Léim ar aghaidh chuig an bpríomhábhar

Seanad Éireann díospóireacht -
Thursday, 15 Jan 1970

Vol. 67 No. 10

Health Bill, 1969: Second Stage (Resumed).

Question again proposed: "That the Bill be now read a Second Time".

I hope to set a good example by being rather brief. A great deal of detail can be gone into during Committee Stage. At the outset I wish to congratulate the Minister on the work he has put into the Department of Health since taking over and on the very patient and cooperative approach he has adopted to this very important reorganisation of our health services. My only hope and wish is that he will be left in the Department to see this through—that there will not be any other calls on his services from another Department.

We have been impressed by the way the Minister has quieted down the turmoil that has surrounded health in this country for many years. He has cleared up many of the misunderstandings and misapprehensions that were prevalent in former years. The general tone in this debate so far, and the general feeling abroad, is that the Minister can be assured of the cooperation of all in his efforts to make a success of this reorganisation.

Health is something that touches all of us very intimately. We all share the concern to make available the best facilities possible to all, but we must equally be realistic and appreciate that this costs a great deal of money. We have got to face up to financing: we must all the time be conscious of the fact that we cannot provide as much as we should like to because of considerations of finance and shortage of skilled personnel. We can always go on improving and having our goal continually set for the future.

Regionalisation is certainly overdue because no longer can administration on a county basis serve our needs. Therefore, the division of the country into eight regions would seem to be a fair arrangement and there should not be any real geographical difficulties. However, it is a very big undertaking and the amount of money involved at present, between contributions by the Central Fund, by rates, by voluntary bodies and so on, must be somewhere in the region of £100 million a year. Consequently, the administration of this is a major undertaking and I welcome the initiative of the Minister in this Bill in selecting the chief executive officers for those regions even before the setting up of the regions concerned and, if necessary, sending these CEOs away for training.

That, of course, is as it should be because hospital administration has become very specialised. Especially in the United States, there are many excellent courses available that profitably could be taken by future administrators here. On this matter, however, I suggest that the Minister does not go far enough. I do not think it is sufficient to pick merely the No. 1 man in each area. The second line are even more important still because they in their way carry much greater specialisation than the CEOs in the different areas, whether it be responsibility for engineering or the other main subdivisions of the health boards. I would suggest, then, that the Minister should adopt a very flexible approach to this.

It may not be possible or even desirable to pre-empt these posts below CEO level but certainly training grants should be made available on a very substantial scale to suitably selected persons who are anxious to train themselves for consideration for these posts. Young graduates of two to five years standing might be interested in taking up a career in hospital administration. Provision should be made now to give them the necessary scholarships to enable them to go to, say, the United States of America, to England or elsewhere in order to get the necessary training. Then they would be suitable for consideration for these posts.

On a lower level still, the Minister would do well to approach the university authorities about the provision of graduate diploma courses in hospital administration. In future, hospital administration will be quite different from what it has been in the past. Hospital administration will draw much more heavily on the skills of management, operations research, and all the rest. It will become increasingly involved with the computer. It is desirable, therefore, that there should be the necessary training background. It is a type of training for which a diploma could be provided. It probably would take two years for graduates from various streams, the commerce stream, the engineering stream, to gain the diploma. Some qualified medicals might wish to take the diploma. The need for the diploma exists. The Minister might consult the Higher Education Authority in regard to the provision of the diploma or, alternatively, he might make direct approach to some of the university centres with a view to establishing the diploma.

Unfortunately, in the past, a great deal of hospital administration has been bedevilled by a clash between the professionals and the non-professional administrators. Only three days ago I was speaking to a resident medical superintendent of a large hospital. I was shocked by the picture he painted of the idea of administration possessed by some of those in high positions in the health authority. Apparently they had no hesitation in going right through his line of authority and contacting people in his hospital in any way they wished without his knowledge or without going through him. In modern administration that should not happen. He had often heard secondhand about happenings in the hospital in connection with appointments. He had heard about them from others before he was officially communicated with. Therefore, I would ask the Minister to clear the channels of communication in his investigations into proper administration.

We must look to the future. With increased opportunity for university education these administrative posts will be filled by persons who have a basic university degree. Otherwise, why are we encouraging university education on the scale on which it is being encouraged? The graduate has a very distinct contribution to make, especially in dealing with professional people and, above all, in dealing with the medical profession. Very often there is a great deal of misunderstanding in communications. If the Minister could persuade persons with medical education and with a talent for administration to go to the States and to take a two year course in hospital administration he would have the ideal type of CEO for these health districts.

On the question of specialisation, the Minister has mentioned the scarcities involved and the necessity to conserve specialists. I fully agree with conservation and with the proposal made by the Minister. I would, however, suggest that in the recruitment of specialists we have been a little too orthodox in our approach in that we define a specialist, largely, as a man who has a particular training or speciality at the time at which we want him, whereas in an economy like ours, in a situation where there is change, we should be eager to get persons to specialise, to go away to study and acquire a qualification.

If radiologists are not available in sufficient numbers I would suggest to the Minister that it is a case, again, for going along and saying that we want to give six, eight or ten attractive fellowships that will appeal to existing people who are already in pretty good positions to change their line of work and become qualified as radiologists. The same approach should apply to any other specialisation. The graduates are there, they are people with a fundamental training and they are available in most positions. What is missing in many cases is anticipation of demand in various specialist areas. I suggest that we can solve that simply by selecting and sending abroad.

Again, a speciality which the Minister will require very much in this matter in the future is aid to medicine by the computer, whether for storage of case histories or statistics, data, etc. This is a very rapidly developing side of medicine, in fact in America you are almost completely handed over to the computer in many instances. I suggest that this is something we should act on quickly because we are going to have to move with this as well. Again the question is one of having people trained on the medical side of computer usage and it is a very important one. Indeed in connection with the three regional hospital boards in each of those areas Dublin, Galway and Cork we have computer facilities based on the universities. It would be a very profitable and long-sighted act by the Minister to make available in each of those centres sufficient to appoint to the computer centre in those places one research officer to develop and investigate and get established locally the use of the computer in the medical problems of the area. The cost at most would be a few thousand pounds in each area, yet if this is done, and done pretty soon, the computer capacity is there at least for the experimental stage and it can be experimentally used, with certain of the hospitals in the area and the necessary knowledge for more widespread usage can be built up.

Speaking for Cork, I know that the computer centre at the university there would be very happy to co-operate in that work, but the plain fact at the moment is that their very meagre resources in the computer centre are already strained beyond breaking point with our immediate problems of servicing the university departments concerned, and therefore I would say that nothing short of having one well qualified man completely designated as research officer in the application of the computer in medicine would really achieve quick results. I would therefore commend this to the Minister for what it is worth.

I am glad that in the Minister's introduction and also in his provision for Comhairle na nOspidéal and the health boards recognition is given of the work done by the voluntary hospitals and of the great contribution they have made. We can never be too grateful to the voluntary hospitals and the voluntary educational bodies for what they have contributed to our country at a time when finance was scarce and the idea of the State getting more actively involved in those areas was not operative. Now in the development for the future we should see these in as active members. I think that nobody need worry about the fact that the voluntary hospitals are going to take over the country or anything like that. The statistics show at the moment that they cater for 44 per cent, and this is a declining percentage, due largely to the expensive equipment and the fact that the recruitment of members for orders and so on is posing further difficulties. All this means that there is going to be a gradual decline in the amount that will be done by voluntary hospitals in the future, but the amount that they are going to do is really very important, both because of what it provides and also the type of somewhat different service or approach compared with the public run hospital. There will be a difference of approach, and that is all to the good. Each will learn from the other. By and large the voluntary hospitals tend to be more personal in their approach, and again that is very good. I would suggest that just as in every other field we have recognised that we have here a mixed economy, neither socialist nor capitalist, in so far as education, industry and so on are concerned, and that we should encourage and promote partnership so that the voluntary or private sector does what it can and the State complements or supplements it where necessary, the same thing, I hope, will characterise and mark the Seventies in the evolution of this Health Act.

