I was talking about the expressed desire to reexamine the structure of the health services in general. Implicit in what Deputy Haughey was saying was the suggestion that we ask ourselves now where we are going. Perhaps a more relevant question is to ask: where are we? By comparison with what the health services cost even a few years ago the present level of expenditure is astronomical. Yet Deputy Haughey complained that services are declining and Deputy Dr. O'Connell complained that hospitals will not be able to keep going beyond December next. I agree with the basic proposition that something has gone wrong and that we are not getting value in terms of services commensurate with the increase in the cost of their provision. As I wrote in the Irish Medical Times, I fear that the health boards are a failure. Indeed, listening to the experiences of individuals dealing with health boards, reminds one of a Health Robinson contraption and in particular that vastly amusing one about the Christmas dinner. Heath Robinson apparatus depicted on a wall is very amusing, but a health board structure which at this stage, on admission of the Minister, requires re-examination is anything but amusing. But when it is accepted that there is duplication, waste, too much paper work, that too many people are involved in doing the same job, or a job that could be done by one person, then these are things, at the present cost of administration and of the administrator, which seriously require examination. I welcome the fact that the Minister recognises that this is so.
The proper jumping off point for any examination of what is happening today has to be the publication of the white paper in the mid-1960s. As I said elsewhere, I have now the gravest misgivings about the wisdom of the then Government's decision to implement the recommendations of the white paper in full. I do not doubt the sincerity of the Government; I do not doubt the sincerity of the people who carried out the massive re-examination process at the time and emerged with the recommendations which subsequently formed the basis of our present legislation. I do not doubt my own sincerity, for instance, in going about trying to persuade local authorities that the new health board structure would be more efficient and would result in the provision of a better service for the patient, the sufferer. Nor do I doubt the motives of any of the people involved.
However, the fact is that, in practice, these boards have not emerged in the way that had been envisaged at that time. They do not appear to have achieved the fundamental objective envisaged for them in the white paper proposals. It is a very difficult thing to dismantle any such structure once created. The creation of positions is one thing; their amendment or abolition is another. If restructuring of these boards is required in the future I warn the Minister, this House and the public that it will require strong-minded and determined effort by all concerned inside and outside the Department, inside and outside the medical profession, inside and outside the subsidiary boards, committees and so on.
That is why it seems to me to be very welcome that the general feeling is that these are issues which transcend party politics and should be dealt with, and seen to be dealt with, without party political bias. Indeed, I believe that, all down those years from the time that the idea of examining the existing services was thought up 12 to 13 years ago, all of the people involved have been motivated in the best possible way and have not been interested in self-aggrandisement or basically in party gain. They have been motivated by a genuine, sincere desire that people who suffer and need help, either in a curative way or through preventive medicine, will not suffer in the future. I am convinced that all of the people concerned were motivated by the highest of ideals and the fact that re-examination is necessary now does not reflect on anybody concerned. It is a good thing that the Minister recognises that even now, a bare couple of years after the creation of these health boards, the time has arrived for some sort of committee to examine their operation.
The question arises also of the overall level of expenditure in this field. The Minister comes in here, not just as Minister for Health but as Minister for Social Welfare also. One must judge overall expenditure in this field of social protection, if one may call it that, by adding up the total of what social welfare and health attract out of the national revenue. Taking the overall figure it does seem that the portion now being given to health and social welfare combined is quite generous and yet the Minister complains about allocations where health is concerned and has become involved in cutting back expenditure which may lead to the kind of situation Deputy O'Connell mentioned in which wards will be closed down later this year.
Has sufficient study, I wonder, been given to the question of the application of the aggregate amount of money being spent between social welfare and health? Is too much being given go social welfare and too little to health? Which is the better way socially to go about things, to give more for certain aspects of health or more to social welfare? That is the question I pose. Quite honestly, I do not attempt to give an answer. I have my own views about certain aspects of the social welfare system. I have my own views about the ultimate effect of paying money to people who are in good health and do not need help from any health services. There are instances when people must be aided by the State. Nobody fought harder than I did in the late fifties to see to it that the small farmers in the west, for instance, would be given a naked and unshamed subsidy to enable them to keep on living there. But times change and the question must arise now, and must continue to arise, as to when it becomes improper to give money to people who are otherwise in good health when that money should be diverted directly to the health services, particularly to those people instanced here so often who have to wait a very, very long time for remedial treatment for non-acute conditions.
