periods for the refund.

I wish to compliment our dispensary doctors, who are providing a great service for our people living in rural areas. I want them to know that we appreciate their very good work, as do our health board executives who are very anxious to ensure that they continue serving the needs of rural Ireland. Too many areas lack their services. I can assure them that any difficulties that may arise with our existing dispensary doctors will be resolved as quickly as possible by our health boards. There is a system of late whereby dispensary doctors are being allowed to purchase the residence to ensure their permanency in the area. I would appeal to all health board executives to see that no difficulty will be put in the way of these doctors in relation to staying in the rural areas.

With regard to the impending ministerial announcement on the county hospital system, our hospital in Nenagh has a continuing important role to play in the lives of the people of North Tipperary, and I know the Minister will bear this in mind when he makes his statement. Finally, on behalf of all our people, I compliment the health board employees on a job well done and wish them continued success.

Mr. Farrell

At the outset, I wish to pay tribute to the health boards. As a member of a health board from their inception may I say that valuable work has been done. The setting up of the health boards was a great step forward, and in saying that, I am not casting any reflection on the work that was done by the county councils since the foundation of the State. When the county councils had the responsibility for health they did not have the same opportunities. They had so much other work to do they could not get down to all the work done by the health boards. I would urge the Minister to make his decision on the regional hospitals as soon as possible. This matter is still causing some concern to members of the different boards, because they feel they may be left out, and this is interfering with the proper working of the health boards. If they knew where the general hospital was going to be situated, they would be able to plan effectively.

The most important aspect of community care is to provide services to keep people out of institutions rather than put them into institutions. If proper inducements could be provided to encourage the community to keep their old people at home it would be a great saving both financially and in hospital beds. With this in mind more day facilities should be afforded. People needing psychiatric or geriatric treatment could be brought in during the day and go home at night. In our area, in Castleblayney and Trim, there are two very fine hospitals in which we are able to do this work. Last year, for example, between 500 and 600 people were treated there. They were collected five days a week by minibus, examined, treated and left home in the evening. From the 1st June it is intended that the same system should operate in Drogheda. In Drogheda and Dundalk we have psychiatric units. People can come into the hospital during the day and go home at night. There are 50 people there at the moment. It appears that the pattern of the service in the future will be that a large number of patients will require short-term treatment. They might have to go back for six weeks at a time, but in the long run we should be able to do very good work. Many patients could be treated on a day-to-day basis and return home at night.

I believe there was some agreement recently in the dental service which would require an amendment to the Act to allow for the employment of dental hygienists. If this were done, those people could do very valuable work in going around our schools lecturing boys and girls on dental care.

There should be more emphasis on child care. Perhaps more nurses should have some formal training in this field so that they could advise mothers and mothers-to-be on child care. They could also better help mothers with handicapped children, mental or physical. Those of us who in the past have been members of voluntary organisations know what this would mean to mothers of large families, some of whom are handicapped.

In our area, the North-Eastern Health Board, we are increasing the number of public health nurses to eight per annum. If public health nurses can go around advising and helping people, we can keep such people out of hospitals. There should be continuing liaison between community and hospital services, and in this matter general practitioners could play a very important part. I know from experience in Drogheda and Dundalk that very often people are notified to attend and will come to a clinic from a distance of ten or 20 miles, wait a couple of hours and then find the consultant was held up perhaps through no fault of his own and might have to leave early, with the result that people who had travelled a long distance would have to return another day. For some time I have been advocating that only a certain number of people should be notified to attend, a number that the consultant could deal with in a given time, whether the clinic lasts one hour, two hours or three hours. People should be saved unnecessary trouble and expense particularly those without means to buy meals during their long wait.

The new posts of directors of community care are very important and they should ensure co-operation within the community and between the community and the hospitals so that better liaison would be achieved. Better out-patient facilities at hospitals could reduce admissions. A better out-patient diagnostic service would avoid some strain on accommodation. There is great need for more consultants in the acute and general hospitals and there could be fewer house doctors. A better consultancy service would mean improvement in many ways.

We also need services for disturbed youth. The number affected by alcohol is now assuming very serious proportions and I would ask the Minister to give this matter consideration. More remedial teachers are needed in both urban and rural areas for young school children. Some children are backward and unable to keep up with their fellows in school. Better liaison is required between the voluntary bodies, lay and religious, in devising services both in in-patient and out-patient care. Much could be done in this field and perhaps health boards, where possible, could meet this need.

Although the Minister's opening speech was very good and he gave the impression that there was money for everything, I know from experience on health boards that we have not sufficient money and the need for more funds and less departmental controls is urgent. Boards should be allowed greater latitude and if they are able to effect savings under any heading they should be allowed to spend their savings as they see fit. The executives and the members of boards are responsible people. They include 16 members of county councils and 14 nominated by the Minister —all very responsible people. Given more authority and responsibility they would achieve better results.