Above all in the representation on the various boards I think that the Minister should see that those voluntary groups are adequately represented. I share Senator Keery's questioning of the percentage on the health boards, that more than half should be elected directly by the local authorities. I think that the other half would provide for election of medical groups, by nominations by the Minister and so on. I have a feeling that a half is going too far and I think that one-third would probably be more reasonable, especially as the main claim in the past by the local authorities to be represented was the fact that the financing was so dependent on the rates. Now there is a shift away from financing by the rates and that shift will become much more marked in the decade coming; in fact I would suggest to the Minister to do the bold thing right now and cut the financing from the rates. I would be realistic about it in so far as rather than cutting completely we should freeze it at its present level of contribution or else freeze at the present level of contribution as a basis with a sliding scale that would be applied nationally. The sliding scale need be no more than taking account of the depreciation in money values. Thereby you would ensure that all the wrangling that is bound to arise as to whether the rates should be increased by this extra amount to provide those extra services would no longer be needed. That is a type of arid controversy which we should seek to avoid. After all, whether you provide the money from the rates or from central taxation, it is coming from the taxpayers in any case. This would lead to much cleaner administration and the removal of needless controversies, if some formula could be worked out that would rule out in the future any discretion at county level as to the amount that the rates have to pay for the health services.

Membership of those boards, especially health boards covering an area, is a very specialised task and therefore it should be something much more than the undoubted good service that local representatives have given in the past. It is now removed that much further from the local scene and consequently, as the Minister indicated in his opening speech, the board should be prepared to allow the running of affairs to the officials. They are becoming more policy-minded; they are moving up a stage and there is a logical case for more specialised representation so that each member of the board will be seen to be capable of contributing not merely to the health problems of his own district but to the development of a health system for a region of three or four counties which requires a totally different approach and much bigger thinking.

The other necessity for the local knowledge and the intimate link with the people would surely be better met in the subsidiary local committees that the Minister envisages the health boards having in the various areas. I share Senator Keery's fear that the Minister has gone too far both in taking over past ideas of representation and in yielding too much to pressure for a democracy that does not altogether fit in with the best functioning of health boards.

I welcome the efforts by the Minister in the Bill to ensure that local authority representations will be proportionate. Where each member is elected by a quota of the council it means that each section in the council will have its representation on the health board and there will be no case in which because one party or another controls the council an undue proportion of places on the health board are taken by such a party. This is a worthwhile provision and I hope it will be followed in regard to representation on other boards.

I think the provision whereby GPs can be admitted to local hospitals on the lines suggested in the FitzGerald Report is good and long overdue. I have often felt there was too much of the closed shop element in the medical approach to the question of who in the profession had the right to enter hospitals. Admittedly, this is at the lower level of hospitals but it is still a step in the right direction. I can see the Minister's concern about the provision for a proper coverage of GPs throughout the country especially in remote areas. Undoubtedly, inducements will have to be given but the main thing necessary is to try to organise the provision of these services in a twentieth century manner. We no longer can have a situation in which one man is on call 24 hours a day. A panel system is overdue whereby you have three, four or five members with regular hours and, consequently, a doctor available at all times. This is beginning to operate in the cities and is doing quite well. The Minister should encourage this as much as possible. It is the only way to make life tolerable for GPs and at the same time ensure that for any really serious cases medical advice is available 24 hours a day. That is a real step forward.

The provision of home nursing and home help is very well worthwhile but, as envisaged, I think it is largely intended for those qualifying for free services. The need in all the other income groups is just as great but they are quite prepared to pay for the service provided they get it. The paradox of the modern affluent society is that things that really make life pleasant such as provision of home help in case of sickness or when otherwise required such as at the time of having children and so on are far less available than they were 30 or 40 years ago. This service is something that, perhaps, will require to be organised on some kind of co-operative basis. Paying for it is never a problem; it is a matter of getting suitably trained people for the service.

I suggest to the Minister that services made available for the homes of those qualifying for free treatment should also be made available to all who need such services but on the basis of paying an appropriate fee. Not alone will that give an excellent service to those in the paying category but it will demonstrate that the same service is available to rich and poor alike. It is the quality of the service and not who pays for it that really matters.

Help through local community efforts should be stimulated. We find local voluntary groups making great efforts to help old people, for instance, by means of meals on wheels, holidays and so on. Very often these efforts are hampered by lack of funds. Could funds be made more easily available to such voluntary groups while at the same time calling for the maximum voluntary help from the community?

We are dealing with the most expensive side of living in the health services and consequently we have a right to look for economy and efficiency. The key is provided by the medical schools turning out well-trained graduates equipped to deal with the community, providing refresher courses and everything else required. Under the present system of financing of our schools a great deal is left to be desired and I ask the Minister to take some interim steps to try to increase facilities. Above all, I appeal to the Minister to look at the whole question of medical education and our involvement in it in the context of the world and examine how far we in this country can get into the medical training business for the world as a whole, whether in the training of medical personnel for the ordinary medical functions or training for the hospital administrators I have mentioned or for any one of the myriad skills that are required in the administration of a health service.

How far can we go to get into that industry? I use the word "industry" deliberately because this is something that is required and will always be required by the world at large, and they are prepared to pay for it. I believe that when we have sufficient people trained for ourselves, there is unlimited scope for training people for other nations, on a strictly commercial basis. We have the example of the College of Surgeons doing that here in Dublin and doing it very successfully. The other facets of a modern health service can probably be approached in the same way. Let us see how far we can go.

I have great respect for the Minister's imagination. I know he is capable of envisaging the day when we are really in the export business in this field.

Most of the other points can be left to Committee Stage. It is more satisfactory when we can have question and answer and when we can really tease out the problems. The success of this service will be ensured if the Minister can avoid local "wrangling about increases in rates due to this amalgamation. He can do that only by working out some formula or scale that will make the local contributions completely mandatory, and decided on a national basis. If this can be worked out, we will get away from looking at it on a county basis. We will get away from feeling in one county that we are paying through the nose for a huge establishment in another county. We will get away from that parochialism. The Minister has his remedy if he puts the rates contribution on a mandatory basis.

This is a good Bill so far as it goes. It is right to hope that, as a result of it, in the future we will have more people availing of specialist services and more economic administration. If I were to offer any criticism of the Bill it would be that I feel it has not gone far enough.

First I should like to deal with the boards and particularly with the remarks made earlier by my colleague, Senator Keery. Senator Keery appears to have joined the intellectual snob wing of this House, that wing which believes that unless a person has academic qualifications he is not fit to be a representative on any board.

On a point of fact, I did not say any such thing.

I did not say you did.

I did not refer to academic qualifications. I referred to the experience of voluntary social workers in voluntary organisations.

All I can say is that I think Senator Quinlan, who has been the great exponent of this policy down the years, seemed to have taken Senator Keery under his wing when he was speaking.

I believe that if you have got training it must be worth something.

No one is disputing that.

Otherwise why send people to the university or to any other courses?

Senator Quinlan and Senator Keery must realise that there are people in Ireland with training other than university degrees. This, too, must be recognised.

I never questioned it.

We never questioned that.

