Vol. 294 No. 9
I move:
That a supplementary sum not exceeding £11,484,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1976, for the salaries and expenses of the Office of the Minister for Health (including Oifig an ArdChláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants and certain grants-in-aid.
I move:
That a supplementary sum not exceeding £10 (ten pounds) be granted to defray the charge which will come in course of payment during the year ending on 31st December, 1976, 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.
The Supplementary Estimate for £11,484,000, which was passed earlier, will increase Exchequer non-capital health expenditure to £253.967 million in 1976. This compares with an Exchequer expenditure of £207.561 million in 1975 and represents an increase of 22.4 per cent over last year's out-turn.
It will be seen from these figures that Exchequer non-capital expenditure on health care has increased faster than inflation in the present year. This represents a significant achievement in our current economic circumstances.
In introducing the main Estimate for the Department of Health earlier this year I said that my aim in 1976 was to maintain 1975 service levels. I believe that this Supplementary Estimate will enable that objective to be substantially met.
Early this year, I explained to health agencies that the economic conditions facing the country made it essential to maintain very tight control over health expenditure in the current year. I informed them that it would not be possible to continue the rapid growth in health services which had been achieved in earlier years and that a temporary period of belt-tightening was required.
I am pleased to say that all of these agencies responded to my request. They have all undertaken close scrutiny of their expenditure patterns and they have all exercised economy in the use of the financial resources allocated to them.
As a result of their efforts, we have come through the present difficult year with relatively few problems. We have not, of course, been able to expand our health services as we would have wished in more favourable circumstances, but we have been able to maintain service levels substantially in line with my stated objective.
The present Supplementary Estimate is accounted for mainly by additional costs which must be met by health agencies and which were not provided for in the original Estimate.
These include increases in welfare allowances, in pensions, in social welfare contributions and, in pay under the national interim agreement and following awards made following decisions of the Labour Court. In addition, provision is made in this Supplementary Estimate for increased services provided under the General Medical Services scheme and for unavoidable costs which accrued in a range of other health services, particularly residential services for the blind, the deaf and the mentally handicapped.
In distributing the additional funds which will be available to my Department, my objective will be to direct additional resources as far as possible to those areas of our total services which have come under most pressure in the current year. We will not, inevitably, be able to meet all requests for additional funds, but I am satisfied that we can alleviate the problem considerably and, in so doing, ensure the retention of our present high level of health service provision throughout the remainder of this year.
As I have said, I made it clear to the House and to our health agencies early this year that 1976 would be a year of economy in health expenditure. I explained that this year health services would have to stand still to enable the Government to maximise their efforts in getting the economy back on the road to recovery. That policy, which was the only rational one in the circumstances which faced the country, has been adhered to and is succeeding.
Towards the end of the year, however, I did detect some limited areas of our health services which clearly required additional resources to enable that policy to continue to be met. For example, some residential institutions were clearly in difficulty and I am making more funds available to them as I have said. In addition, it became clear towards the latter part of the year that, in a small number of isolated instances, temporary difficulties in the provision of chiropody services and the supply of spectacles for adults did occur. Steps have now been taken to remedy these unforeseen difficulties and to resume services at normal levels.
I believe that the Supplementary Estimate for £11,484,000, together with the original Estimate, will ensure that our health services are ready to move forward again as overall recovery takes place. I am conscious that we have not been able to initiate any new developments in services in 1976, but I am pleased that we have been able to carry our health services intact and undamaged through what has been a year of profound crisis for our society in general.
The introduction of this Supplementary Estimate by the Minister for Health at this stage represents a classic case of bad administration. It is a clear example of how not to conduct government business, of how not to administer a public service such as the health service. The Minister, in pursuance of the usual practice, in the early part of the year introduced an Estimate for his Department. Many of us pointed out to him, as clearly and as strongly as we could, that the allocations we were making were inadequate and would not enable the institutions concerned to get through the year and provide the level of services available in previous years.
It was obvious to everybody at that stage that the provisions being made by the Minister were inadequate and the fact that he is now bringing in this Supplementary Estimate for approximately £12 million proves we were absolutely right in what we said to him at that time. However, let us look at what has happened to the health services during the course of the year.
There have been dislocations and cutbacks, some services have been terminated and others run down, all because of this unreal economy by the Minister who endeavoured to push it through, presumably at the request of the Minister for Finance. It was obvious that the economies the Minister was attempting to impose on the various institutions would not succeed and they have not succeeded. The Minister has now to come along and provide the money he should have in the original Estimate. In the meantime, the time and energy of the health board executives and the hospital managements have been taken up with trying to do the impossible, trying to meet the stringent economies laid down by the Minister and at the same time carry on some level of service.
On the 30th March last we were discussing the Health Contributions (Amendment) Bill, 1976 and as we came to the end of the Second Stage discussion I asked the Minister very specific questions. I want to quote from the Official Report, Volume 289, No. 4, column 522 of the 30th March, 1976:
Mr. Haughey: Before we take a decision on Second Stage I want to know from the Minister are the allocations made to the different Health Boards final and can they be increased under any circumstances.
Mr. Corish: They are final.
Mr. Haughey: Will they not be increased under any circumstances?
Mr. Corish: They are final.
On the 30th March, 1976 the Minister for Health indicated to the House clearly and categorically that those allocations would not be increased under any circumstances, that they were final and conclusive. The unfortunate executives of health boards, the management of the hospitals and all the people throughout the health services at the different levels took that statement by the Minister at its face value. They took his word and they proceeded to cause disruption and chaos throughout the administration of the health services.
I want to go a little further and point out that at that time of the year also during the course of the same debate on the Health Contributions (Amendment) Bill on the 24th March, Volume 289, No. 2, columns 270 and 271 of the Official Report I said:
It is very difficult for anyone outside the official establishment to quantify what additional amount is required to finance our health services this year. From my own limited knowledge and using whatever information I can assemble, I believe that the regional health boards between them would require an extra £8 million this year if they are to maintain their services at a satisfactory and adequate level.
Mr. Corish: Each health board.
Mr. Haughey: No, between them. That is the calculation I made to the best of my ability. I have taken them all together and put particular emphasis on the Eastern Health Board and have looked at the others and the difference between their budgets and what has been allocated to them. I believe that the eight regional health boards between them would require an extra £8 million this year to provide adequate health services at the same level as existed during 1975.
I believe that another £7 million to £8 million would be required for the voluntary hospitals and the general medical services payments board. This means that in the region of £15 million would be required in the Estimate for the Department of Health to enable our health services to get through this year without serious disruption....
