Dáil Éireann debate -
Tuesday, 8 Mar 1966

Vol. 221 No. 7

Committee on Finance. - Vote 48—Health (Resumed).

Debate resumed on the following Motion:

That a sum not exceeding £17,337,000 be granted to defray the charge which will come in course of payment during the year ending on 31st day of March, 1967, 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 Local Authorities, miscellaneous Grants and a Grant-in-Aid.

(Minister for Health.)

Mr. P.J. Lenihan

I spoke at some length on this last Thursday and all I want to do now is to emphasise a few points. I should like to mention again the geriatric services. The care of old people brings out the best in the members of voluntary organisations and every encouragement should be given to such organisations. Paragraph 84 of the White Paper points out that voluntary organisations can often provide the most effective home aid. It also urges co-ordination between the work of voluntary bodies and the appropriate public officers. When I speak of encouragement, I do not mean lip encouragement but actual financial encouragement. In Westmeath we are giving financial encouragement to a voluntary organisation in Athlone who are building a home for old people and providing them with amusements such as cards and television two or three nights a week.

Again I should like to congratulate the Minister on what he has done for the rates by freezing the cost to the rates of health services at the figure obtaining in 1965-66 and ensuring that any growth in the health services in future will be the responsibility of his Department and not of the rates. It is a big step forward in the stabilisation of rates and the Minister deserves thanks for it. I am sure when we come to strike the rates in Westmeath and other counties, due tribute will be paid to him for what he has done.

I want to make a slight correction. There was a certain amount of doubt regarding the origin of this White Paper. Fine Gael claimed it was theirs and Labour said it was in their policy document. To illustrate, I asked if this White Paper was by O'Higgins out of O'Malley or by Kyne out of O'Malley? One thing is certain, however, O'Malley is the mother. He deserves every thanks for the introduction of the White Paper and the matter of freezing the rates as I mentioned.

Mr. T.J. Fitzpatrick

(Cavan): I suggest it might be stillborn.

Mr. Coogan

We have heard a lot about health over the past few days. Many of us feel after this winter things are not so healthy. I should like to draw the Minister's attention to the serious situation that obtains at the Regional Hospital in Galway. That hospital is crowded to the door and there are young nurses and other staff run off their feet trying to cope with the situation while, within a few miles, at Merlin Park, there are empty beds, empty units, that could cater for this overflow. This has been put to the Minister recently and I hope he will give it sympathetic consideration.

Another solution would be the extension of nursing services to the homes of old people who are sick. That would relieve the situation in the hospitals. We are clearly blessed in Galway in having the St. Joseph's Nursing Society and I take this opportunity of paying tribute to them for the trojan work they are doing silently. If this work could be extended throughout the county it would help enormously. We have the other nursing groups who visit the homes but not to the extent that I would like to see it done. Take the case of a man who has to go out to earn his bread and leave a sick mother or father at home. The situation may become so serious that he has to give up his job, but if it is his mother who is ill he would certainly not be able to nurse her. The suggestion I have made in regard to home nursing would relieve the pressure on our hospitals.

Recently I brought to the attention of this House the case of four young nurses at the Regional Hospital in Galway. The Minister did not cover himself with glory in regard to the line he took on this case. I should like to repeat what I said then. A number of young nurses who had worked all night were expected to get up after two or three hours' sleep and attend lectures several days a week. They were dismissed from the staff of the Regional Hospital because, being so fatigued, they could not attend these lectures. These nurses were prevented by the authorities from sitting for their examination. Due to the great work of the Nursing Association they were allowed to sit here in Dublin for the same examination as their colleagues had done. I am proud to say that three of the girls who sat for it passed in flying colours. These girls were not given a fair crack of the whip in the first instance, and the Minister should ensure that such a situation does not arise again.

With regard to medical cards, what happens to a breadwinner who becomes ill? Heretofore, he did not qualify for a medical card. When he falls ill, he has to provide very expensive drugs. There is no income. Those drugs are required immediately and the longer the delay the longer the return to health will be delayed. I would like to know if in the interim, anything can be done to deal with such a situation? The kind of situation I have in mind needs to be dealt with fairly quickly because the unfortunate man cannot pay for the drugs and he might decide to do without them. This would endanger his life and the future of his family. I would like to know if anything can be done to deal with such a situation. There is no income or little or no income and something should be done to meet the situation.

With regard to the issue of medical cards I cannot understand why we have not a set standard throughout the country. It is rather strange that in the western part of the country fewer medical cards are issued, pro rata than in the eastern part of the country where the land is rich, unlike the poorer sections of the west. Why are the standards against the people in the western regions while they are with the people, if I may say so, in the eastern regions? Those unfortunate people have been deprived of medical cards. There is many an unfortunate case which we raise and the people get the medical cards because we bring forward the actual facts that may have been ignored.