The best type of training available is the training a public representative receives from his entry into politics until he reaches those boards. Experience has taught us that many members of such boards have, as a result of their experience, contributed a lot more to those boards than any university man. Senator Keery, of course, is new to public life. He has been with us for a few months only but, when we send him to a few by-elections in Dingle, Galway, West Donegal and Cork, we feel we will be able to knock some of those ideas out of his head, and he will return convinced that public representatives have a very important and responsible part to play in the running of boards of this kind.

Not 50 per cent.

More than 50 per cent.

That is where we differ.

I might warn Senator Keery, indeed, that if he should contest the next Seanad election on my panel I will endeavour to ensure that every county councillor in Ireland gets a copy of his speech here today. So, I would advise him not to run on my panel.

Does the ability to do that make the Senator a better representative on a health board?

This craft, the Senator means? I would hope that the medical profession do not receive too strong a representation on these boards. I certainly agree that they are entitled to a voice, but only a voice.

Five per cent?

I am not certain what their representation is. Any member of a local authority or a committee who has a financial interest in any debate by that authority or committee is obliged to disclose his interest and leave the meeting. This is a very important regulation and unnecessary trouble could be caused if it were not there. Here we are to have on the regional boards men who have a definite financial interest in the discussions that might take place, men who have a definite stake in them. If they are to be given this representation there should be a regulation that when a subject of financial interest is being discussed they are precluded from voting on it.

Earlier on I said I do not think this Bill goes far enough. There is nothing in it to prevent abuse in the Irish medical service as we know it. I should like to discuss local authority hospitals in particular. We are told that the local authority hospital caters for people in the lower income group and people in the middle income group, but there is no obligation on that hospital to cater for anyone in the higher income group. This was a statement made by my county manager some seven or eight years ago in reply to a query at a meeting of Donegal County Council. From that one would get the impression that the people in the two groups mentioned are the people who benefit most from the local authority hospitals. But that is not the case.

Senator O'Brien told us earlier today that we still had the three groups and I believe that, so long as we have them, we are encouraging class distinction. We are encouraging snobbery and we are encouraging wholesale exploitation by the Irish medical service. I speak as a representative of Donegal County Council who, down the years, since the building of a county hospital in my county, has fought to prevent such exploitation in my county. There is only one solution to the problem: there must be no private beds in local authority hospitals. No specialist should be allowed to have private rooms, or private beds, in his hospital. Until we reach the day when specialists are paid a salary and are not dependent on private patients then, and only then, will we be in a position to say that we have a fair medical service. Until we reach the day at which everyone who enters a hospital, be he rich or poor, is treated in the same way then, and only then, will we have a fair medical service. I know that such a service would be very expensive. I do not know how it could be provided, but I hope that the day is not far distant when we will have a free medical service for all. By not having a free medical service for all, by making the rich pay, one might imagine that we are giving the advantage to the poor. That is certainly not the case in some of our local authority hospitals. By making the rich pay we are giving the advantage to the rich and the poor are suffering.

The Minister may recall my drawing his attention to this when he visited my county. In Donegal we have a situation—I am sure the same situation obtains throughout the country—in which a medical card holder who wishes to avail of a clinical service is placed on a waiting list for two, three or four months. There is evidence of this in my county. I am quite sure there is evidence of it throughout the country. On the other hand, if a patient wishes to see a specialist in a private capacity an appointment can be arranged within one week. Is that a just system? Can we do anything to prevent it? How often have our dispensary doctors told their patients, particularly those in the middle-income group: "If you want your operation immediately you should go in as a private patient. If you do not want it immediately you may have to wait a few months for it". That is the advice, provided, of course, that the operation is neither urgent nor dangerous.

This is a serious situation. It is one which has not been tackled. It must be tackled. When the Minister's predecessor toured the various county councils and spoke at public county council meetings on this matter he summed up the position by saying: "Let us face it. The £ still works". There is only one way of solving this problem; that is by treating everyone the same. We have in our hospitals private patients who benefit by better food, nicer, daintier trays and better quality cutlery and china. The public patient does not receive the same amenities. Because of that we are encouraging a society of snobs. We are certainly encouraging class distinction. I know many people in the middle-income group who could not afford to be private patients but who feel their neighbours would talk if they were to go into a public ward.

I do not subscribe to the view that a physician, a surgeon or a gynaecologist should have the benefit of a room built by the ratepayers and taxpayers for the accommodation of his private patients. I do not subscribe to the view that such patients should be fed by the staffs employed by the county council, tended by nurses employed by the county council. Above all, I do not subscribe to the view that these patients should receive priority at all times in county hospitals. Some may say that the number of specialists who would indulge in practices of this kind is small. I hope it is very small.

I had occasion to table a motion at a meeting of Donegal County Council seven or eight years ago on this matter and when I handed that motion to an official of the county council, he said: "Thanks be to God that someone at last is raising this matter". It is too bad, to say the least of it, that the first question a patient is asked when he goes into hospital is what his income is and the first decision to be made is whether or not he pays. The county physician in Donegal stated on oath in a court of law: "One generally treats one's private patients oneself. One generally treats one's public patients through one's house surgeon". The physician sued for fees because the defendant refused to pay in the belief that the physician was charging too much. That was the opinion of a specialist who could quite easily be a member of the regional board in the Donegal/Sligo/Leitrim area.

The ratepayers and taxpayers are providing hospitals for specialists, one of whom stated under oath that, if you can pay, he will treat you; if you cannot pay, his house surgeon will treat you. That was published in the local papers. This kind of practice cannot but lead to many abuses. I remember a colleague of mine in Donegal who complained that an old age pensioner was treated and charged as a private patient. The county manager maintained that he had signed the form indicating that he wished to be treated as a private patient. An investigation took place and, as a result of that investigation, it was found that the old age pensioner had something wrong with his hand; he had not written for years and the form was signed by one of the nurses, at the behest of the specialist, because it was thought the old age pensioner had a bit of money.

Two years ago a doctor in Derry, whose practice is on the Donegal border, told me he had to send his Donegal patients to the County Hospital in Letterkenny. He was often amazed, having sent some most interesting medical cases to the specialist there—cases which any specialist would give his right eye to get—to receive an acknowledgment of the case, the first line of which would read: "Can this man pay?" I know it is difficult but I should like to see this sort of abuse stopped. The vast majority of the medical profession will put the interests of the patients first but it is the few exceptions who can cause trouble. Anyone earning over £1,200 today must pay through the nose for his medical expenses, yet these people, through the rates they pay, are already contributing a large proportion of money.

Up until now an X-Ray cost anyone earning under £1,200, 7/6. The charge has been dispensed with in this Bill. I know of someone earning over £1,200 who paid £6 16s for an X-Ray this week. That person may only be earning £1,250 but still he must pay. Admittedly, he only looked for the X-Ray one week ago and because he was a private patient he was able to get that X-Ray within the week. I know of people in Donegal who have been waiting two months for X-Rays and they will wait on because they are not paying a specialist.

I hope the day when there will be no private beds in local authority hospitals is not too far distant. If a consultant wishes to provide private beds let him do so in private nursing homes and, if necessary, let the State assist him to provide them. We are codding ourselves that we are really catering for the medical card holders. If two people have the same complaint and require an operation or need treatment under a physician in a local authority hospital and one is a medical card holder and the other is in the higher income group and prepared to pay privately, which of the two will get that bed? It has certainly been my experience that the man who is prepared to pay, and pay well, will get priority in every case.