These are questions which involve deep political considerations and they are questions which have to be answered politically. I was talking earlier about what the new president of the association, Dr. O'Donnell, said in Kilkenny. He referred to the development of St. James's Hospital in Dublin. This brings me now to the question of hospital reorganisation and rationalisation about which so much discussion has gone on over the years. In fact this has been very difficult to achieve. Dr. O'Donnell said that one of the tests of the sincerity of the Minister—to him anyway and, I take it, to his association—is the completion of St. James's and of the facilities to be provided there. He would regard that as a touchstone. I think he could be right because I believe that, as in previous years, money is still being dissipated in providing help for equipment here, buildings there and staff somewhere else in institutions which should no longer exist. This applies especially in Dublin. St. James's should be a first priority. There you have a hospital complex where some of the buildings are so old and decrepit as to be a fit object of scrutiny by the dangerous buildings section of Dublin Corporation. Within the same complex you have a new building without any equipment. That raises the question as to whether even now a proper system of priorities has been established.
I appreciate the difficulties. There are political difficulties. There are personal difficulties and the personal difficulties are often political. They are not party political; they are medical political. They are no less complex and difficult for being medical politics rather than party politics. At the rate hospital charges are rising throughout the world we just have to come to grips with the problem. Deputy Haughey referred to experiments in other countries designed to reduce hospital charges and so on. There is an article in the current issue of Time Magazine about experiments being carried out in America where people, who are able to look after themselves, after careful screening are given certain minimal facilities in an institution and, after that, they are made to look after themselves. These would be certain types of cancer patient, people recovering from strokes, paraplegics and so on. The cost of a hospital bed per day is in the region of $113 which is a rather frightening figure when translated into sterling at its present value. In New York, Washington and other big centres the cost is $200 per day or even more. Experience in recent years has shown that slowly but surely every country is beginning to approach the cost level in the United States and we have only to look at the situation in western European countries over the past five to ten years to realise that this is so.
I remember on one occasion meeting Mr. Walter McInerney, the head of the Blue Cross in America. He was going to Washington to try to pilot his budget through whatever federal agency was involved. He said: "You know, what I am beginning to worry about now is not the cost of medicine but whether we can afford the premium". The Blue Cross system is roughly an insurance system and he was worried as to whether or not people would be able to afford the premium. When we talk here about a compulsory insurance system, an extension of the VHI, or any other system, we must do so against the background of rising hospital costs, with no evidence to show they can be controlled, certainly not for specialist acute treatment. Looking after people on the lines suggested in Time Magazine would be very helpful because it would mean that people who are capable of looking after themselves could do so during the periods in which they require certain minimal treatment, but would not have servants, nurses and nurses aids surrounding them to make their beds, bring them their breakfast in the morning and bring them their drugs, medicine and so forth. It shows what the savage increases in the cost of hospitalisation generally has resulted in in other countries. Anything which is done elsewhere is worth looking at by us.
Some people are bound to get hurt in the rationalisation of the structure of hospitals. From that point of view I regret the implications of the Minister's announcement that Mallow Hospital will be retained as an acute hospital. I have nothing against Mallow or against the idea of retaining a hospital there. My misgiving arises from the fact that a great deal of political pressure was exercised by and on behalf of the people concerned in Mallow. This criticism is not aimed at the Parliamentary Secretary who comes from Mallow and who would have been involved in the representations. Mallow is now to be retained as an acute hospital after being told it was to be a community care centre. It is not relevant to me whether the original decision or the present decision is right. This decision will be interpreted as being the result, although this may not be the case, of sustained political pressure at every possible level. This hospital will now be equal with a hospital in Cork city with which it will work as a component part.
I have always felt that too many public representatives are too sensitive about decisions in matters like this and I speak in the presence of Deputy Enright who will probably be talking about Tullamore hospital very shortly. I accept his reasons but I do not accept, in regard to many other parts of the country, that the cases put forward by politicians of various views were basically valid. I regard their behaviour in general with something not too far removed from contempt.
I will give an example from the other side of the matter. The recommendation some years ago that certain facilities should be withdrawn from Wexford was not appropriate. It was admitted afterwards that it was not appropriate at the time. It opposed the establishment of a structure which did not exist. The withdrawal of the services from Wexford was not envisaged until the infrastructure was available. I can understand the attitude of public representatives saying: "For God's sake, how could you do that?" I agree that they had a good point but there are other parts of the country where I do not agree that if the public representatives were looking at things from a national point of view as distinct from a parish pump point of view there was any validity at all in the cases they were making to whoever was Minister for Health at the time.
Reorganisation of the hospital services in Dublin and throughout the country is a key to the improvement of the health services and must be done as a national imperative even though certain individuals on the medical side will get hurt in the process, even though the part that will be played by particular institutions in the health services will be changed and even though what appears to be downgrading of certain areas becomes necessary.