We have been told about the White Paper on health. Between all the promises Fianna Fáil have given, white papers, blueprints and what not, there is more paper in my home than would wallpaper many a house five times over. What do they amount to? We have a promise of this being the cure for all ills. We have been told, for instance, about the choice of doctor. What choice of doctor will the people in the isolated parts of the country have? Take, for instance, the Islands of Aran. What choice have they of a doctor there? We know the doctor is based on the larger island. I concede you could not have a doctor on every island. That would be a financial impossibility. In the very rough weather such as we experienced recently and as we experience every winter, the people are isolated completely and it is quite impossible for a doctor or a priest to get to Inishmaan. The priest comes first and the doctor comes second to Inishmaan. The island of Inishmaan and the island of Inishere are very particular cases and I would like to know if something can be done with regard to them? They have a priest in Inishere and they have a priest on Inishmore but on Inishmaan they have neither priest nor doctor. The people are at the mercy of the elements and during the greater part of the winter things there are in a very bad way.

Last Friday I got a ring from the Aran Islands and I was asked what the possibility was of getting a helicopter for two days. A man on the island was very ill. The weather was such that while a lifeboat could go out it could not get to the island because of the rough weather. The lifeboat people were willing to help. They rang me to inquire about the possibility of getting the helicopter. I contacted the medical people and they said it depended on the doctor on the main island. The doctor on the main island did not know what the condition of the man was. He could not diagnose and he could not get there to help. In such a situation has the doctor to consider the financial implications and play for time while an unfortunate man is left with his life perhaps ebbing away? This can happen around those islands.

There will have to be some under-standing so that a doctor will have a free hand to call a helicopter. As I said, I got to know of this on Friday evening and I told the people on the island it would be impossible to have a helicopter there at that hour because daylight would be against them. I told them to ring me in the morning and let me know what the seas were like. I hoped the lifeboat would be able to go out. They rang me in the morning at 11 o'clock and said the seas were still very rough and no boat could land. I contacted the medical people in Galway. I pointed out the situation and said that this man required both priest and doctor and something would have to be done. In the meantime, I rang Baldonnel. I told them I had no authority to call a helicopter but I said the reason I rang was if a doctor rang them it was important that they would be ready. I pointed out that the man was extremely ill and needed a priest and a doctor.

Half an hour later I had a ring from Baldonnel saying they were on their way and they were treating this as a mercy mission. I would like to pay tribute to them for the part they played and I would like to pay a special tribute to the officer in charge. He did not waste time but dealt with the situation as it should be dealt with. They asked to have a priest and a doctor ready at the Regional Hospital in Galway. They went to the island and they brought back the patient. The whole thing was carried out in a few hours. There should be some understanding, when a situation like that arises in the islands of Inishman and Inishere, so that a helicopter can be made available. Are we going to measure life by a few pounds? That was treated as a mercy mission by the Army and I do not think there can be any charge for such a mission. In fact it was the medical authorities who called. I only pointed out the situation. They acted, and rightly so, and dealt with the case. I would like the Minister to do something to ease the situation of the people on those islands. I am surprised to note that more medical cards are issued in the wealthier counties than in Galway. The standard should be checked by the Minister to ensure that people who are entitled to medical cards in my area are not deprived of them.

Once again I appeal on behalf of the parents of the mentally handicapped children, and especially those of the low grade type. Unfortunate people are trying to deal with them and they find they cannot leave their homes —somebody has to be around all the time and such cases are crying out for the Minister to do something to help them. I can, as can every Member of this House, point out such cases and I would appeal to the Minister to do something to expedite the hospitalisation of such unfortunates.

The Minister should check up on and do something about an improvement of the hospitalisation at the regional hospital to prevent overcrowding. I fear to think what would have happened had we had an outbreak of influenza such as they had in the North of Ireland. Thanks be to God we were spared that but the Minister might examine that position and implement the request of the deputation met by him last week.

Mr. Davern

I wish to compliment the Minister on the degree of energy he has displayed in bringing forth this White Paper and, furthermore, to congratulate him on the way in which he has introduced it in this House—not as an instrument for political hatcheting, but rather to get a clear overall picture from each and every representative in the spirit of co-operation and constructive criticism because, without constructive criticism any health scheme we formulate, or is formulated in this country, cannot be effective. Therefore, we must view this not as anything partisan but as something which will redound—if properly legislated and implemented—to the success of the entire community. It is on that note that this debate has progressed so far and, indeed, I would hope it will eventually terminate on that note.

We must at all times be conscious of the health of our nation and, in particular, we must lay emphasis on that of the poorer sections of our community, many of whom cannot, through their financial resources, avail of specialist treatment or the aid of specialists at present. It is our duty as a Government, as a Christian community, to ensure that lack of financial resources will not preclude anyone from gaining the very best medical advice and treatment available within the State.

In an ever changing world we must constantly review all regulations but particularly health regulations. The dispensary system which has operated here for a long number of years was, and is, indeed, today, satisfactory. It was in its time even more so because it brought to the rural community, in particular, and to isolated areas, the service of a doctor for not only the very low income group but for the middle income group also and even those in the higher income brackets. It was, in fact subsidisation of a doctor in some areas which might not normally have been able to support a private doctor. Therefore, we have a lot to be thankful for as a result of the dispensary system, but we cannot allow things to remain static. Where improvement can be effected, it is our duty to do so and to ensure that the best possible value for money is obtained from the service provided by this State.