I recall the case of a man living five miles from a county hospital who had an appendicitis. He was refused admission to the county hospital in Letterkenny. He had to be driven, even pushed through the snow in the Barnesmore Gap, in order to get to the Shiel Hospital forty miles away in Ballyshannon. Yet, in the county hospital in Letterkenny there were four private rooms for each specialist and still a man with a burst appendix had to be pushed through the snow. Until we treat everyone the same, until we make the medical service available to rich and poor alike, until we do away with private beds in county hospitals to my mind we will never have a fair medical service.

I should like to join with other Senators in paying tribute to the Minister for the very co-operative and helpful way he has met the various groups of public representatives during the regional conferences he held throughout the country. I should like to pay him personal tribute for the very patient way he dealt with the many points put forward at the meeting of the mid-western regional group at Nenagh a few weeks ago. The Minister has indicated to all of us that he is prepared to co-operate fully and deal sympathetically with helpful and constructive suggestions put forward by public representatives and in this regard we all wish to pay him tribute for showing a degree of flexibility that is not always associated with a Minister for State.

Generally speaking, and certainly from the speeches that have been made so far today, Members of the Seanad appear to be in agreement with the proposed outline for a health service in this country under the terms of the Health Bill, 1969. Certainly, I support the general outline. I think it is reasonable to divide the country into eight regions. There may possibly be some criticism on the grounds that the population between, say, the smallest areas with fewer than 200,000 and the largest area, the Eastern Health Board, with almost one million. These differences are rather wide but on looking at the circumstances in each area I do not think the Minister could have come down with a more suitable solution. In the mid-western area of Limerick, Clare and North Tipperary we have the advantage of being an established grouping for economic development and also for tourism, and as far as we are concerned the proposed set-up under the new Health Bill is very acceptable. This was indicated by the representatives of all three participating counties and the Limerick Corporation, irrespective of political affiliations.

Health services can be divided into three categories—prevention, cure and rehabilitation. This Bill deals fairly adequately with the cure and rehabilitation of patients.

However, I suggest to the Minister that more emphasis, particularly in regard to one factor about which I propose to speak at some length, should have been laid on the preventive side of medicine. As the Minister pointed out in his introductory statement, the cost of specialisation accounts for 75 per cent of the total health charges in the country, which is a very substantial amount. The smallest charge and the one that has given the greatest results at the lowest cost is that appertaining to preventive services. We can all boast with considerable pride that successive administrations and successive Ministers for Health have succeeded in eliminating certain sources of illness, and in some cases death, amongst our people in past years such as diphtheria and polio and to a very considerable extent tuberculosis. These have been eliminated under the policy of preventing disease rather than curing it and rehabilitating the patient afterwards. More emphasis and more money might be directed towards preventing illness rather than spending money on curing it and rehabilitating the patient afterwards. In this regard I should like to pay tribute to the district nursing service which I regard as one of the very successful services under the health services. The fact that that service is going to be extended is a very worthwhile step.

The question of financing the services has been touched on by almost every speaker and indeed the Minister heard many comments on the matter from the various local authorities he visited. This Bill proposes that the State will make a minimum contribution of 50 per cent and this will be supplemented thereafter by a sum to be decided on by the Minister. I did make the point, and it is worth reiterating it, that having regard to the fact that the realistic State contribution is in excess of 50 per cent—it is 55 per cent or 56 per cent—and that the declared intention of the Government is not to call on the ratepayers to carry a larger burden, a start might be made in this Bill towards transferring the greater proportion of the health charges from local to central funds. In other words, instead of the figure of 50 per cent which the Minister has written in, a figure of 55 per cent at least, which is the present minimum figure, should be written into the Bill. The Minister did not accept that and I do not know whether he has had second thoughts about it, but it would be an indication of the Government's feeling that the rates are no longer a suitable means by which to get the health charges, if he did this.

Those of us who are members of local authorities will admit that unless something can be done to reduce the health charges there is no possible way open for reducing or even controlling the huge and rising burden of rates in every local authority. I should like also to touch on this proposal to sever public assistance from the public health service. Under the present system of health boards, such as we have in Limerick, public assistance is administered by the officials of the health board and it is now proposed that public assistance will revert to the county councils or corporations as the case may be. I understand that to some extent the Minister has met this point by agreeing that public assistance will be administered by the new health boards but financed entirely by the contributing authorities. It is very difficult to draw a line of demarcation between public assistance and public health and I should like the Minister to have another look at the question of financing public assistance through the new health boards.

After an illness there is a period during which the person requires rehabilitation and that rehabilitation must be provided in various ways, such as by medicines, but also by some form of monetary assistance. For this reason you cannot divorce public assistance from public health. The two, in my view and in the view of other public representatives, should form a single service and be financed from the same source. It may only require some adjustment of the contribution made by the State but I do not think it would be outside the competence of our public officials to find such a means. Although I do contribute to the ideal of having a choice of doctor I must confess to having some doubts in regard to how the matter will work out in certain rural areas. I know that in theory it would appear to be a desirable solution, and indeed it is, but in practice it may not be possible to work it. In sparsely populated areas it may not be possible in practice to give a choice of doctor and before changing over completely from the present dispensary doctor system there should be a period of transition to see how the new system is working. I hope the Minister will allow for this.

The subject on which I should like to speak in some detail is the very important subject, and one which is growing more important every month, of the efficient supervision of food and drink supplies. By drink here I mean milk. The present legislation governing the supply of food and drink is highly complex and that is understandable in view of the fact that the various orders and enactments governing the supervision of food and drink go back to the start of this century. To take an example: the duties of a whole-time veterinary inspector in a county borough are concerned, amongst other matters, with: public health duties under the Local Government (Sanitary Services) Acts, the milk and dairies code which imposes obligations on various sanitary authorities, intercounty arrangements whereby services are supplied by, say, corporation staff to health authorities to ensure the discharge of important duties under the Health Acts and food hygiene regulations by qualified personnel, the Slaughter of Animals Acts which necessitate the supervision of abattoirs by sanitary authorities and the Diseases of Animals Acts. All of these form part of the general protective health code of the country. The administration of this complex set of Acts and statutory orders can result in difficulties which include overlapping, lack of efficiency and high costs where control does not rest in a single authority.

A fair example, and one which probably applies more directly to my own county of Limerick, is the inspection of dairies in rural areas. These inspections are carried out by two groups of people: (a), veterinary inspectors employed by county councils as sanitary authorities or (b), health inspectors employed by health authorities acting under powers of food hygiene regulations. The end product, milk, sold in adjoining urban areas, is subject to another set of inspection which cannot be reasonably effective except in county boroughs and a few other areas where whole-time veterinary inspectors are employed. An anomaly arises here because chief veterinary inspectors and chief medical officers, who have serious responsibilities for the health of the community, have not the effective power to remedy unsatisfactory supplies at source.

It must be appreciated, of course, that legislation governing the supply of milk was introduced when boards of health and public assistance were single authorities dealing with all health and sanitary matters. In prewar days, the only division of control related to Diseases of Animals Acts whose operation continued to be the responsibility of county councils. In fact, we have now reached the position where a revision of the old order, without applying the methods of that old order, is called for so that all these various enactments and powers controlling the efficient supervision of food of all kinds, from the producer to the consumer, is necessary. To ensure its efficient working, it should be administered under the new health boards.

The responsibility of the health authorities for personal and public health matters has produced a new set of circumstances, and a very strong case now exists for the transfer of inspecting functions and supervisory control of the production of food and drink to the new regional health boards. In 1935 the Oireachtas made provision for sampling and examination in bacteriological laboratories. The procedure should now be streamlined to ensure that samples effectively can be examined in special laboratories of the health authorities under control directly of the county and city medical officers of health, as the case may be. In this manner, enforcement of food hygiene regulations could be effectively combined with the administration of Food and Drugs Acts and the milk and dairies code in a single supervisory system.