I went on to say that it was difficult for somebody in my position to try to calculate exactly what the short-fall was but I gave that £15 million as my best estimate. I further said:
I suggest that the Minister should try to get it across to the Government, where the ultimate decision in these matters lies, that that additional money must be provided by the Exchequer. I also want to make it clear that it is not my responsibility to propose how those funds should be provided as I have not the details of budgetary policy and the different demands and pressures which would enable me to decide where that £15 million is to come from. That is the responsibility of the Government.
I want to submit that what I said at that time was as near to being accurate as it could possibly be. We now have the Minister coming before us looking for an extra £12 million approximately. I said in March that he should have added an extra £15 million. I submit that the case I made at that time has been fully borne out by events. If the Minister were to put the matter on a proper footing at this stage, he would probably make this Supplementary Estimate £15 million as I stipulated at that time.
The Minister, in any event, is now looking for an extra £12 million. Why did he put the general public, the health boards and all the people concerned to all this agony? Why did he subject them to all this disruption throughout 1976 when everybody knew that sooner or later he would have to come along and make this money available. It is a classic example of bad administration and a short-sighted approach to this crucially important aspect of Government administration.
There is a further thing about this that we must take account of. Will anybody ever again take the Minister for Health seriously when he comes along with a particular Estimate, puts it before the House, the institutions and the agencies and says: "That is the allocation for this year"? He has done a very serious, far-reaching dis-service to the administration of the health services by the way he has carried on this year. He came before the House and said: "This is the allocation. It is final. Under no circumstances will anybody get any more money." It could not have been more categoric. Under tremendous pressure from this side and his own side of the House and from all round the country he stood fast and said: "Under no circumstances will there be an extra penny granted. You have got to live within these allocations." We now find that was all bluff, that it was some sort of exercise he was going through. He is now making the money available in spite of those categoric statements he made.
I am not interested in exposing that particular piece of deceit by the Minister but I am concerned about the lasting impression this conduct will have on the situation in future years. When the Minister for Health comes to the Department and the Dáil and puts forward an Estimate and says: "That is final, that is it for the year" nobody will believe him. The health boards will say that it is only an exercise and he has to go through this formality because the Minister for Finance is slashing all the Estimates. They will tell people not to worry, to carry on as they are, to spend whatever they feel like spending, that the Minister will bring in a Supplementary Estimate at the end of the year and that everything will be all right. That is a very unsatisfactory and unhappy situation to which the Minister is now committing us. I suggest that by his behaviour in this regard this year he has seriously undermined the credibility and the future of the departmental Estimates process. The different bodies, the different institutions, the different individuals concerned in future will not take seriously the Estimates as put forward by the Minister for Health.
The Minister did not comment in detail—in fact he hardly commented at all—on what happened to the health services during 1976. We all know what happened. We know 1976 was a bad year for our health services. It was a year of confusion, a year of dislocation, a year of deterioration. I do not think any sensible objective commentator could suggest there has not been a deterioration in the health services in every area during 1976. A number of very important and very valuable services which were being brought along and built up over the past four, five or six years were suddenly set back, terminated or reduced in scope.
It is not enough to say there was no development during 1976. There certainly was no development, no improvement, no expansion in our health services. More than that, because of the Minister's approach to the financing of the health service there has been a serious deterioration in many areas. I would have thought the Minister, in introducing this Supplementary Estimate, would have commented in some way on how things developed during the course of the year. Every Deputy knows the damage done in particular areas. I suppose the hardest hit area was the area of community services. The very valuable progress which was being made in the building up of these services received a very traumatic set back.
Anybody engaged in social work knows the extent of the damage done. Meals on wheels, home help and a whole variety of these essential basic community services were seriously interfered with, cut down and emaciated. Quite a considerable amount of hardship was caused throughout the community as a result. On a number of occasions we have discussed in this House the question of the school inspection scheme. There again very serious disruption has been caused and very serious cutbacks inflicted by the Minister's Department.
It would be impossible to over-emphasise the importance of that scheme. Admittedly some of our medical men in the House argue cogently that they would prefer to see all the inspection and examination which need to be done, done before the child goes to school. I suppose in an ideal society that is the way we would like things to be, that we should not have to wait until our children are at school before having this inspection carried out and having whatever defects or ailments exist identified. Whatever about that counsel of perfection, it is certainly essential at this stage that the school inspection scheme should be fully, completely and comprehensively administered every year.
Apart from the health of the community and the happiness and welfare of the individuals concerned, it is good economics to detect ailments and defects at that stage so that the necessary corrective treatment can be applied. Ultimately this must redound to the health of the community and to reducing the cost of the health services to that extent in the future. That is one area in particular which has been seriously affected by the approach of the Minister to the financing of the health services this year. Everybody connected with the services knows there has been a deterioration in the administration of that scheme. I suppose at this stage all one can do is urge that in the Estimate for the coming year the matter will be put right. As I say, it is not just good welfare policy but also good sound national economics.
The dental service is another area related to schools where the situation is appalling. Every Deputy knows how bad things are and how long the waiting lists are. It is an inadequate skeleton service at this point. Whatever attempts were being made to improve matters down through the years were suddenly rudely set back this year and the situation is now worse than it ever was. The same applies to ophthalmology. I understand the waiting period for glasses for those who need them has lengthened very considerably, up to three months now and over three months in some cases.
Another very false economy was the cutting out by many of the health boards of the transport service provided for patients who have to get to hospitals or clinics. Again, every Deputy has first-hand knowledge of the hardship this caused throughout the community. As we always do at these times, we heard a lot of scare-mongering stories about waste and inefficiency in the administration of this transport service. There will always be some element of waste and inefficiency in the administration of any public service. The brutal approach by the health boards, at the instigation of the Minister, to this transport service caused untold unnecessary hardship in those areas of our community where it should not be caused, and where we should go to any length to avoid causing hardship.
Sometimes it is difficult not to become cynical about this sort of thing. One has the Parliamentary Secretary to the Minister for Social Welfare, Deputy Cluskey, coming in here lecturing us, talking of schemes to combat poverty, going through a whole rigmarole of pilot schemes to root out poverty and combat it. Does this not all become a bit sickening when, on the other hand, we see the same person doing these sort of things to basic, humanitarian community services? A mentally handicapped child living in a Dublin suburb or in a remote rural area is being deprived of transport to the clinic or hospital to receive the attention he needs. What is the point in talking hypocritically about combating poverty when we have this sort of thing? Before we start on any textbook, pipedream type of activities, let us deal with the simple services we have available to the community. Let us make the necessary finance available to ensure that they operate with a reasonable degree of efficiency and comprehensiveness.