In many instances, it will not be practicable or possible to give a choice of doctor to each section of the community but, where it is possible, it is highly desirable, not only from the medical point of view, because there may not be a terrible difference between one doctor and another, but also from the psychological aspect. When a person knows there is a choice, it eliminates a lot of frustration and a lot of the feeling that he is only taking Hobson's choice. Therefore, the Minister made a very wise suggestion when he intimated to the House, through the White Paper, that a choice of doctor will be available, where practicable.

We can also gain much from viewing our health services and their future improvement against a background of past experience and in the light of economic growth and future development. Our social system has revolutionised itself completely since the dispensary system was first introduced. Therefore, it is high time that we should review and appraise critically the present health system with a view to bringing about worthwhile and effective changes. We can also concede that, with the passage of time, health has become a very expensive commodity when it breaks down. Sickness has become prohibitive not alone for the lower income group but for the middle income group and, indeed, for some of the higher income group who have long and protracted illnesses or a repetition of recurring illnesses. Those people, irrespective of what their income may be or what their valuation may be, must be catered for in any future health proposal. People with £2,000 a year, if committed to a constant heavy and expensive demand on their resources, will soon feel their income and their standard of living being depleted by this heavy drain on their income. So, it is imperative that we should embody in the future development of the health services some clauses which would cater for such eventualities. They are not isolated; they occur daily, monthly and yearly.

The Minister made one great concession to the health services and, indeed, to the local authorities who in many instances operate the health services in their area in so far as he has frozen, at this stage, the heavy demand on the rates. The benefit of any increases effected this year may not be felt this year due to the fact that many councils and local authorities have now got to make good the debit which they did not fully levy last year but in the future development of any health service there will not be retardation of progress because of people's natural reluctance to increase rates. This I feel will redound to the benefit, not merely of the rates, but will also redound to the benefit of the entire population because a more comprehensive form of health service will be envisaged and implemented in the future.

The regionalisation of our health services is also a very practical and worthwhile development when all too often, we have had duplication and wasteful costs in administration. Services which could have been regionalised for specialist facilities, which might not have been provided in each local authority area, can now be availed of in the centre of the region and the very best and the ultimate in scientific equipment and in practical experience from specialists can be made available to the people resident within that region. In this the Minister has made a very worthwhile contribution in so far as the proper co-ordination of our hospital and health services will again redound to the benefit not merely of the profession and the people who have to operate and manage the hospitals but also to the benefit of the public at large as well. They cannot but again from such a fund of skill and equipment being made available within easy reach of each local authority within the region. I have one misgiving. I am afraid that the local people might be inclined to lose contact with it if a proper liaison between the authorities, the local councils and the regional boards is not maintained. We must ensure that such a severing of contact between the boards and the populace does not occur.

I am disappointed, frankly, that greater emphasis was not laid on mental health. The mental health service is the Cinderella of the health services. I speak not merely of the mentally handicapped but of the mentally ill. These people are for the most part housed in antediluvian and early Victorian hospitals which were established when the whole concept of mental treatment was far different from what it is now. I would ask the Minister, when the commission's report on mental health comes before him, to pursue a vigorous policy to rectify the tragedy whereby many of our people were locked away, forgotten and isolated from the realities of life behind high walls where they could neither see nor be seen. With a more enlightened attitude on mental health we should develop this aspect of the health services, and give it top priority in any future development of capital expenditure on hospitalisation.

The provision of drugs and medicines is a very worthwhile exercise. When the cost of drugs even for the ordinary person who is ill once or twice a year has become exorbitantly high, we must ensure that people in the middle income groups are catered for in a special way, and that they will not have to pay the tremendous costs—the extortionist costs I may say—which are at present charged.

The White Paper has brought to the forefront the role of the nursing profession and shown it in a true light. Without the great devotion and the high degree of expertise these people have attained through their career and training, no health service can function nor can it be implemented fully. The White Paper has given a new status to these people to whom I feel a proper recognition of their profession is long overdue.

The dental services leave much to be desired and I am glad the Minister is revising the dental services as such. They are now to get an impetus which will do credit to each and every section of the service, and to the Government for implementing it.

This scheme or any other scheme cannot be fully implemented without the full and proper co-operation of the people entrusted with it. Therefore, it is of paramount importance that those who are engaged in the health services should give of their very best, and there should be no frustration or impeding of the desire of the Minister and the House to give better services to every section.

The abolition of the health card will be of benefit. Laying down standards for the nation will abolish completely the most degrading part of the present health services, that is, the investigation before the granting of a health card. At times that investigation was rather peculiar, and oftentimes the people concerned were not consulted, but their neighbours and other sources were consulted, and it was on that information that their entitlement was gleaned. This built up a resentment, and a justified resentment, at the method which was used. I trust that setting down a national wage level and a poor law valuation will eliminate that obnoxious element from the health services.