If I may suggest to the Minister the outline of the possible type of organisation that I think would fulfil the responsibilities I have outlined during the past few minutes, I should like to suggest that in each regional health board area a chief veterinary officer should be appointed. At the moment, there are only five chief veterinary officers in the country—two in Dublin, two in Cork and one in Limerick. My suggestion would entail increasing these appointments by another eight or ten chief veterinary officers, thereby apart from ensuring an efficient supervisory system of food and milk, opening the way for promotion to young men in this profession. It entails also the establishment of regional food hygiene laboratories where all food and milk could be tested by qualified personnel; the transfer of functions at present carried out by a section of the Department of Agriculture and Fisheries dealing with food hygiene matters and milk inspection, to the Department of Health; the appointment of whole-time county veterinary inspectors to be assisted by part-time officers under the regional health boards; and finally, and most important, the revision of the existing laws relating to food and milk inspection.

The changing circumstances of our times, to which I have made some reference, necessitate that food regulations, the supervision of all food and milk products, must be brought, of necessity and quickly, up to the highest international standards. Tourism, our increasing export trade, the provision of faster and bigger aircraft, particularly the jumbo jets, all point to the necessity of ensuring that the quality of our food products will be as high as in any other country, and not only must we do this but we must be seen to have an effective system of supervising the production and distribution of food right down to the consumer.

As the Minister is no doubt aware, under the Milk and Dairies Acts, milk cannot be inspected in hotels. Under the proposals which I have put forward, this can become the responsibility of the new health boards, and properly qualified officers would be entitled to call at hotels and have examined milk and food products served to customers generally.

I have spoken at some length on this because I feel very strongly on it. I mentioned it at the conference at Nenagh but the Minister said then that he saw some difficulty because the Department of Agriculture and Fisheries at present have responsibility for some of these services. However, my feeling is that we are now setting out on a new form of health service structure which offers the present Minister a golden opportunity, perhaps, the last opportunity, of bringing our outmoded health and food hygiene regulations up to date, co-ordinating them and ensuring their efficient operation under a single authority. The obvious authority to do that, in my view and in the view of most Senators, would be the new health boards. I hope the Minister will take particular note of this point. He has shown himself to be receptive to new ideas in regard to all health matters and I should like to think he will give this facet of our health services his sympathetic consideration.

From all speakers has come general praise of the Bill now before us and congratulations have been offered to the Minister for his handling of the Bill. I should like to associate myself with these sentiments. I do not intend to go into detail on the Bill but I should like to repeat what the Minister said in his opening statement to the effect that much more is contained in this Bill than has been suggested here.

One sweeping change envisaged in the Bill is the disappearance of county boundaries for the first time in the administration of our health services. One can see the advantages of such a change. From a point of view not connected with health, it will be interesting to see how this proposal works because in any regionalisation scheme that has been introduced up to date county boundaries have been firmly entrenched. Here we talk of catchment areas rather than county boundaries and this, I think, is a development to be welcomed. I hope it will be successful.

The Minister referred a few times in his opening statement to the FitzGerald Report. Therefore, I feel that I am in order in speaking about this report in so far as it deals with the future structure of the hospitals of the country.

The Minister said on the Committee Stage of the Bill in the Dáil—Volume 242, column 2026 of the Official Report:

Obviously, the report needs study and, no doubt, there will be amendments and changes to it. It is not a sacrosanct report.

This was a great relief to persons who felt that in a large measure the regulations under this Bill would be centred around the FitzGerald Report.

The Minister, again at column 2026 of the same volume, said:

I could comment on certain inadequacies in the FitzGerald Report, not caused deliberately, but caused simply because it was a report prepared by people who did their best to examine the whole hospital situation in the country. They could not possibly have known all the factors surrounding the hospitals in different places.

One has now to stop and consider why, then, the committee took it upon themselves to make a report of the nature which they did make, when they were not in full possession of the facts. As a justification, may I say that we know they were asked to report back in six months whereas one would expect a report of such magnitude would have taken, at a very minimum, two years to complete. It took two and a half years to examine the general medical service in the highlands and islands of Scotland. This was a service for approximately 278,000 people.

Everybody will agree that there are some excellent suggestions in the FitzGerald Report and that some form of regionalisation and centralisation is required to make the most economic use of manpower and of the expensive equipment available. Indeed, it is a welcome thought that we will have down through the country large hospitals with facilities that perhaps heretofore existed only in Dublin.

We must however guard against too much specialisation if it is going to be detrimental to large numbers of the rural population. The hospital plan for Scotland of 1962 advocated the building of ten new hospitals in each of the main areas of population and states that this should reduce the degree of dependence on the regional centres and —something that I would consider very important—the amount of travelling for patients and their relations. It also states that there are parts of the country where the population that a hospital can conveniently serve is too small to warrant a district hospital of normal size but where facilities for acute treatment must be provided to avoid travelling.

The hospital plan for Northern Ireland of 1966 provided for district hospitals in many of the smaller towns. At least as far ahead as can be foreseen these hospitals will continue to provide the basic specialities of general medicine, obstetrics and gynaecology with the addition of other specialities as may be appropriate to the needs of the population and the distance from the main hospital.

Both of these reports are based on situations which are very similar to the situation which prevails in Ireland. In fact the North of Ireland is part of our own island. They are diametrically opposed to what is stated in the FitzGerald Report.

The FitzGerald Report is almost silent on the question of transport, both public and private, and ambulance organisation. The logistics of the ambulance service have not been worked out. No matter how sophisticated the service is that may be envisaged—and it must be sophisticated in the sense of the skills and appliances available to offset the time lag in dealing with emergencies—there are still the hazards beyond human control of flood, snow and ice, common in our situation. There is also the hazard of the increasing motorised traffic, the traffic load on roads, particularly at peak tourist and holiday periods and at holiday weekends. Apart from the type of ambulance and the degree of skill of the crews, the number of ambulances that will be required and the bases that they will need will represent a very big capital outlay. It would be only reasonable to evaluate and quantify this and to weigh the cost of such a structure against the capital and revenue charges of a simple addition of beds to already existing modern hospitals.

Here, like every representative, I come to my own neck of the woods, which is Roscommon, where we have a modern hospital, built in 1941, extended in 1953, extended again in 1968, where there are at present 126 beds and where an addition of 74 beds to bring the hospital to 200, and a duplication of the specialities required to make it comparable to what is proposed for Letterkenny, might be a far more feasible proposition than to try to provide the roads, the ambulances and the skills that would be needed if the surgical facilities at Roscommon were to be closed and moved to Galway. This is something that was not considered by the FitzGerald Report. They did not examine the ambulance situation at all. I hope that the Minister, before taking any decision on the downgrading not alone of Roscommon hospital but of other modern hospitals, would take this into consideration.

I should like to congratulate the Minister on his mention of the mentally handicapped. Mentally handicapped and mentally retarded children and their parents have not got a very fair deal up to this under our health schemes. Certainly, mildly or moderately handicapped children are being fairly well provided for, perhaps in a large measure through voluntary effort. The severely mentally handicapped child is not being provided for. There is a great need for more beds to be provided very, very quickly for this type of child. I should like to join with Senator McDonald and Senator O'Brien in pleading the cause of these children. Any public representative will know of cases of extreme hardship where there are children who need care and who cannot gain admission to homes and where there is extreme anguish caused to parents every day of the week.