It is very difficult to understand why the Minister for Health permitted himself to be walked into this type of situation this year. I do not know who is at fault. It is not fair to blame the Minister for Finance for everything; he has his job to do and is subject to various budgetary pressures. Naturally he endeavours to keep all the departmental Estimates as low as possible. But the Minister for Health should not have accepted this situation. As we asked, he should have indicated to the Minister for Finance that this would not work, that this extra money was needed. In my amateurish, outside way, with no access to any figures, I see that what was estimated at £15 million has turned out to be £12 million. He should have told the Minister for Finance he would have to get the money at some point during the year. He did not and he must be held culpable for that.
I should like to avail of this discussion to mention one or two matters of pressing importance in the present administration of the health services. Admittedly these are difficult times from the point of view of financing all of our public services. Because of the serious mismanage-of our finances over the past four years the Government now find themselves in a position in which it is difficult to obtain the necessary resources for the most essential services amongst which, of course, health would rank as a top priority. Nonetheless I want to draw the attention of the Minister to some matters which should be under consideration at present. Not all of them involve additional finance. One I want to mention does—it is the question of the EMI scanner. This matter was raised here on a number of occasions.
I want to ask the Minister, or his Parliamentary Secretary, to give very serious consideration to the situation which has arisen in regard to the provision of a scanner. Everybody engaged in medicine and the administration of the health services is convinced that we must have at least one, and possibly two, of these magnificent new machines and that they would result ultimately in very considerable savings. I do not think a decision in ths regard can be postponed much longer.
Perhaps I might be allowed to make one remark in that respect. The Minister, or the Parliamentary Secretary, never said that they would not be prepared to make money available for the purchase of this scanner.
Did they ever say that they would make it available?
Yes, one. The hospital authorities came up with some proposition, not for buying four, but for one at £250,000.
I fully agree that it is a situation that must be dealt with by the Minister. We cannot have everybody in the country who wants an EMI scanner going off and buying one. That would be ridiculous. These are very valuable pieces of equipment and relatively expensive. Certainly the situation must be assessed in the national interest and whatever number we are going to buy, one, two, three or whatever they must be strategically placed so that we can reap the best possible advantage. If the Minister is prepared to make the money available—and it comes as a pleasant surprise to me to hear from the Parliamentary Secretary that he is—the next step is for him to take this by the throat and insist on a rational approach to the provision of this equipment.
One of the major areas of neglect in our health services is that in regard to the mentally handicapped. Most people would agree that this has reached a crisis stage. I am not being party political in this regard but we simply have not made the necessary provision for the adult mentally handicapped. Some people might argue, perhaps with some justification, that we have done fairly well in regard to juvenile mentally handicapped persons. Certainly when a mentally handicapped person reaches the age of 18 we have not made the necessary provision on a national basis. Of course, this is bound up with our whole approach to the psychiatric services. In many instances what is happening now is that mentally handicapped patients are being placed in psychiatric institutions where they should not be. Certainly in the Eastern Health Board area there has been a lamentable deterioration in this regard during the year in the approach both to the mentally handicapped and psychiatric services.
Some progress was being made in the process of de-institutionalising both of those services. That is the way we must progress in the future. We must ensure that, to an increasing extent, the large central institution for psychiatric patients is dispensed with and that both the psychiatric patient and mentally handicapped person are placed out in the community in suitable circumstances. There can be no question of going too quickly in this sphere, no question of merely closing down institutions and putting patients out on the streets. That would be disastrous and totally unacceptable. But there is a right way of doing it. It is something on which we must make progress, providing amenities, facilities and accommodation in the community, getting a very high proportion of psychiatric patients and mentally handicapped people back into the community. That is the sensible way of proceeding in this area.
I mention this because there has been a serious degeneration in this whole area in 1976 as a result of the Minister's approach. Programmes and plans which were going satisfactorily have been held up and dislocated and in many cases the situation is much worse now coming to the end of 1976 than it was at the beginning of the year and now we are making money available which could have prevented all those things happening. What is happening about the consultancy services? What is this review body doing or is there any progress in that area?
Another matter which will become critical soon is the question of medical registration. There is no doubt that we need a new Act in this area. The requirements of the European Community have to be met. We have a new situation where there is freedom of movement by professional people throughout the countries of the Community. We have to face up to that and make appropriate provisions for it. I understand that it is accepted that we will have to have a new Act dealing with medical practice, registration of doctors and so on. I would like the Parliamentary Secretary to tell us something about that, the time scale involved and when we can expect this Act, and if he can, to give us some indication as to how comprehensive this new legislation is likely to be. Medical education is an area which has to be comprehensively re-examined and legislated for. Some rationality must be introduced into the situation, so that we will produce the right amount of doctors and not produce doctors for export.
Allied to that is the question of the recruitment into the nursing profession. Deputies are constantly approached in this area. The present situation is chaotic and something will have to be done to rationalise it. Every girl who wants to become a nurse has to apply to every possible institution in the hope that she will get into one of them eventually. Some procedure should be devised whereby the right number of suitable girls will be recruited and trained to man our services. While on that question I would press the Minister to sanction the arbitration award for clinical teachers and nurse tutors about which we all have been approached by the Irish Nurses Organisation. That is an injustice and the Minister should get on with sanctioning that arbitration award.
The national hospital building development programme which the Minister announced is another area in which there is a great deal of doubt and where there is a considerable lack of knowledge about what is happening or is going to happen. The general impression seems to be that nothing is happening, that the Minister just announced the programme and then left the whole situation in the air. I do not want to go deeply into this question at present but the aspect of planning must be mentioned. If capital money is not available for a hospital building programme we should at least get on with planning hospitals. The planning of a modern hospital is a long drawn out business. It takes a very great amount of time from the moment a decision is taken to build a hospital until the construction work can commence. At the moment we have very considerable underemployment of professional people in this field. Architects, engineers and other people in this category are finding it very difficult to carry on and get enough work to keep their offices going. Many are going abroad looking for work and they are undertaking work in other countries, particularly in the Middle East. Many of them I understand are providing services for the building of hospitals in other countries. In that situation I want to emphasise the importance that only Irish professional persons are employed in the hospital building programme. We have the competence, skills and knowledge to do any type of planning that is necessary in regard to hospital building. I want to make this point strongly. The Minister will be doing a good day's work if he gets on with the planning of these hospitals, because the spare capacity is there in the community. Engineers and architects could be put to work on this, so that when money becomes available we do not have to incur the delay of waiting for the plans. The plans will be there and it will only be a matter of taking them down.