The Local Appointments Commission deal with the appointment of staff and frequently there are delays up to 18 months before an important post is filled for a consultant or a dentist. It is very annoying to have such a long delay. Would the Minister see if something could be done in this regard?

The ambulance service is a very important facet of the health service. I attended a meeting at the Custom House when machinery under the Health Act was first being set up and it was then announced that the ambulance services would have to be modernised by having a radio control centre in each region so that all ambulances could be radio-controlled and each ambulance going to an accident would be properly equipped and carry a doctor and a nurse so that on arrival at the scene the doctor could make a quick diagnosis and radio to the hospital which would be able to deal with the patient's injuries. Since then what happens is that an ambulance goes out with a nurse and driver and brings the injured to the nearest hospital. Later, perhaps, it is found the patient has injuries which cannot be treated at that hospital and the patient has to be sent to another hospital. This delay can cause loss of life. I ask therefore that the ambulance service be brought up to date with radio control and ensure that patients are sent to the proper centre.

Finally I would urge the Minister not to bring any more people into the health scheme until he is sure, and until the public can see that he is sure, that those already in the service have all the services they are supposed to have. We know that at present with the buildings, the hospitals and the staffs we have, it is not possible to give proper treatment to those entitled to it. In most areas there are long lists of people waiting to go into hospital for various reasons and if we bring all the people of the country within the Act we will not have the services to give them. Before the service is extended the Minister should ensure that there will be proper means of treating those entitled to benefit.

Mr. McLaughlin

First, I should like to congratulate the Minister on doing an excellent job. His work is very extensive, particularly in view of the changes that have taken place in the last few years.

The health services were administered by the local authorities until about three years ago when the health boards were formed and I think we owe a lot to the people who were in charge of them—the members, the county manager, the county secretary and their able staff—for the trojan work they did in difficult circumstances. In those days they had not the accommodation and they had not the organisation, but now we see the health boards provided with offices, with staff and all the help required. We owe a lot to the people who carried on these services until the establishment of the health boards. The Minister has quite a responsible task in conducting and administering the health services throughout the country. It is easy for us to come here and speak on behalf of the people in our constituencies. We are more or less speaking on local level but the Minister has to deal with the problems arising throughout the Twenty-six Counties, problems which are many and difficult.

My chief concern at all times has been the mentally-retarded child. I live convenient to Creggs Hospital outside Sligo and I have very often been approached by parents who were desperate to have their child or children admitted to this hospital. The hospital started as Creggs House, with a very limited number in it. The previous Government spent a large sum of money in carrying out extensions but there is a lot of room for further extension at the hospital because we have quite a large number on the list for admission there. When you go to the hospital and ask for an admission, you discover that the waiting list is so long that these people have not got a hope of having their child or children admitted and this is something that needs immediate consideration. I am speaking only from my local knowledge but what about all the other counties and areas which have the same problem, greater perhaps than what I know of? I am very anxious to see progress being made in this direction. There is nothing more upsetting or more likely to interfere with the happiness of a home than a mentally-retarded child where the other children are concerned and where the parents are concerned and where it is often the sole responsibility of the mother to look after the child. We all know how difficult and unmanageable these children can be.

I want to emphasise this because I have made recommendations to other places throughout the country, only to find that the waiting list was very long and there was no hope of having children admitted, except in the case of one, and another in 12 months' time. I must say that we owe a lot to those people who are working on behalf of these mentally-retarded children and doing this trojan work for rehabilitation of many of our boys and girls. The Parliamentary Secretary was in Carrick-on-Shannon last week and was approached by a very hard-working committee from Sligo who are making great progress towards the establishment of a rehabilitation centre. They have bought two small concerns and are carrying on as best they can. Now they have bought property which gives room for extension but money is the problem. I know that the Minister and his Parliamentary Secretary will go as far as they can towards helping those people. One of these concerns was opened by the Minister some time ago in Ballinamore in County Leitrim. It is a great success and many people are finding useful employment there. Many of them have adjusted to normal life despite their disabilities and handicaps, and are very happy there. This voluntary organisation has been working very hard and I want to bring it to the Minister's notice that these people will be coming from Sligo in the near future to put the case to him on behalf of the people who require treatment.

I have already had discussions with the Minister about the Nazareth Home in Sligo, another centre which is doing very good work but which needs a lot of money. That institution has now spent over £120,000, a very considerable sum, without any grant or assistance from anyone. It is now nearly completed. All the provisions with regard to fire prevention and so on have been approved by the fire officer and others concerned and these people will be coming to his Department in the near future for money. This in itself goes to prove how much money is required to meet the demands. A very substantial amount of money is required and we all know how prices are soaring and that what can be done this year will sometimes cost double what it would have cost last year. The Minister has to find money to meet those demands.