I can cite the case of a little boy who is now five years of age and who is the same as he was as an infant. His name was put down very early on in several institutions to try to get him in by the time he was five. He is now nearly six and his name is 72nd on the list, which means that in the normal course of events he will be 28 years of age before he could be taken in and be hospitalised as he should be. We did great work when we were trying to eradicate TB and I cannot see any reason why such a drive and effort cannot be made now. The Minister has expressed himself as being extremely interested in child care. I feel that when he has this Health Bill through, which of course has occupied a great deal of his thought and time since he became Minister, that he will apply himself with the greatest energy to this and that within 12 months there will be a definite stride forward in this field.

The Minister, too, is to be congratulated on the speed with which he acted in bringing in a section to deal with drugs. Those of us who are parents of young children are very worried about this problem. We know that extensive and good legislation will come in on it later, but I think that coupled with this must come a massive education system, whether it is done by the Department of Health or by the Department of Education or taken up by the press and the radio and television I do not know, or whether it should be a combination of all these things, but it certainly is needed, because this is a growing menace and children and parents must be warned of the dangers.

It is indeed a very welcome thing— and I forgot to mention this when mentioning mentally handicapped children and disabled children generally—that means tests are being abolished, because people who are in the middle income group and the higher income group even have such ghastly bills to meet with regard to long disablement that they find themselves not in the higher or middle income group but very much in the lower income group by the time that they have their bills paid for those people. It is the same thing with the drugs and medicine that will be provided. I realise that it is very hard to give everybody everything they want, and this is a step forward, but we have a long way to go if we are to supply the type of service that we would all desire. But this Bill is certainly going a long way towards providing the ground work for it.

In the administration of the health boards, I should like to say just a word in support of Senator Keery who I think was misinterpreted by a Senator on our own side here. Senator Keery was looking for representation of voluntary groups on the boards, and I think that in this he had a very logical point. As a fairly prominent member of one voluntary organisation I know that the voluntary organisations of this country have a lot to offer and if given a place on those boards they would certainly pull their weight. It is time, I think, that the efforts of the voluntary organisations in the country were recognised in this way.

I should like to speak about what Senator Quinlan said as he was finishing. He mentioned that he could not see why we should not become the medical school of the world. I feel that somewhere along the line he must have read something that I had written at one stage on this. It is one of my pet theories, and I actually wrote at one time, when I was talking about the consumption of butter and the export of our food, that I felt that what we have a need for in this country is to bring people in to eat our food rather than export it and subsidise it for people to eat it abroad. One of the things I did say at that time was that in the seventh, eighth and ninth centuries we were the university of Europe. I cannot see why, when our Health Act is in operation and we have the marvellous hospitals that will be built under this in the future, we cannot be the university of health for the world.

In conclusion, let me congratulate the Minister for his patience and forbearance in sitting listening to yet another criticism of the FitzGerald Report.

Miss Bourke

A number of Senators who spoke yesterday said that they would confine themselves to a few remarks because they regard this Bill as basically a Committee Bill. I have looked over it and obviously it is a Bill which will have to be taken extensively in Committee; but we must appreciate that this is the first time that this Bill has been debated before this new Parliament on its general principles at Second Reading. I have heard the debate so far and I think that it has been well worthwhile. We have been discharging our duty in this respect on the Bill.

It is necessary, in considering an important piece of social legislation of this sort, to speak on the general principles before getting down to the details. Perhaps the new Dáil were at a slight disadvantage in that they had to take the Bill at the Committee Stage. Nevertheless, I would agree with those Senators who have already stressed the extent to which the Bill was improved as it went through the Dáil, and I associate myself with the remarks made complimenting the Minister on his willingness to accept amendments, and I also associate myself with the compliments of the last Senator who congratulated him on his stamina in being present here at the debate. As one who is used to speaking before Parliamentary Secretaries, it is a great pleasure to find oneself speaking in the presence of the Minister concerned. I should also like to say that, even though there is an obvious value in getting this Bill on the Statute Book in the very near future, I should like this House to be treated as a body which can make a positive contribution and which can put forward further amendments to this Bill which will improve it. I hope that we will not be regarded as a rubber stamp or that there would not be a priority put on getting it through the House, but rather that we should be enabled to make a constructive contribution.

Looking through it in my relative inexperience of medical matters, but with some experience of looking through legislation, I can see already a number of matters which might be improved and a number of amendments which could be put in. I hope that they will be treated in the same spirit as the Minister showed in the Lower House and that he will not try to confine himself to the Bill as passed by the Dáil.

Having made these general remarks I should now like to turn to the Bill itself, which I regard as an extremely important piece of social legislation which will determine the future of health services in this country for the next decades. The first point is that, as has already been noted by some speakers, the provisions of the Bill are largely based on the FitzGerald Report. This was a report of the Consultative Council on the General Hospital Services, which reported to the Minister in June, 1968. I wish to ask an important question: whether this report had its priorities right in providing health services for this country, because to me the first priority is the people of Ireland. Looking at the composition of this FitzGerald Commission, there were 18 members, of whom ten were Dublin-based and eight were from around the country, four of them county officials associated with the medical schools in Cork or Galway. It is noticeable that a commission reporting on the health services of this country had no medical practitioner representative. I find that rather a narrow basis, and it may be responsible for the fact that there is a certain concentration on what I would regard as important matters but not necessarily the first priorities, such as the future of the teaching hospitals in this country and future specialisation.

In my view, where there is regionalisation—and I would agree that in theory regionalisation can be helpful in the employment of facilities—the rationalisation of priorities must not be to improve either teaching facilities or specialisation at the cost of depriving people around the country of a lifesaving type of medicine. I do not want to exaggerate this point but, since the Bill is largely based on the FitzGerald Report, it may be presumed that its guideline will be followed to some extent. Map 3 on page 37 of the report sets out 12 general hospitals as well as regional hospitals. All other hospitals in the country will presumably be diverted to other purposes such as geriatric homes, mental institutions and so on. The point made in the FitzGerald Report is that, except for a few areas of Donegal, Mayo, Clare and the south of Kerry none of these general hospitals will be more than 60 miles from the people of any county. In commenting on this structure members of the Commission stressed that with the increased improvement of roads et cetera these journeys will no longer be a problem. I happen to know from my own experience, having a father who is a general practitioner, that there is already a problem when the nearest general hospital is 30 miles away if there is a serious accident. The first quarter of an hour is often the time that determines whether a person's life or limb can be saved. Further—and this is an extremely important factor—there is no likelihood in the near future that we can have the type of ambulance service that would be necessary to make 60 miles a viable distance in order to save life. The type of injury we are discussing is that arising from road traffic accidents often of a very severe nature, involving head injuries or accidents with heavy agricultural machinery. Looking at the turnover in general hospitals throughout the country, it is easy statistically to prove that these hospitals have an enormous turnover in the fields of general medicine, general surgery, obstetrics and gynaecology, a much wider turnover than many of the larger teaching hospitals in Dublin in strict surgery cases where it is a matter of saving a life or a limb.

This is one of the points I am making. Has there been a tendency to think in terms of administration, in terms of teaching hospitals and specialisation rather than of ensuring the first priority that the people of Ireland, including the people of rural Ireland, will continue to get the necessary lifesaving hospital service they must have? I stress this point because I know from various contacts in the country that there is a general fear in rural areas that they will be deprived of hospitals within such a distance that if they suffer either a serious accident or serious disease they will be able to reach a hospital in time to save life. I know that this is the awful problem bothering many medical practitioners.