That is happening.
I would like to have some evidence that it is happening. It is simply common sense that to the greatest extent possible planning should be proceeding in these areas, even if the actual starting of building and construction is not in sight at the moment. It is absurd in our present circumstances to go outside the country to bring in professional people to do this work, when we have people at home who can do it. It should be obvious to everybody that this is common sense. These are just a few points which seem to be of importance and I want to avail of this opportunity on this Supplementary Estimate to direct the attention of the Minister to them.
In conclusion, I should like to say again that the way in which the Government are dealing with the health services is very unsatisfactory. At the commencement of the year they introduced an Estimate and endeavoured to force it through. Its implications were imposed on everybody concerned so that there were restrictions, economies, cutbacks and the elimination of certain services. Then, at the end of the year, when it is too late, the Government decide to provide the money that everybody knew would have to be made available anyway. In the meantime all this dislocation has been caused. It is a bad day's work on the part of the Government and brings into disrepute the whole question of the financing of our health services. It will be very difficult in the future to get a rational and sensible approach to this question which is vitally important from the point of view of the whole area of public administration. In every modern community the cost of health services is increasing and there is a need, in our case in particular, to have some long-term national approach to the amount of the community's resources that are to be made available for the field of health. That would have been a difficult task in any event.
There was some suggstion that an all-party committee would be set up to consider this matter. I do not know what is the latest situation in that regard but if such a committee is set up, we shall be very glad to participate in it and to co-operate fully in regard to it. In any event, there is a need nationally for an approach to the whole question of the level of health services that are to be provided, to the question of the cost of these services and of how these costs are to be met. We must decide, too, what proportion of community resources are to be allocated in future to the health services. It will be difficult to put the whole situation rationally on a long-term basis but the behaviour of the Minister this year has made this task all the more difficult with the stop-go policy of saying at the beginning of the year "That is all you are getting; the Estimate is final" and then at the end of the year saying, "I did not really mean that and I am now making available the money that was needed".
We are agreeing to the Supplementary Estimate because we recognise the need for it. It is necessary to keep the services going to the end of the year and to that extent we facilitate the Minister in putting it through the House. All we can say about it at this stage is that the money should have been voted at the appropriate time, which was the beginning of the year so as to avoid the chaos and dislocation that have been caused.
I wish to avail of this opportunity to say that we consider the amount being voted in this Supplementary Estimate to be inadequate by far to service the needs of the hospitals. In introducing the Supplementary Estimate the Minister compared the figure this year of £253 million with an expenditure last year of £207 million and told us that the increased figure represents an increase of 22.4 per cent on last year's figure. This is not something about which the Minister should be proud. The Government are responsible for the huge increase in the cost of servicing hospitals. Apart from wages and salaries which this year have practically been held, one of the biggest factors in the increased costs relates to lighting and heating. The increase, too, in the price of petrol has meant very high delivery expenses and the hospitals need delivery services for laundry, food supplies and so on. For some time I have been maintaining that if the Government were to reduce the cost of fuel generally the cost of hospital services would decrease considerably. This week I visited the Hospitals' Joint Board establishment at Rathfarnham where laundry is undertaken on behalf of about 67 hospitals. I was impressed with the efficient manner in which the establishment is run and also with the very good staff relations that exist there. A very efficient job is carried out but the cost of transporting the laundry to and from the various hospitals is exorbitant.
The Government and in particular the Minister for Health seem to be out of touch completely with the reality of the whole situation in regard to the cost of living. Not so long ago I was talking to a doctor from a hospital who told me that at the hospital's board meeting those in attendance were informed that if they politicised the situation in any way or made any noises their place for priority might well be in jeopardy when funds would become available for equipment and so on. On the other hand, there are hospitals where members of boards boast of the vast savings that have been effected as a result of the cutbacks, implying that there had been a high degree of wastage.
That was so.
There will always be some wastage. Regardless of what savings may have been effected, there is a great shortage of money in all the hospitals. The position is such that when funds become available the log jam will be so great that it will take years before the medical services are really moving again.
Deputy Haughey spoke of the plight of handicapped adults because of the lack of facilities for them. He referred to the fact that younger people, mentally handicapped children, were better catered for, but the situation exists in which young children when they reach adulthood have nowhere to go from these institutions which are designed for young people. There are insufficient adult institutions with the result that many adults are being retained in institutions which are primarly for young people. This results in many young mentally handicapped children being unable to gain admission to these institutions and a backlog of applications is building up. I am sure the Parliamentary Secretary is well aware of the pressure to open up Bawnmore in Limerick so that the backlog can be reduced.
With the difficulties at present prevailing in the medical services we are very much aware that some great opportunities are being lost by health boards. In my own area, for example, the Eastern Health Board was offered an acre of land worth £40,000, free. A religious order offered this land and there is planning permission for building houses. This offer could not be taken up by the health board because the money was not available. It was to be used as a welfare home for elderly people. This is sad because it is very difficult to retain this land for a welfare home. When houses are built in an area people want any available space immediately used as an amenity area and it is hard to get them to realise that the land has been earmarked for a welfare home when funds become available. This home would have cost about £150,000. I think about five or six similar buildings are held up at present for lack of funds. Problems are not becoming any easier.
Although I have not yet had a direct complaint from a constituent, I have been told that in the case of the free drugs scheme which applied up to now for expenditure over £3 per month the figure is to be raised to £6. Could the Parliamentary Secretary say if this is correct?
Between £5 and £8. Anything over £8 is fully recouped.
As against £3 at present. When will the increase operate?
It is operating at present.
It must have only started because I have not got the feedback yet. There are and always will be abuses where free services are provided but the number of abuses is minimal in relation to the vast majority of people who really need these services. People may say that an increase from £3 per month to £8 per month is not very great in times of inflation, but the fact is that money values have deteriorated so much that increases in welfare benefits have not kept pace with inflation and people are constantly finding themselves worse off than they were previously. Most of those availing of what was virtually a free drug service will suffer a considerable set-back by this increase. They would be mainly elderly people with very small incomes. There are also very many younger people availing of the scheme but the vast majority are the elderly who also have to pay more for fuel and electricity, even if they have 100 units free, if living alone. They can see nothing but a bleak future ahead. I do not know where this will end.