If one of the by-products of an all-party committee on financing and restructuring the hospital services and if necessary the realignment of expenditure between health and social welfare was to be that we as public people could finally adopt a hospital rationalisation programme broadly acceptable to all we would have done a marvellous century's work for this country. It must be accepted by the representatives of the medical profession and other organisations concerned that people will be hurt in the process. It is because I believe an all-party approach is possible and that it is also possible to get broad agreement in principle from the associations for such a programme that I am optimistic enough to believe that li = "2" fli = "-1"what everybody agrees to be necessary can be achieved.
Another matter which concerns both health and social welfare and also involves the question of payment is whether or not any function basically in regard to health should remain in social welfare. There is a health element in the insurance stamp. Would that be better abstracted from social welfare and the stamp devoted purely to employment and so forth? Is this not an area which should be reexamined? Would it not be better to have those things controlled by one agency and not divided up among two or three where collections are made under one heading by one Department and under another heading by another Department and there is an independent collecting agency in the middle? This could be regarded as part of the brief of the new Department of the Public Service where this duplication of effort within Departments, with regard to collecting money and in regard to responsibility, should be straightened out. Anybody who has any knowledge at all of the working of Government Departments will realise each likes to hold on to every area of responsibility it enjoys, to expand it as far as possible and hates to be told that it is to lose responsibility even though the circumstances of its having that responsibility may be entirely incongruous. Again, there are human factors involved and if the Department of the Public Service are not prepared to study and make recommendations on matters of this kind they will have to be studied, adjudged and implemented at political level.
The examples given by Deputy Doctor O'Connell of people with, for instance, osteoarthritis and such diseases having to wait upwards of two years for operative treatment raise a question as to what the Department could do to improve that situation. There are other examples in the non-acute field of very long waiting periods in the case of patients. While this is partially a problem of personnel it goes back ultimately to the question of hospital reorganisation because if we knew what facilities would be available we could arrange, at least in the long term, to train the appropriate personnel and if we could not train them, to acquire them.
I should like to praise all those involved in the various aspects of the health services which have definitely shown great advances over the years since they were first envisaged. Community care in general is much better now than it was in the past. The great improvement in the number of nurses in the field is very welcome. The continual addition to the number of institutions catering for elderly people near their own homes is also very welcome. The overall functioning of the general medical service is praiseworthy. There are certain abuses within that service and I hope they will be eradicated although, human nature being what it is, there will always be a small percentage of people who will abuse a system such as that which operates to-day.
I was astonished by the figures given by Deputy Haughey showing that 65 per cent of the cost of the general medical service arose other than by payments to doctors but I am sure the doctors cannot complain about their conditions now or about what they are being paid. As I have said elsewhere they would not have done as well had I been Minister instead of my successor. But they have given good service in return and too much emphasis should not be placed on the occasional breakdown. While every effort should be made to ensure that the sort of incidents mentioned here and rightly publicised in the newspapers—who are still our friends despite what we may have said about them—should not develop. Doctors should be capable of, and are sufficiently well paid to be capable of organising a service which will, on the existing structure, operate on a 24 hour basis. That should be accepted by them and they should be able to organise it with or without group practice so that nobody in a given area at any time is left without a doctor when a doctor is urgently needed.
Many people have worked very hard and, in general, the service has at certain levels improved enormously but the cost has got out of hand and re-examination is definitely necessary, preferably without party political overtones. I think this reflects every-body's view. Nobody—at least I have not—has any doctrinaire conviction as to how financing should operate or what categories of people should be envisaged. I dislike categorising people because sometimes in doing so we put the emphasis on the wrong end of the scale. We should be thinking of providing a first class service within a first class structure and not trying to amend a third class service to cater for people's needs and this appears to be what is being done consciously or unconsciously for some time past. Reappraisal is certainly needed and we, on this side of the House, will certainly be glad to give our support to practical measures to bring the system nearer the desire of the hearts of all who were involved ten or 12 years ago in the decision to uproot the old and establish the new system. All concerned were motivated by the highest principles. The fact that we are disappointed and in some ways disillusioned now should not take away from that fact but should spur us now to the same idealistic approach and the same unselfish attitude so that whatever is necessary on re-examination we will get down and do it. Even if difficult political decisions must be made, these should be faced.
We must avoid a situation where we lose control over what is happening in regard to our services and we must not be afraid to look at the question every day and decide what service is genuinely needed by the community, because service per se is merely a word and the idea that people are entitled to service by definition applies only to a very small section of the community. We should re-examine our whole approach to the matter, because words are only words and we should not allow ourselves to be cribbed, cabined and confined by doctrinaire ideas of any description or any background, historical or otherwise. We should look at our own unique country and see what we can do with its resources. We should employ those resources to the best possible advantage of those who need service. We should not be afraid to amend, withdraw, or otherwise change, if we keep the ultimate objective firmly in our mind.