Mr. P. O'Donnell

We all appear to have become very health conscious in recent years. It would be no harm if we threw our minds back and gave credit to those who really did something for the health services of this country. When this State was established we took over hospitals, some Victorian, many archaic, and many in a deplorable condition through lack of building or reconstruction as a result of lack of capital during World War I. The old Cumann na nGaedheal Government—and I do not think they ever got the credit they deserved—set up the Hospitals Sweepstakes Trust and as a result many millions of pounds were poured into the building of new hospitals and the renovation of old hospitals. We remember how at that time the Bill legalising the Hospitals Sweepstakes was bitterly opposed on many grounds, but without the millions of pounds which we received from the proceeds of the Hospitals Sweepstakes I wonder what condition would our hospitals be in today, and I wonder how many hospitals we have got would never have been seen. We took for granted the flow of funds from the Hospitals Sweepstakes and we never gave credit to the people who first initiated them, and made them a success, and had the foresight to introduce legislation here to legalise this method of procuring funds.

We had a change of Government in 1932 and things were let drift. Nothing was done for the health services for at least ten years, or possibly 12 to 14 years, after Fianna Fáil came into office. We find that in 1945 the median age of death of those suffering from tuberculosis was 30.6 years. The first inter-Party Government took office in 1948, and the first thing they did was to acquire buildings in an endeavour to eradicate the dreadful disease of tuberculosis. The House will recollect that at that time the Minister for Health was instructed by the Taoiseach and the Government of the day to acquire buildings for the purpose of housing and giving hospital treatment to sufferers from TB.

In my own county, an industrial school was taken over and made available to patients who suffered from TB. Regional sanitoria were set up throughout the country. As a result, we find that, instead of 30.6 years being the median age at death in 1945, it had risen to 58.8 years in 1964—practically double. The first inter-Party Government deserve credit for that and for endeavouring to wipe out human tuberculosis in this country. They succeeded in doing so with the result that some of these sanitoria are now being closed down. Even in my own county, the sanitorium taken over in 1948 is now about to be closed through lack of patients, thanks be to God.

The policy of Fianna Fáil is "Anything you can do I can do better than you". While we were in the actual process of drafting the Health Act, the first inter-Party Government went out of office and, in 1953, the Health Act, 1953, was introduced. We were assured by the then Minister for Health, Deputy James Ryan, who is now a member of Seanad Éireann, that that Health Act would cost 2/- in the £1 on the rates: He said it in this House. I myself heard him say that it would cost 2/- in the £1. Let us look at the graph of costs of health services since then. In 1947-48, the health services cost £5.7 million: today, they cost £30 million and it is now proposed to add another £4¼ million to that figure. All during the time, we have had a falling population in this State.

When the turnover tax was introduced here, I distinctly remember saying, that the ramifications of its introduction, particularly on local rates, would not be felt for some time. Looking at the graph published on page 57 of the White Paper, we find that while the average increase in health services from 1947 to 1962 was approximately £1 million per year, there was a jump between 1963-64 and 1964-65 of £5 million. Can anybody tell us or can anybody seriously suggest that we have got value for that extra £5 million spent in that particular year? I do not think so.

While we accept this White Paper, we say it does not go far enough and it has come too late. While we accept it, we do not accept the method of raising taxation for the purpose of implementing what is contained in that White Paper. We think that the health services of this country should not cost the taxpayer and the ratepayer £34¼ million in the year. I am aware that the Minister has told us, in writing, and has also stated in the White Paper that he is satisfied that the local rates are not a form of taxation suitable for collecting additional money on this scale. He says, also, that the cost of further extensions of the services should not be met in any proportion by the local rates. He gave an undertaking that the Government would ensure that the total cost of the services falling on local rates in respect of the year 1966-67 would not exceed the cost of the year 1965-66. The Minister has given us that undertaking. I certainly would accept that he will keep his word.

Yesterday, in Donegal, we had the unfortunate privilege of striking a rate representing an increase of 6/1½ in the £1. We in Fine Gael who are on that council proposed that we should defer striking the rate until after the Budget until we would find out if the Budget would have any impact on the rates. We were then assured that any additional cost which may be incurred in the health services as a result of further taxation which may be imposed in the Budget would be borne by the Minister and, on that undertaking, we struck this rate. I presume the Minister will carry out his undertaking and that, if expenses are incurred as a result of the imposition of any further taxes, the local rates will not be asked to bear them. I am glad to have the Minister's consent to that statement of mine and that he agrees with it.

One of the principles—and it is a principle with which I agree—in this White Paper is that there should be a choice of doctor. But are we not makeing too much of this? Where are we to have a choice of doctor? The only places I know of where we can have a choice of doctor are in the cities or the towns of Ireland but certainly you will not have a choice of doctor in rural Ireland. Indeed, the position at the moment is that we are very glad to be able to say we have doctors in some of the dispensary districts of rural Ireland because some cannot find doctors. This White Paper will not be implemented for some years to come. Unfortunately, there is an unrest growing amongst the medical profession in the country through lack of directive from the Department of Health. We are told we will not replace dispensary doctors pending the implementation of the White Paper. We are also told we cannot say exactly when this White Paper will be implemented.