I sometimes feel that consultants should from time to time be subject to the Prices Commission as regards fees. Only a week ago a constituent of mine who was beaten up went to a hospital and was treated in the accident department. The Garda wanted him to prosecute his attackers which he was willing to do but the Garda said he would need a medical report. He asked for this in the hospital and apparently they declined to give it to him. I spoke to the hospital secretary and he said a report would be sent out. In due course, the man concerned did get a report, not by the doctor who had examined him but by a consultant who composed a short letter on an ordinary quarto sheet running probably to 15 or 20 lines. The report stated what the doctor who had examined the man found. This was sent to the man involved with a bill for ten guineas. I think that is wrong—ten guineas for copying out a few lines of a report and sending it out. I know the cost of running a Rolls Royce is increasing daily and I have not very much sympathy with the owners, but this man had the cheek to send a bill for ten guineas for writing out a report that some houseman had prepared and which, in all likelihood, would not even be admissible because——
Is the Deputy suggesting that the consultant did not even examine the patient?
No, he did not examine the patient at all. He said in the letter that he had studied the report of the doctor who examined the person and that his findings were as stated. For that, he sent a bill for ten guineas. I told the man not to pay it under any circumstances. I think the public should be told that when they are faced with this kind of charge they should send it to the Department of Health who could deal with it in their own way, refer it to the Prices Commission for examination. I think this type of charge is immoral. It is absolutely wrong and I do not think any Minister or Parliamentary Secretary would stand over that.
I would not condone it.
This is what sometimes brings members of the medical profession into disrepute. There are members of the medical profession in my own family and I know how hard such people work and how much effort they put into every day. Most of them have a very short life-span. They are very prone to coronaries, and I do not begrudge them at all making a good living. However, where this kind of abuse does take place there is an obligation to stop it.
One of the services that has suffered recently in Dublin is the home help service because of cutbacks. Recently our local health board had a visit from one of the people who operates one of the home help services. They cannot pay the people to come to visit the homes because of the big cutback and the Eastern Health Board does not have the money. My attitude all along, and I have expressed it to the members of the Eastern Health Board, is that no-one should die for lack of treatment and if all the money allocated for this was spent the health board can go to the Minister and say "We have not got a red cent left. What are we going to do?" The Minister is the man with the responsibility and the Minister will just have to come up with the money.
I do not think this money that has been voted here today is adequate at all to meet the needs. No Members of this House knowing the short-fall of their own health boards will disagree when I say that.
One last point I would like to make is in relation to the treatment of disabled patients. I sometimes feel that if I were Minister for Health one thing I would like to do would be to call personally to every hospital in the country. I do not know how many hospitals there are in the country.
That is the dream of every Minister for Health.
Probably I will never achieve the situation of being Minister for Health and never will have the opportunity of visiting all those hospitals, so it will be a dream unfulfilled. Recently, a case came to my attention where a man who was physically disabled in a very bad way was impatient to get home because he was not too happy in his surroundings. He asked the doctor if he could go. The doctor said "You can go any time you want". At six o'clock in the evening the matron came along and said to him "Pack your things, you are going home now". It was a wintery evening, freezing cold. There was nobody living in his house; neighbours had to be called in to light a fire, air his bed and various things like that. I think it was a shocking thing. The doctor said "You can go any time you want, now or tomorrow" but this person was told at six o'clock on a very cold and wintery evening "out". The man is back in hospital again.
Another matter is the number of cases which are being taken against people for non-payment of bills. I know there are legal problems in my next suggestion but for people who are in the VHI scheme the hospital rather than the patient should be paid directly. We know there are people receiving the money and not paying the hospitals. If the VHI were to issue a letter or a form to their members to the effect that "I authorise VHI to pay the hospital on my behalf", I for one would be quite happy to sign it. People may be short of money. They have all sorts of problems. They come out of hospital, get a cheque for, perhaps, £200 or £300 and they think "I will use that for a few days or a week" or something like that. There are wealthy people who owe large sums of money to the hospitals. I have no sympathy for such people. There are others who are hard-up. People generally would accept, and it would be a worth-while exercise, if the VHI would use a form such as I have suggested.
One case recently was amusing and tragic—tragic in that a person was in a hospital because of his—to use that popular word—"nerves", a nervous disorder. He was let out of hospital and he had not paid the bill. He received a letter from one of those firms like Stubbs stating that if the money were not paid within seven days the matter would be put in a solicitor's hands. That man is back in that hospital again, a complete nervous wreck after that letter. The hospital——
Is desperate?
——will still not be paid. They have created another problem for themselves and another large charge. When hospitals put the collection of bills in the hands of bill collectors they should know whether the people they are billing are liable in the first instance. It is sometimes to relatives or in-laws who are liable so, therefore, the first thing they should do is find out the people personally liable. When a person who is not liable in law to pay a Bill gets a letter from a firm like Mercury House saying that if the matter is not settled within such and such a period he will be in the gazette and brought to court, if he comes to me directly and says that this money is owned because the in-law, nephew, niece or whoever it was is liable, I will make some arrangement to pay it, but when the hospital seeks this remedy they can go and whistle for the money. It is very important when they give these cases to these debt collectors that they are aware of the background of the case and whether or not the people are in law liable. If the person's financial circumstances are such as not to allow payment of the lump sum they should be able to say to him: "Will you make a monthly payment to us, so much a month?" At least the hospitals will be getting something, whereas the other way they get nothing.
These are ways and means, I know the hospitals in their desperation for money resort to this. There are cases where I would advise them to put the matter in the hands of debt collectors because the people concerned are obviously wealthy and known to be, and I would have no reluctance at all about bringing these people to court. In fact, I would not even bother to warn them. I would simply bring them to court. If a few possibly well-known names were published in the newspapers perhaps these bills would be paid a bit more speedily. We all know that if any of our family go into hospital we would sell the very houses that we live in so that they would recover health. You do not very often hear of undertakers, for example, taking their clients to court because people do not argue the price and they pay most times there and then. In the country it may be different but in the city they all know one another and that there is that call in relation to that aspect—I was going to say of life but I say—of death.
The Minister should make funds available for certain pieces of equipment. I am a member of the board of a certain hospital and some equipment is required. It is a children's hospital and one always feels more emotional about young children. Even a young adult of 20 years has had 20 years of life but a new-born infant may be dependent totally on up-to-date intensive care. I think most adults would be prepared to make sacrifices so that proper equipment might be available for those young children. The hospital I am referring to is the children's hospital in Crumlin which is an excellent one.
I agree absolutely.