One problem which I do not think will arise is that which Senator Jessop mentioned. He may have overlooked the statement of the previous Minister, Deputy Flanagan, who introduced the Bill in the previous Dáil regarding the possibility of a clash between the dispensary services and the new provisions. I quote from his statement at that time: "Within the general framework of policy, however, the Bill proposes a number of important changes. The most notable of these is the intention as expressed in section 56 to replace the dispensary service with a service offering choice of doctor in the general medical service for the lower income group...." We have already had praise of this improvement in the system but as I read it—and I would ask the Minister to clarify this completely in his reply—the old dispensary system will no longer operate and that it is hoped to have general medical service giving a choice of doctor to which existing permanent dispensary doctors and also general practitioners throughout the country will belong through a panel and that the number will be restricted.

One of the things I noted in reading the Bill is that nowhere in the Bill is there a guarantee of security of payments or that the present position of the permanent dispensary doctor will remain the same and that they will not be at a loss. In his explanatory statement the Minister said that agreement has been reached on most points of the new arrangements in relation to medical service and he said it had been agreed also that a special guarantee in relation to entering the new health service will be given to those permanently established dispensary doctors and presumably the same type of guarantee will be given to any type of medical practitioner, not a dispensary doctor, who joins the scheme. My point is that this is not something that should be left to ministerial regulation. The principle should be contained in the Bill but it is not; certainly, I could not find it there. The implementation of this measure may very well be carried out by regulations but the principle should be in the Bill because you there confer a definite right on dispensary doctors.

I raise this point because I know from my own experience—again I dissociate myself from Senator Jessop's praise of the existing system which I know is not working very well—that in the area from which I come in Mayo—I think it is the same in many other areas—there is a shortage of dispensary doctors. Many of the posts that are filled are filled on a temporary basis because they cannot get permanent staff. When we talk of priorities, I think the first priority in health legislation as comprehensive as this should be the people of Ireland and I submit that the second priority is the doctor. I have heard it said many times in academic circles that we tend to educate too many doctors and that we educate doctors for export, that the State is contributing a large measure of finance to the training of young doctors and such a large percentage of them go abroad to work either as practitioners or to specialise. The tragic counterpart of that is the great shortage of doctors, either dispensary doctors who will be the new doctors taking over the new health services or general practitioners. That is the tragedy for this country. We are perpetrating that tragedy and, perhaps, increasing it if we do not give basic guarantees that there will be no loss to the permanent dispensary doctor in joining the new scheme and if possible that his remuneration will be improved. It is my opinion that dispensary doctors and GPs in this country are not paid in proportion to the work they are expected to do. I noted that it is hoped to encourage group practice and I think that is a practical way of attracting young doctors to remain and work here. I would, therefore, regard the service to the people as the first priority and I would not recommend rationalising and centralising and regionalising to the extent of depriving them of basic services. Secondly, there is the priority of ensuring that we shall have a strong force of medical practitioners and former dispensary doctors—in other words, doctors who will participate in the scheme around the country.

Another matter that has been commented on already and which strikes anybody reading the Bill is the extent to which this is a skeleton Bill which will be implemented by ministerial regulation. In large measure this is the nature of this type of Bill. You can only lay down general principles and there must be a certain flexibility in implementing them. I hope that, as the Bill goes into Committee Stage in this House, we shall go through it with a fine comb and prevent, if possible, by amendment, any unnecessary delegation of functions and any unfettered discretion either on the part of the Minister or the council concerned.

In relation to this, the type of thing I am referring to is contained in section 40 of the Bill which refers to the setting up of Comhairle na nOspidéal. It sets out the functions of the council which are very vital ones. Subsection (1) (b) (vi) of section 40 says that the functions of the council shall be "to perform such other functions in relation to hospital purposes as may be prescribed"—in other words, to do anything in relation to hospital functions that may be prescribed. Under paragraph (d) of section 40 (1), it is provided that regulations under the subsection may provide for procedure for the selection of persons for appointment to the council. These seem to me to be very wide statements. I am taking them as examples of what occurs frequently throughout the Bill. I do not deny that there must be a certain amount of regulation within the general framework of the Bill; I still say there is a real danger in unfettered discretion. This is something that leaves the regulations outside the control either of the courts, because they would not interfere with ministerial discretion, or of the Committee on Statutory Instruments since, if the power of the Minister is too widely framed, it will not come within the terms of reference of the committee to be drawn to the House for special intention.

Another point which I want to make on this Bill is that the Minister said:

The FitzGerald Report emphasised the desirability of having a common corps of consultants, under the regional hospital boards, who would serve in the different kinds of hospitals and who would be selected by common selection procedures.

I would certainly echo that. It is a very fine suggestion but on my reading of the Bill—again I would ask for clarification—further on in section 40 there is a very unnecessary problem emerging. It may be that we will have two types of consultants, one for the State hospitals, if you want to call them that, and the other for the voluntary hospitals.

It appears that the consultants to the voluntary hospitals, although they will be paid by the regional boards, will be governed in their day to day operations by whatever the hospital board is, whereas the consultants to the other hospitals will be paid by the regional health boards and yet appear to come under the local health board for their day to day regulation. Coming under the local health board means coming under the executive officer of the local health board particularly if sections 21 and 22 apply. These refer to the suspension of members.

I do not say whether this is good or bad but, from my knowledge of consultants, I do not think you will get them to work in terms of reference under which they can be suspended by the chief executive officer of the health board. They just will not accept that. Therefore, you will find that there will not be interplay between the consultants to voluntary hospitals and hospitals set up under this Bill. This would be very sad because it would only perpetuate and continue the distinction which people now make, and often quite a wrong distinction, that the voluntary hospitals are somewhat better than the local authority hospitals or the hospitals to be set up under this Bill. I would ask for clarification particularly on subsection (8) of section 40 because it seems to me that a distinction is being made between consultants to voluntary hospitals and consultants to other hospitals which would prevent what the Minister obviously wishes for, the interplay between the consultants when this distinction no longer exists.

Since one tends to be critical rather than complimentary in referring to a Bill, I should like to say that there are a number of small matters I hope to see amended on Committee. Apart from that I welcome the Bill. It is a very commendable piece of legislation. It has been brought in, in a short time. I associate myself with those who complimented the Minister on getting it through the Dáil so rapidly and yet accepting so many good amendments from all sides of the House. I would again appeal to the Minister not to regard this House as a rubber stamp but to realise that we are willing to do our homework in the hope of contributing other amendments so that the legislation will reflect the best health services for this country.

Ba mhaith liomsa, leis, comhgháirdeachas a dhéanamh leis an Aire as ucht an Bhille seo a chur fenár mbráid. Tá a fhios againn go bhfuil an-shuim ar fad aige i gcúrsaí leighis, i gcúrsaí sláinte agus traoslaím dó agus guím fad saol dó san obair atá á dhéanamh aige.

I wish to add my voice to the voices of those who complimented the Minister on bringing such a well thought out and well designed Bill before us. Some time ago I had the privilege and pleasure of listening to the Minister delivering a lecture on health and the health services. The enthusiasm with which he spoke and the fervour of his words and sentences showed how his heart was set on healing which in essence is, I suppose, one of the greatest extensions of the precept of charity.

I remember that night when I listened to him some words of St. Luke's dealing with the miracles of Our Lord came to my mind: "When the sun went down all those who were sick with divers diseases were brought to Him and He laid His hands on them and healed them." Those are the sentiments of the Minister. They are our sentiments. It was with a sense of shock that I listened to the contribution of Senator McGlinchey when he so rightly exposed what he considered to be abuses in the health service as it exists now. I am sure this came as a shock to most of us. We were not aware of such abuses. Even though there may be abuses, and there possibly are abuses, I like to think that there are very very few and that, by and large, our medical service in all its disciplines is one of the finest in the world.