We have some dispensary districts at the moment where we cannot find even a locumtenens for the area and, if I might mention one, it is Aranmore Island, an island off the north-west coast of Donegal. We have neither doctor nor nurse on the island and we are unable to procure one. Some dispensary doctors have been unable to take a holiday because they cannot find a locum, unless the doctor in the adjoining dispensary district is prepared to oblige him. There is a growing unrest throughout the medical profession in this State through lack of some positive directive from the Custom House on this particular matter. We have only to look at the staffs of our hospitals throughout the country to observe the number of nonnationals employed there while our young graduates are finding employment in America and elsewhere. It is not because of lack of reasonable remuneration but it is through lack of some security of tenure that these young men are being driven abroad. I should like if something could be done to ensure that there will be a steady flow of our young graduates from the medical schools into the health services of this country.

Despite what we are spending on health services—£30 million—we find that the dental services throughout the State are completely unmanned. Most local authorities are unable to procure whole-time dental surgeons to man the posts vacant in their areas. We find even in the case of the school inspection of children that there is sometimes a lapse of three or four years between inspections in relation to the health of children in isolated schools. Recently, I discovered a case where the schoolteacher had not seen the school doctor for almost three years. On inquiry I found that owing to periods in which we had no assistant county MOH, we were unable to carry out the usual inspections that should be carried out in these schools.

Again, people entitled to dentures under the Health Act have been unable to procure them and many Deputies, particularly county councillors, are continually making representations to local authorities to ensure that dentures will be given to those entitled to them, but nothing can be done. I know people, holders of medical cards, who had teeth extracted three or four years ago but are unable to get the dentures to which they are entitled.

I think Deputy Davern referred to the nursing service. Jubilee and district nursing services are one of the greatest social amenities but there is an unfortunate tendency now to ignore these services and in many cases in rural Ireland where such services were provided, no attempt is being made to continue them. That is a tragedy, particularly when there is so much emigration. The young people have gone and there is nobody left to look after the aged when they need attention. District or Jubilee nurses are absolutely essential in those circumstances. If the Minister gave that minor branch of the profession his attention, something good might come of it.

I wonder what is the reason for the high cost of drugs. I fear that drug importers and those who have a monopoly in that regard are responsible. One has only to cross the Border to see the difference in the cost there. Has the Minister gone carefully into the question of the importation of drugs from the US? Has he tried to find out if there is not a monopoly of the agencies and also a monopoly in the importation of the drugs? That could possibly be the cause of the high drug prices here and should be looked into. I think the Minister did this once before and some good resulted in the case of a certain drug, the price of which was drastically reduced.

I sincerely hope that no district hospital built in the past 14, 15 or even 20 years, since the war, will be closed. In my own town of Dungloe, the inter-Party Government built a magnificent district hospital which we had sought for years. The Minister's immediate predecessor said it should never have been built and it was with the greatest difficulty that I persuaded him to advertise the appointment of a permanent medical officer. I do not think such a permanent appointment has been made or that it was advertised for a considerable time. I sincerely hope that hospital which serves a very poor part of the western Gaeltacht and provides much needed service, will never be closed.

I am glad something is being done for the mentally handicapped but if we are to get the medical services that we all wish to see—and that includes the Minister, I am sure—we should bear in mind that taxpayers and ratepayers cannot afford it and some other method of procuring money for these services must be found. There is no better method than that suggested by Deputy T.F. O'Higgins, namely, insurance. We know how well it has worked in the Voluntary Health Scheme for the middle or higher income group. Nothing is offered in this White Paper to the middle-income group other than that where there is excessive expenditure on drugs, there may be a State contribution. I am certain anybody in permanent employment would have no objection to paying a weekly contribution for a medical service and no employer would object to contributing, provided he was satisfied that in time of need the employee, his wife and family would be adequately looked after and dispensary, specialist or hospital treatment provided. That would be a much better way of paying for health services than asking the taxpayers to pay when this White Paper is implemented, if ever, over £34 million.

If the cost of keeping up the hospitals continues to rise at the rate shown in the graph published in the White Paper, the taxpayers cannot bear the burden. I remember President de Valera, then Leader of the Opposition, on one occasion when the Budget was being introduced by Deputy Sweetman interjected: "We have reached the limit of taxation". I wonder what he would say were he sitting in the same seat listening to the present Minister for Finance introducing his Budget tomorrow. Not only have we reached the limit of taxation at a local level but we have also reached it at the national level.

Mr. Kenneally

I do not intend to delay the House although I could talk for hours, giving examples and quoting problems from my constituency. I think the House has heard enough of those cases but I want to add my voice to the voices of those who have acclaimed the contents of this White Paper, having studied it objectively.

Quite obviously, what is proposed will improve the existing services substantially and, as has been admitted by the Opposition, the present services are quite satisfactory in many respects. The most satisfactory part of the new proposals is the choice of doctor and chemist which must be loudly acclaimed as a positive step to give those in the lower-income group a general practitioner service similar in every way to that enjoyed at present by those who can afford to pay. No longer will the poorer sections be a class apart, nor will they suffer some of the frustrations associated with the present dispensary system in regard to the supply of medicines and drugs.