There is a marvellous, dedicated staff there but I know that the intensive care unit could be improved. I am picking my words very carefully and I am making a special appeal to the Press who may be noting this that this part of my speech should not be reported. People may get alarmed if they read that an intensive care unit in a children's hospital is not all it should be. It is bad enough to have a child in hospital but it could be sheer hell to a parent who thought the facilities were not what they should be. I have spoken to the Minister about this matter in the past but nothing has been done. I appeal to him to ensure that this matter is rectified. Last year the amount of money involved was in the region of £46,000 and this is a very small sum in relation to the figure of £254 million for this year. I would ask that the matter I mentioned be given top priority. Let us ensure that children have a 100 per cent chance of life. A rate of 99.9 per cent is good but I should like the extra percentage, even at the expense of other matters if that is necessary.
I hope there will be an improvement in the new year. I should like to pay tribute to the hospitals who have worked so hard to keep down their costs. I can understand the pressures the Minister is under from the various hospitals for the much-needed equipment, for the scanner which Deputy Haughey mentioned and for various other pieces of modern machinery. All of us want to see these items of equipment made available. Perhaps the Minister would consider as the policy of his Department having an A.1 list which would cater for the care of children. We should not stint on that item.
At the beginning of his speech the Minister stated that his aim was to maintain the 1975 service levels. He thinks this Supplementary Estimate will enable that objective to be met substantially. Later on in his speech he stated:
We have not, of course, been able to expand our health services as we would have wished in more favourable circumstances, but we have been able to maintain service levels substantially in line with my stated objective.
At the end of his statement the Minister said:
...I am pleased that we have been able to carry our health services intact and undamaged through what has been a year of profound crisis for our society in general.
Does the Minister really believe that?
Does the Deputy?
No. What has happened has been atrocious. There have been enormous cutbacks and even making money available at this stage cannot undo the pain, hardship and damage caused to sick people and those in need of physiotherapy, chiropody and so on. Can this money now help the needy children for whom milk supplies were cut? Can the damage caused be undone with this money now?
I do not think the Minister can honestly say that services have been maintained at the previous level. I know of cases where the provision of physiotherapy services were curtailed severely and the same applies to chiropody services. People suffered mental anguish because of the cutbacks. Even the money now available will not undo the damage caused. It will not restore the confidence and morale of those in need.
Perhaps the Parliamentary Secretary would like to comment on the number of people awaiting various aids and treatment provided by the health boards. On 17th November, 1976 I asked the Minister for Health a question concerning health aids and I received a tabular statement in reply. From that statement it appeared that in the Eastern Health Board area the number of children awaiting dental treatment on 1st November, 1976, was 6,996; the number of adults was 6,757 and the number of adults awaiting dentures was 1,458. That is a very bad record. In the Western Health Board area the number of children awaiting dental treatment was 13,739. Yet, the Minister has told us that we have come through a year with health services intact and undamaged.
It is obvious that the waiting lists have grown enormously. This applies to those people requiring spectacles or ophthalmic treatment. If after a school medical examination a parent receives word that a child must be referred for some form of ophthalmic treatment or further examination, naturally that parent will expect that the treatment will be available within a short period. The parent is quite entitled to expect this service. I hope the Minister in his reply will indicate if the waiting lists have extended enormously. Have more people been added to them or is the delay occasioned by the cutback in services? I cannot understand how the Minister maintains that service levels have been maintained substantially in line with the stated objectives.
Thirty-six per cent of the people now have medical cards.
Yes, but we must look at the number of unemployed, the number of extra students and the young boys who have no income.
The Deputy should deal with the Supplementary Estimate.
I will deal with the GMS. I anticipated that the eight CEOs would have come up with a review for the GMS and increased the guidelines around last August but this review has not yet been completed. The cost of living is still increasing. My post is full of letters from people whose medical cards have been withdrawn. My clinics are also visited by such people. The Parliamentary Secretary is correct when he speaks about the number of people with medical cards but we must examine the basis for this. It is because of increased numbers of people unemployed, adverse economic circumstances, and young people especially who are entitled to medical cards because they have no work. This means that other people who anticipated continuation of those medical cards have been cut off. The people who are there to administer the health services and whose minds should be focussed on health and what is good for the people have instead been focussing their minds entirely on finance.
The Eastern Health Board especially have been used to borrow money for the Government. The Government were not in a position to borrow it themselves so they used the health boards to obtain overdraft accommodation. On the 2nd September, 1976 the Eastern Health Board consented to the temporary borrowing by way of overdraft up to an overall limit of £7.5 million during the quarter ended 31st December, 1976. Why are they borrowing that money? They are doing it because the money is not coming through from the Department of Health.
I know that the Supplementary Estimate does not deal with capital allocation. Let us look at the number of units throughout the country that have been built out of money provided in capital allocations during the last few years which are now lying empty because the staff cannot be provided to man them. There are still difficulties in relation to the limited eligibility scheme. People make annual contributions to the Revenue Commissioners. They receive back a receipt for this and they consider that this entitles them to some form of service during the period of time for which they have paid. If those people become ill and have to go into hospital, they are presented with bills afterwards and told that when the review of their income took place they were deemed to be over the figure. The Revenue Commissioners then refund that year's subscription. Why can an acknowledgement of such a payment not be valid for the 12 months immediately following the date of the demand? Why can the person not be eligible for those 12 months? Is it possible that there are people still making those annual payments but not finding out until they are hospitalised and their circumstances are examined that they are ineligible? I hope when the Parliamentary Secretary to the Minister for Health speaks he will deal with that point. Could things not be arranged so that cover will extend for 12 months after a payment is made to the Revenue Commissioners?
My information is that prima facie that is true.
Prima facie that is true but it needs a lot of tightening up. I spoke about this previously when we dealt with the eligibility clause. I hope the Parliamentary Secretary will tidy this up because it is causing a lot of anguish to people. There are many magazine articles and radio programmes at the moment which deal with depression and people feeling low. Many people because of this go around feeling they ought to feel low. I hope the Health Education Bureau, which has been doing very good work, will take cognisance of this and try to stop it. There is so much about this depression and feeling low that people are coming around to believe that they ought to feel that way. I would like to see the Health Education Bureau taking a positive stand about this and come up with a campaign for better health and more involvement. This would make people feel better and want to be involved in things. This goes back to the adage that prevention is much cheaper than cure.
I believe we are having too much centralisation. The idea of setting up directors of community care and health services in various counties is an excellent idea but I do not know if those people have any powers. They should have more say in the administration of the GMS card system because they are in close contact with people. I regret to see the introduction of computers in this area in the city. I find that when people in Wicklow apply the matter goes to Dublin and weeks elapse before a reply comes back. Could this matter not be put under the aegis of the director of community care for the county? He could deal with the things more effectively because he would have a better knowledge of the matter in his county.