I am glad to note that in the near future Cloonamahon monastery will be opened by his Department. That fine hospital will cater for the needs of the people of the area. I appeal to the Minister to ensure that the local demands are met in relation to the facilities to be provided there. Local parents who are seeking to have their children admitted should be given first priority. Local families will be in a position to visit their children regularly and take them home for weekends and holidays. The present attitude to the caring for such children has a lot to recommend it.

In the past children fortunate enough to obtain accommodation in such hospitals never got home. The result was that they lost contact with their parents and other members of their families. The coming and going of these children in some way compensates these parents for the hardships they must endure.

The Minister, and his Department, deserve congratulations for the services being provided in remote areas. Old people in such areas when ill were unable to call for medical attention and with the closing of neighbouring homes found themselves completely isolated from the rest of the community. It is heartening to see public health nurses and officials of the community care service journeying to remote areas to tend to the needs of old people. It is also pleasing to note that those in need of hospitalisation do not have to wait for any undue length of time before gaining admission. Money is well spent in regard to the health services. The old people being cared for in hospitals and in their homes made an outstanding contribution to the development of this State and it is only right that we care for their needs in their old age. The people in receipt of an allowance for caring for aged relatives appreciate this help. This allowance is greatly appreciated in the rural areas of my constituency.

The hospital in Sligo has been improved greatly in recent years but the Minister will be receiving a request for a further extension to it in the near future. I visit that hospital regularly and I have seen how the existing accommodation is taxed to the limit. The authorities there have had to put up to four more beds in each ward. I understand that plans for an extension to the hospital have been prepared and I appeal to the Minister to do all in his power to have that work carried out without delay. The doctors and nurses there are doing a wonderful job under difficult circumstances. I should also like to pay tribute to the doctors and staff of Our Lady's Hospital, Manor-hamilton. Some people tried to create a scare 12 months ago by announcing that Our Lady's Hospital was to close down. I am glad every effort is being made by the Department to up-grade Manorhamilton and improve the facilities there. The people of the area are pleased to know that the hospital is there to stay.

With regard to the cost of the health services, if the services and facilities are improved their cost must increase. Under the health boards the transporting of patients has improved. Prior to the establishment of these boards each county was responsible for the conveyance of patients in that county to the hospitals. If a serious accident took place in a county, the only ambulance that would go to the scene of that accident was one from the county where it occurred. It happened that people died only 30 yards away from a county where an ambulance was available. This matter created scenes at many county council meetings. We have a first-class ambulance service. We should not wonder that the health boards cost a lot of money to run; we have provided services for the most remote parts of the country and where it is necessary we transport patients to Dublin for treatment. It is a comfort to people who are in ill-health to know the health boards will arrange for treatment for them.

I was glad to see the Parliamentary Secretary in Leitrim last week and to discuss the health services with him. We are proud of the services available for geriatrics in Leitrim. There is a new geriatric home in Sligo and it is one of which any county could be proud. We have several geriatric homes in Leitrim also: there is one at Rossinver, one at Mohill and it is proposed that the Minister for Health will open a new home at Carrick-on-Shannon in the near future. Our county has a population of only 28,000 and approximately 17 per cent are more than 65 years. I remember some years ago we had only one geriatric home at Manor-hamilton and it was in a very delapidated condition. I admit that a stigma attached to the old county home and, to some extent, that stigma still remains. However, the older people have now the consolation of knowing they will be cared for by concerned staff in modern homes. It is inevitable that costs will increase and we must be prepared to pay for the services.

A problem exists in my area regarding the availability of a specialist in speech therapy. The health board were fortunate for the last two years that they had a specialist residing in the area but now a specialist is available only once per month. That is of no use and will not give the treatment that is necessary. Another problem arises with regard to orthodontic treatment. This service is not provided on a wide scale in the North-Western Health Board area. I would ask the Parliamentary Secretary to take note of these matters to see if anything could be done to give a more regular service in these areas of medicine to the people in the area.

We should thank the Press for providing much-needed information to the people who are not familiar with the services available. There are many people working on farms in isolated areas who may not know what is available with regard to health services. Because of pressure of work even Deputies are not always fully aware of these services. The Press deserve our thanks for giving publicity to this matter.

There are some instances of administration by the health boards that need examination and I will give one example. A child was admitted one morning to a hospital for an eye operation but the specialist who was to carry out the operation could not do so because the child was not admitted to hospital the night before. The parents had not been told about this regulation and, as a result, the child will have to wait 12 months before the specialist can do the operation. The parents in this case had provided transport and it had cost them a considerable amount of money. In such cases patients should be free to go into hospital on the morning of the operation rather than the night before.

People owe a great deal to the members of the various health boards. In many cases these members of health boards have to leave their homes and their businesses and proceed to spend the day, perhaps, 100 miles away attending health board meetings and the only compensation they get for a hard day's work is travelling expenses.

Debate adjourned.