I also welcome the intention to make better arrangements to assist persons in the middle-income group to obtain drugs where undue expense arises. As a member of a health authority, two proposals interest me particularly. First, it is the Minister's intention to define by regulation the limits of eligibility for general practitioner services. This will remove anomalies as between one health authority and another and will also save the public representative from making many representations he has to make at present. Applicants will know where they stand. This is one of the best features of the proposals. The Minister has said it is his intention to issue a booklet telling each individual to what he is entitled. Secondly, I welcome the relief of the rates which the Minister's initiative has already brought to pass through his undertaking regarding future financing as far as local contributions are concerned.

Deputy O'Connell referred to psychiatric treatment and said that the Minister should study the results of the inquiry made in this regard and act on it as quickly as possible. For the information of the Deputy, I should like to say that the Minister has already made a move in this direction. We in the Waterford Health Authority have been pioneers in regard to psychiatric treatment in the General Hospital at Ardkeen where a special unit has been established for patients requiring psychiatric treatment. This has brought about a wonderful break-through in this field of minor mental disorders. It has also removed the stigma which used attach locally to people suffering in this way. Nowadays if a patient is sent to this unit, people merely say that he has gone to the psychiatric department of the hospital, just as they would say that a person has gone to, say, the orthopaedic department. From my dealings with the doctors and staff in this unit, I can assure Deputies who are members of local authorities that if they require any assistance in this regard, it will be readily forthcoming from this staff. In conclusion, I wish the Minister every success in his approach to this whole question of medical services.

Mr. Ryan

The very sad thing about this particular debate is that it is related to a document called "The Health Services and Their Further Development". It might be better entitled "How We Propose to Make a Silk Purse Out of a Sow's Ear". It would be much better if in this day and age the National Parliament were to take a look at the human and moral need that there is to make medical services available to all and see how best that could be done, rather than that, in the second half of the twentieth century, there should be published, under the auspices of the Minister for Health and the Government, a document which is no more than an apologia for continuing into the twentieth century a medical system which was introduced, not to provide medical or moral comfort, but rather to prevent the spread of plague and fever at a time when the country was riddled with famine, fever and plagues which, thank God, no longer afflict the people. We should consider man's status as a social being and from that status consider what obligations or what rights flow.

We find that there is the obligation to render help to one's fellow-members of society and the right to expect help from one's fellow-members of that society. At this point of time, surely we should consider whether or not it is within the capacity of our society so to arrange things that those in a position to help their neighbours and themselves could do so under a scheme which would apply to all, and by so doing, make the benefits of medical services available without all the restrictions which are inevitable as long as we try to graft on to nineteenth century legislation the future development of our health services.

I do not speak of these things lightly and I do not say them for the purpose of taking partisan advantage. I express these thoughts because I am appalled by the experience of this debate and by the acceptance that it is impossible for us so to arrange things that every person who is earning an income should contribute a little, a minute portion of that income, so as to provide insurance for himself and for other people against the day of illhealth which is inevitable as long as we are on this earth. I am also disappointed that we have once again not learned by our mistakes. The underlying approach of the Government to national problems is spelt out in black and white in their 1958 White Paper on what they called the economic development of the nation and in which they rejected as incompatible with economic expansion the provision of better social services. It is time that we accepted without argument the fact that health is wealth and that if we accepted that, we would be contributing substantially to the economic development of the country, and that we would be preserving the wealth of the country if we ensured that the health of the country was also in good order.

At present, through absenteeism, we lose 14 million working days per annum, an equivalent of seven per cent of the labour force available. That is a figure which is five times greater than what we lose through the now much attacked industrial disputes. One would not be so rash as to suggest that we could reduce that figure to nil. We could not. However, if we were able to reduce it by half, we would be contributing substantially to the health and economic expansion of the country. There is no doubt that if we limit our future health policy to the targets which the Minister puts before us we will not reduce substantially the amount of absenteeism we have and we will certainly compel tens of thousands of people to continue, as they have in the past, to delay obtaining medical aid and to put off the purchase of drugs because they find it beyond their means to buy them.

For these reasons I express not a little disappointment with the underlying philosophy in the Government's approach to the health problem. It is entirely inadequate. It is entirely unsatisfactory and the consequences are going to be a continuation of personal misery and substantial economic loss to the nation. We in Fine Gael have twice invited the public to vote upon our health policy and on each occasion, as the Minister in the course of interjections has pointed out, we have been unsuccessful in getting the support of the people. Of course, the reasons for that are not related to the acceptance or otherwise of our health policy. Rather it is a multitude of influences which come to bear on general elections, many of them to some of us irrelevant, many to many people unworthy, but none the less those influences do operate at general election times. We have no doubt that if there was a referendum on the question of the Fine Gael health policy there would be an overwhelming majority in favour of it and there is no doubt whatsoever about the sincerity of our invitation to the Government to have such a national referendum on the Fine Gael health policy. They could have it on 1st June.