The money provided in the Supplementary Estimate is very welcome but it is a pity that the advice of our spokesman on health, Deputy Haughey, was not taken. This would have avoided a lot of the cutbacks and the hardship involved. We cannot undo the damage that has been done by services that were required and have not been rendered in physiotherapy and chiropody but we also have interest charges which will now have to be paid. It is important to consider what some health boards are paying out in bank charges and interest charges on money borrowed. Many health boards, when they look at a programme on community care or a capital programme say: "If only we did not have to pay those huge sums and if only some money came through in time we could have embarked on those programmes". Why is it that money voted for medicine must go to pay interest charges? I still maintain the Minister is not correct in saying we have been able to carry our health services intact and undamaged. Too much money voted for health is now going to pay off interest charges.
I sincerely regret that the original estimates of the health boards were not accepted and payments made based on those estimates. It now appears that the health boards will require a little more than they thought, and the estimates of the Department for Health were much too low. Money has gone astray and the services have been cut back seriously.
The Minister said he wanted to maintain the 1975 health service levels. He also said he believed the Supplementary Estimate would enable that objective to be substantially met. I am glad he used the word "substantially" because, even with a Supplementary Estimate for £11 million or more, the 1975 levels will not be met. We all agree on that. He also said it was only later in the year he became aware that certain institutions and certain health services could not carry on until the end of the year. In fact, these points were put to him six, seven or eight months ago and he refused to listen.
The Supplementary Estimate covers various allowances and increases granted by one Department or another for social welfare pensions and welfare allowances, and the national wage agreement. It does not add ½p to the general administration of the actual health services. Directions were given to the health boards at the beginning of the year to exercise economy and all the health boards did that. The only areas in which they could effect economies in the eight health board areas were, by and large, by cutting out transport facilities such as the hiring of taxis and hackney cars and the use of private operators to bring patients to and from clinics and hospitals. These were replaced by the use of health board ambulances, very costly items of equipment. Usually those ambulances were replaced every three years on average. Now, because of their extra use as a result of the non-employment of private operators they will have to be replaced more frequently, thereby effecting no economy or saving and just putting off the day of reckoning.
Another major item which was cut back in the health services was the purchase of supplies. Stocks have been reduced in every health board area. This shows we are only fooling ourselves by thinking the health services can be operated within a particular financial allocation. In each health board area, in every hospital and institution stocks are lower now than ever before. In certain circumstances the necessary stocks and supplies for the treatment of patients are not available, or are not as freely available as they were in the past.
The Minister said that substantially the levels of the 1975 service had been maintained. This is not the case. Because of the financial restraints imposed on the health boards, members of staffs could not be replaced when they retired, or were on holidays, or on sick leave. This caused a substantial increase in the waiting lists for almost every kind of treatment throughout the health services. That is another example of a major cutback and another decision by the Minister to put off the day of reckoning. This caused hardship to many people. People who should have been treated for various ailments during the course of the year will have to wait until next year, or perhaps, the year after, because of the non-availability of the additional staff required to treat them.
The Minister said:
I am pleased that we have been able to carry our health services intact and undamaged through what has been a year of profound crisis for our society in general.
I question that statement, bearing in mind the points I have made. There is no doubt confidence in our health services has been damaged enormously by the attitude adopted by the Minister and the Government to the finances required to run what were very efficient and effective, improving and expanding services. People have lost confidence in the ability of the Department to provide the necessary funds. This is a tragedy.
People at large were just becoming used to the changeover in the administration of the health services from the county councils to the health boards. Then the axe was dropped and the moneys were cut off. Now there is a general feeling throughout the country that the administration of the health services should revert to the county councils. A short while ago, Deputy Coughlan asked the Minister to abolish the only real contact between the man in the street and the administration of the health services through the health boards, the local advisory committees. Surely it is not the thinking of the Labour Party that the say the local advisory committees have in relation to the administration of the services should be eliminated? That would be a retrograde step.
The amount of money sought in the Supplementary Estimate is supposed to maintain the health services at the 1975 levels, which it will not. Not only do people on this side of the House realise that, but it is evident from the contributions from the far side that they realise it too. The Minister spoke. He had no Member of the Fine Gael Party or the Labour Party to back him up because they know he is not telling the truth when he states that the 1975 levels will be maintained even with the additional resources. We all know that is not the case. We all know the cutbacks will have to be compensated for next year in relation to the provision of transport, the purchase of supplies and, we hope, a reduction in the waiting list for treatment of patients in various levels of the services.
The Minister for Health and Deputy Haughey made the very relevant point as long ago as 30th March last, when Deputy Haughey put forward the view, that approximately £15 million would set the situation aright and, at the very least, maintain the 1975 service levels. That remains correct today but the Minister finds that he is £4 million or £5 million short.
The Minister said today that it was towards the end of the year he detected some limited areas of health services requiring additional resources to enable his policy to be maintained. It is sad that we have to admit that the Minister found this out only towards the end of the year while, as far back as March last, Deputy Haughey was able to tell him that £15 million would be required. How right he was. The many cutbacks implemented are causing hardship in many areas and, in the long term, will do nothing to reduce the cost of administration of the health services.
I hope the Minister will learn from experience and the mistakes he has made in the allocation of funds this year and, hopefully, restore the confidence in the administration of the health services which obtained prior to the hardship imposed by him this year.
Like other speakers, frankly I am disappointed with the Minister's speech on this Supplementary Estimate. I am disappointed in it under a number of headings. No matter what the Minister may say to the contrary, earlier in the year he was aware that whilst he was bringing an Estimate before this House health boards were engaged in dumping large slices of their programmes overboard. This leads me to believe that, far from the tidy administration the Minister would claim to have accomplished, the administration was second-rate, as were the calculations and, in general, fell far short of the targets he presented in this House. I doubt if it is fair to come to the House at the eleventh hour and present a Supplementary Estimate for £11,500,000 to complete the year's work. Those of us who have any interest in health know that the services have suffered during the year, not merely the general medical services part of the scheme but the hospital end also. No matter what the Minister may maintain we contend that the services have fallen short of what we expected under many headings.
Even allowing for the fact that these are stringent times, that money is tight and inflation has run away with the estimates proposed earlier in the year, the Minister or the Government have made no attempt to put a bridle on this runaway horse. It is a runaway horse; it is still galloping.