Healing, as I said, is a great act of charity whether it be the healing of the soul, the mind or the body. Down through the centuries traditionally the healers, doctors, nurses, mid-wives were always honoured and revered in this country. Many of our old surnames—Hickey for example—were derived from words dealing with medicine or healing. A collection of our proverbs on health if put together and expanded would, indeed, make a very fine textbook: "Tosach sláinte codladh; deireadh sláinte osna"; "Is fearr an sláinte ná na táinte."

Our wise men in the past in our own language put in a few sentences what many modern medical textbooks would not say in hundreds of pages. If I say that our doctors and nurses today are in the best traditions so far as healing is concerned, healing of the sick and comforting of the afflicted, I am not guilty of exaggeration because in general, in spite of the abuses we come across now and again, they give something that no Minister could legislate for, that is, kindness of disposition, great charity and a very high standard of integrity. Very often we do not give our doctors and nurses credit for all this. In Britain they are given credit. I have heard nothing but the highest praise of our nurses and our doctors in Britain.

There are many disciplines in medicine and one is tempted to deal with a number of them, but I shall confine my remarks to just one section of the profession. I refer to dispensary doctors. The dispensary doctor is, in my opinion, one of the unsung heroes. As small children we went to him with our cuts and our bruises. He came to our houses and treated our parents and ourselves. He knew us and he always had a kind word. We often called to him on the way home from a hurling or a football match and he tended our wounds, putting in a stitch or two when that was necessary. There was never any question of who would pay or how soon. His main concern was: "What kind of a match did you have?" and, above all, being a local man: "Did you win?" That is my picture of the dispensary doctor and I believe that the more that can be done to facilitate him the better it will be. Many people prefer to go to their family doctor first. No one likes going to a specialist. Many of these dispensary doctors are very skilled men. Not alone have they an excellent medical training but they have a kind of instinctive power of diagnosis. I could give instances of dispensary doctors who diagnosed in a matter of minutes cases which subsequently baffled specialists for quite a long time.

As most Senators agree, this is primarily a Committee Stage Bill. There is just one particular section upon which I should like to say something. I refer to section 65. It is, I believe, the most important section in the Bill. The old apophthegm runs: "Is fearr galar a sheachaint ná é leigheas". Roughly translated, prevention is better than cure. This section deals with the child health service and the school health service. Subsection (2) of section 66 provides that a health board shall make dental, ophthalmic and aural treatment and dental, optical and aural appliances available in respect of defects noticed, without charge.

Speaking from my long experience in a national school, I can say that practically every childhood disease or physical defect hits children from birth up to the age of 14 years. It is in these years they contract measles, whooping cough, skin ailments. It is in these years that defects in speech, in limbs, in sight and in hearing will show themselves. It is a vital matter that these ailments and defects should be diagnosed early and successfully treated. One of the most important examinations a child undergoes is the first medical examination in the national school. The medical officer does not examine the child as the result of a complaint by the child. Normally, people go to a doctor when they feel ill and they are examined for the particular ailment about which they complain. The medical officer in the school examines the child from top to toe and looks for defects. I can give a particular instance.

Some years ago following an examination by the medical officer the parents of one of the pupils called on me. His little girl of 11, a fine healthy child apparently, was ordered to have a specialist examination. She had never complained. To all appearances she was in perfect health. On specialist examination it was found that her heart was defective in some way. She underwent a six to eight hour operation. I was subsequently told that if the operation had not been performed then she would not have lived beyond 35 years of age. There is a happy ending; the child took up nursing herself subsequently.

Many, many children suffer from severe defects in hearing and in eyesight. Very often these defects are not noticed by the parents. Very often they are not even noticed by the teachers, especially if the child has a very high IQ. A child with a high IQ learns to lip-read very quickly and learns to anticipate. In some cases we ourselves performed unobtrusive tests when our suspicions were aroused and recommended the parents to have the children examined and the examinations invariably proved we were right.

The most efficient way in which to deal with these health problems in children is by having regular school examinations. At the moment there is an examination every three or four years. That is not enough. School medical examinations should be held not less frequently than every two years. I note with great satisfaction that the Minister intends to have a pilot scheme in both the vocational and secondary schools. That is all to the good. It is only right that there should be continued medical supervision. The greater care we give children at primary school level, the surer we are that there will be less need for hospitalisation in later years.

I should like the Minister for Health to have an informal chat with the Minister for Education, or some of his officers, in an effort to get co-ordination between these Departments on other health matters. In every primary and secondary school lectures are given on hygiene and health matters. Most pupils in national schools come from homes where they have been well trained, but some are not so well trained in matters of health and hygiene and these require training.

A large number of national schools have no playgrounds or playing fields. One of the greatest safeguards against disease in later life—when I say disease I mean mental and physical disease— is a childhood and adolescence spent playing games whether free play or organised games. Such games give children a healthy outlook. They learn to use their lungs in order to breathe properly; their interests become focused on sports and athletics and they develop a balanced mind. Unfortunately, many people who are mentally ill today lack the training that games can give. We have often heard that the Battle of Waterloo was won on the playing fields of Eton. I am sure my friends on the other side of the House will not take umbrage if I say I believe the last general election was won on the football pitches and hurling fields of this country with particular reference to Cork Athletic Grounds and Croke Park. Be that as it may, I think the provision of playgrounds and playing fields is an investment in health.

I should like to end by again complimenting the Minister on the excellence of this Bill. I look forward to the Committee Stage.

It is generally agreed there is a need to improve our health services. There is a humanitarian obligation on every society to provide a health service for its people. It is not an easy task to draw up a Health Bill. What we are doing today concerns the lives of thousands of people who are walking around at present in perfect health, but when this Bill comes into operation a high percentage of these people will benefit from it.

I am not happy with the Minister's contribution of 50 per cent. I do not think he was over-generous. Rates are a problem. As sure as night follows day the rating system will get out of hand and we shall have to introduce some form of insurance to meet our demands for a health service. At present most firms and responsible trade unions have accepted that a large increase in wages has to be granted. This will directly or indirectly increase the rates because all local authority employees will get an increase as well.

The man earning between £15 and £16 with two or three children is not really covered. That sort of wage is not a colossal amount in the year 1970. Many of these people are paying loans on houses as well as furniture repayments. I do not want to suggest that the health authority was not generous in the past. It gave as much service as possible where hardship was proved but in the sort of case to which I have referred there was no way out. When the wife or one of the children was sick and the doctor had to come to the house, if the family did not have a medical card, the doctor looked for his fee which might be as much as two guineas. If the doctor had to make three or four visits in a fortnight that could well mean eight guineas, almost 50 per cent of the man's earnings.

Another category which concerns me are the people around the £1,200 mark, as well as those with a valuation of £60. When a man in the £60 valuation enters a private ward in a hospital his bill for maintenance alone is £26 5s. That may be an alarming figure but I have checked on it and that is the figure in the Limerick Regional Hospital. I think it is excessive.

I come now to people, who I think have always got a very unfair crack of the whip, and they are the mothers and fathers of mentally handicapped children. I know of cases in my own county where people have to keep the child at home to look after it. It is a very great cross for a family to have a mentally handicapped child. These are not isolated cases. Recently I read that in 1966 in my own city and county out of 3,000 births 75 were mentally handicapped. In view of that alarming figure we should have a single authority under the Minister for Health to deal solely with the mentally handicapped. The matter should be regarded as a priority. In 1948, when a very serious disease threatened the nation, I am glad to say it was eliminated because the matter was taken seriously and treated as a priority. I am referring to tuberculosis which, thank God, is no longer the threat it was in the past. There are many other aspects of the Bill to which I should like to refer but, if I move a little to the left, I hope it will be accepted because I am interested in national health payments.

Debate adjourned.