Mr. O'Malley

If we knew what that policy was.

Mr. Ryan

If they are not prepared to do that, quite clearly the electorate will do the necessary——

Mr. O'Malley

Five different policies.

Mr. Ryan

——by voting for Thomas F. O'Higgins, the social reformer, the man who gave us ten years ago a positive charter, a Christian charter which the Government ten years later are unwilling and unprepared to accept. The Minister has been in the Department for almost a year and he pretends still not to know the Fine Gael health policy.

Mr. O'Malley

Let us have it.

Mr. Ryan

If he does not know it, shame on him. He was a member of a Select Committee which he attended twice.

Mr. O'Malley

That is wrong.

Mr. Ryan

Apparently he has not read the debates here in 1961, when we gave here figure for figure, pound for pound, service for service——

Mr. O'Malley

Five different policies were enunciated.

Mr. Ryan

The Fine Gael health policy was spelled out in no uncertain fashion. Every yob in the Fianna Fáil Party has his views on the health services but they are not the Minister's views. The Minister has not got his mind made up, as he says in the White Paper published at such great expense. It shows the confusion there is in the Department of Health.

Mr. O'Malley

Let us have the Fine Gael policy.

Mr. Ryan

The Minister will get it word for word, figure by figure, hour after hour if necessary.

Mr. O'Malley

Deputy Ryan's or Fine Gael's?

Mr. Ryan

Instead of making these stupid interjections the Minister should read the debates and listen to what is being said. If he did that he would find that every Fine Gael Deputy who has spoken has accepted the Fine Gael policy on health in toto but at the same time has expressed the difficulties which even the Minister realises arise in relation to the application of a health policy in every parish, in every mountainside and in every valley in the country. Expressing these difficulties is not to say that there is any division on the Fine Gael policy, on the underlying principle of our health policy which is one of taking a little every week from those who can afford to pay and charging nobody when they are sick and in need. If the Minister does not understand that underlying principle he is becoming as bad as his predecessor, closing his mind, his eyes and his ears and making it impossible for the truth to penetrate into the Department of Health in the Custom House.

We think that the health of our people, indeed the very lives of some of them, so important that it cannot be determined by competition from other demands on the existing tax fund. As Deputy T.F. O'Higgins said during the debate and as he has been saying for years and years, to accept that a 19th century basis for health services is adequate for the future is to accept a continuation of the inevitability of the age-old struggle between the Minister for Finance and the Minister for Health. We do not accept that. The fact that this battle between the Departments is inevitable is acknowledged in the White Paper and in the Minister's opening statement. It has been acknowledged by every speaker on all sides of the House in the course of the debate. We in Fine Gael say that because it is inevitable in the present system we should reject that basis and should not try to continue to make a silk purse out of the abominable sow's ear which has been put before us by the Minister as being capable of improvement.

The White Paper declares that a higher proportion of the middle income group are to be excluded by ministerial order from the health services. The Minister, in a categorical fashion in his White Paper, says that the limits which he will fix for availability of medical services will not include a high proportion of the population. There are some matters in the White Paper which the Minister leaves open to doubt but one thing which is beyond doubt, beyond comment, is that a high proportion of our people will not be included in the medical services. Having regard to the fact that in some counties a high proportion are already excluded, it is apparent that the Minister proposes in some context to cut down on the number of people who at present enjoy whatever benefits there may be in the inadequate health services.

The Minister has also in no uncertain fashion, in both his opening address in the debate and in the White Paper, guaranteed that he will not remove the abominable charges which are now extracted from people when they are sick and lying in hospital and not earning. May I point out, as Deputy T.F. O'Higgins pointed out and as others did, that this iniquitous charge of 10/- a day, scaled down in some circumstances, was not even envisaged in the health policies brought before the House in 1953? It was introduced four years later in 1957. It means we are walking backwards now and apparently we hope to get increased revenue from this source in the years ahead. I should like to point out that this miserable charge of 10/- a day— miserable because it is imposed at a time of human misery—produces onesixtieth part of the total health bill and we are to keep that and by so doing reduce the chances of recovery by increasing the worries of this section of our people. The justification, we are led to believe, is that it will encourage people to get out of hospital more quickly. I always understood that people stayed in hospital when the doctors said they could and should stay but apparently that is not so. Apparently the Minister accepts the theory that people like to be in hospital and would stay there unless they were charged 10/- a day. They are to continue to be charged this iniquitous £3 10s. a week so long as they stay in hospital.

We in Fine Gael find that unacceptable. We think it is unnecessary and unworthy, particularly having regard to the fact that it represents only one-sixtieth of the total cost of the health services, even allowing for the fact that everybody in the middle income group is not charged this 10/- a day, even allowing for the fact that only a small proportion of those people are called to pay it. The fact is that this charge is imposed at a time when the family income is substantially reduced and the worry of this bill is something which medical men will tell you has a delaying effect on a patient's prospects of recovery. On that account we reject the statement by the Minister that he proposes to continue this.