Not merely in regard to health but in respect of other matters such as social welfare, statements were made here by various members of the Government to the effect that certain things were happening in the economy. Whilst such speeches were made no attempt was made to back them up. Therefore, it may be said that all the shots were falling short of the target, in the sense that no realistic stand was taken to stop this galloping horse of inflation. As recently as this morning it was announced on the radio that Italy led in the European context with the greatest increase in inflation and that we were tight on their heels. Now Italy is a large country; it takes up a large slice of the map. If one compares it with our economy and the size of our country one will soon see that we will find it much more difficult to stop the horse at this stage than will the Italians.
Therefore we may take it that the money being voted in the House today to enable the Minister for Health to complete his year's work will again fall short of what would be necessary for the targets we set earlier, which were a more comprehensive, coordinated, better general medical services scheme together with a better hospitalisation scheme. Let us leave out hospitalisation altogether for the moment. Going through the Minister's speech one finds little hope that the position will be any better, in the year ahead.
Who is putting the reins on the galloping horse?
As far as I can see, nobody. That is the most regrettable part of it. The galloping horse has reached a stage now where he has thrown off the saddle. There is nobody in the saddle. If there was somebody in the saddle putting a rein on the galloping horse those of us interested in health and indeed in other spheres could hold out some hope. Regrettably that is not the case. I am merely repeating some points made last year by some members of the Government warning of the danger signals. Here is a dangerous signal on the floor of the House. We had warning of it as far back as last spring when the health boards, perforce, dumped large slices of their programmes overboard.
Neither I nor any other Deputy— not even the spokesman on Health who always tries to be helpful rather than harmful—wants to injure the health services, the estimates, calculations or administration. But what is one to think when the Minister comes into this House with the weakest statement I have ever heard presented here, containing no hope of a betterment of the services, of even a reorganisation or reorientation of them to meet present pressing needs?
The real expenditure for this year apparently will be £254 million according to the statement. This is roughly about £47 million up on expenditure last year. This is only calculated to keep pace with conditions in 1975 so that we are on the losing end everywhere. If we continue on this trend our conditions in medical matters will worsen. Is it not time that some realistic thinking was done at Government level in order to stop this trend and bring it under control? I am not a prophet nor do I pretend to be one but if this is not done the position will be a good deal worse when the next Estimate comes before the House.
The Minister informed the House that non-capital expenditure increased faster than inflation. The Minister did not attempt to justify that, he did not refer back to it or say what he would do about it. All that that conveys to me is that we had a rapid rate of inflation affecting our monetary system and we had an even more advanced rate affecting our health system. When the Minister comes looking for money he should tell this House what he proposes to do about this matter. It is no wonder, if non-capital expenditure is increasing at a greater rate than the rate of inflation that we have Supplementary Estimates of this size. It is not realistic and it does not denote any sound thinking in regard to health. Health is the one Department which requires a sound system of calculation based on realities in order to lead the personnel of the Health Department, which is a labour intensified unit. The display in this direction is very poor.
I will not harp on this fact throughout my speech. One would love to be able to dwell on other aspects of the Health Estimate. It is apparent that if this trend of current expenditure for the GMS part of the scheme continues to increase at its present rate this sort of expenditure will probably have doubled by this time 12 months. Is this any way to give confidence to the people who are working in health or to the poor patients who are ever present for treatment in and out of hospital? No attempt was made to calculate the cost in order to ensure that the various health boards would be in a position at the beginning of the year to budget for a sum which would take them through to the end of the year.
Those of us who are in public life know of the long waiting lists at present for entry to some hospitals. We know of patients having to wait 12 months and in some cases 18 months before they are able to enter hospitals even for elective surgery. How much worse is it in the case of patients who may be on the waiting list for high surgery? How is it that doctors continue to send maternity cases to hospitals if beds are that scarce? If bed accommodation is so poor as to indicate that there is a waiting list of the length I have just described, how is it that the doctors are passing the maternity homes and sending maternity patients to hospitals to take up beds which could otherwise be available for surgical cases? How is it that they are permitted to do so if we are in a period of such stringency? Their answer to that is the old one that the hospital is a safer place. We invested a good deal of money in nursing homes in the past in the hope of having a competent maternity scheme and we now find quite a high number of nursing homes with under-used beds. I would like the Minister to say whether or not there is a scarcity of beds in surgical hospitals and how is it that a patient in need of surgical treatment finds it so hard to enter one of these hospitals.
I agree with the Deputy, but my reply to that on behalf of the Minister is that the question should be addressed to the IMA.
I would not wish to argue with the Parliamentary Secretary. He and I are very good friends. We have invested a good deal of money in building up good nursing homes and I suggest to the Minister that he take steps to regularise the position. This would have the result of relieving our hospitals of much pressure.
There are many other factors to which one could refer but one in particular which I should like to mention relates to the situation whereby there is a reluctance on the part of our young doctors to work at home. It is difficult to understand this since the rates of remuneration here are better than those which apply across the water. The health boards have much difficulty in recruiting young doctors. If it were not for the fact that we have quite a number of doctors who are public spirited enough to be prepared to work longer hours than normal, the health boards would have great difficulty in continuing to operate. Not only are the rates of remuneration here good when compared with other places but the conditions, too, are relatively better in terms of housing and so on.
Medical students should be given to understand that they can gain experience at home without going away. It is regrettable that after all the money spent on them in their own country they give the benefit of their training to other countries. In some cases the experience they can gain at home is superior to any they might gain in other places. I know of good provincial towns in which a young doctor could have up to 2,000 patients on his panel if he were prepared to put up a plate. It is understandable to some extent that young doctors would wish to gain experience in other countries but every effort should be made to ensure that they stay at home for at least some time. They should have some regard for the country of their birth and in which they received their education. I expect that about 40 per cent of our health services are manned by doctors in the upper age groups. We want these people in our services but we need also the younger men.
I have been endeavouring to put across this point of view for a long time but, apparently, without success. It will be very important during the next ten or 12 years to have a much larger portion of young doctors in the service at home, not merely as general practitioners but engaged also in other branches of medicine. Otherwise the system in the eighties will fall far short of what was visualised for those years when the Health Act was being discussed in 1970. It will be too bad if this trend is allowed continue. Regardless of how hard times may be, we should endeavour to make good use of the circumstances but we will not be successful if we continue with the methods that have been adopted so far.
Other Deputies have commented, too, on the GMS side of the scheme but if one leaves that question aside for the moment and turns to the area of greatest expenditure—hospitalisation—the future looks fairly bleak.