There is another aspect of the White Paper to which I want to alert people to be careful when reading it. When the Minister wants to be specific, he has no difficulty in being specific. But when he wants to confuse and leave things in the arena of doubt and uncertainty, he does so. He leaves in the arena of doubt and uncertainty the amount by which the rates in Dublin city and county are to be increased. He has said in one part of the White Paper there will be no increase in rates in respect of any improvement in the health services. He reiterated that in the introduction to this debate. He went on television and radio and said the same thing. But he did not repeat, as he ought to have, the other section of the White Paper which specifically gives a guarantee that rates in Dublin, and presumably on the eastern seaboard, are to be increased in order to allow him to redistribute the burden of the costs of the health services.

I would draw attention to the fact that in Dublin city only 16 per cent of the population enjoy the services made available to holders of a general medical services card. In Dublin county the percentage is only 13. But in many other parts of the country the percentage is as high as 35, 40 and 45 and in Carlow, it is 47 per cent. If the Minister is going to reduce the burden in those counties where at present over 30 or 40 per cent of the people have medical cards, he can do so only by increasing the cost of the health services in Dublin. If he does it by allowing Dublin the same percentage enjoyment of the health services, it will be bad enough, but from what we can gather the intention is to reduce the number of those enjoying the health services. The consequence will almost invariably be that Dublin will pay a higher rate for a lesser service.

It is about time the Minister was frank with the people of Dublin and of the other parts of the country where he proposes to increase the rates. How soon will he be honest with them and tell them by what amount he will increase the rates, or is this something that will be left over until after the in-famous, long-delayed local elections? Is this one of the factors taken into consideration in determining the timing of the local elections? I can assure the Minister he need not think he will be left alone on this. We will press him month in and month out, and not even the smirk on the Minister's face will be accepted as an answer by the people. We want to know exactly by how many shillings, if not pounds, in the £ the people of Dublin are to be called on to contribute towards his particular silk purse.

The apologia for the health services published by the Minister is more concerned with defending the existing system than with doing something with the future.

Mr. O'Malley

I did not think I wrote it.

Mr. Ryan

This is particularly apparent where it deals with the dispensary service. We are told the dispensary service has many merits. It then recites what it considers to be the merits. It outlines the merits and ends by saying that the only disadvantage is that it does not provide a choice of doctor. I thought we could in the course of this debate simply bury Caesar, but we have come not to bury Caesar but to praise him.

The dispensary service has many defects, not the least of which is the fact that it does not give people a choice of doctor. In Dublin, for instance, in corporation housing estates where the tenants of houses must have families before they are allocated a house and where the new tenants of houses, being young, increase their families in the decade or so after taking up their tenancies, there are dispensary doctors with as many as 8,000 people to look after. It is quite clear that where a dispensary doctor is called on to attend, say, 120 or 140 people in an hour-and-a-half session, he cannot possibly give them a medical service such as the Minister boasts of, which the Department says they have been getting in the iniquitous dispensary service and which they say has only one disadvantage, the fact that it does not give a choice of doctor.

The right of choice of doctor will not make it possible for any man to give proper medical attention to 140 people in an hour-and-a-half session in any morning, and that is what has been happening in our large urban centres where doctors are plentiful, where people pass doctors' surgeries on the way to their local dispensaries. There is no justification for the continuation in any form of a system which compels one State official to see 140 people in an hour-and-a-half session in an area where there are plenty of doctors available or where plenty of doctors would be available if we were to abolish this Victorian concept of providing only a State official to attend the poor in their medical wants.

There are other parts of the country where by reason of the low density in population, dispensary doctors have only a couple of hundred people to look after and if we did not maintain State-paid doctors in such areas, hardship would arise for people there. That has been said by many members of the House, including many members of the Fine Gael Party, and that is not a contradiction of our long-stated intention to do away with the dispensary service where there is a high density of population and where there are ample doctors available to attend to the wants of those high-density communities.

The Minister may, in his supercilious way here and, for propaganda purposes, elsewhere suggest there is a conflict in the Fine Gael Party in relation to the dispensary service. We cannot stop him doing it. We have been trying for years to stop the irresponsibility of the Fianna Fáil Party, but irresponsibility is an endemic disease in Fianna Fáil and we can do little except to continue our best propaganda efforts to counteract the irresponsibility of that Party. However, we shall continue to discharge our duties and hope that, whoever may get the credit for it, some day in our time we shall have a proper medical service, allowing people a choice of doctor, where a choice of doctor is available, and ensuring that doctors are available by paying them out of State funds if the alternative is to be that no doctor will be available in particular areas.

There are certain problems ahead of us in providing the new service, and not the least of those is the provision of surgeries in corporation estates. There are dispensary doctors in some of the corporation estates in Dublin who have been unable to get houses within their dispensary area for the simple reason that every available patch of land has been taken up by the corporation in building houses for their own tenants. As doctors do not qualify as tenants of corporation houses, they have not been able to get tenancies of these houses. At present in most of these estates there are clinics and it is most important that these buildings be made available for doctors in private practice who will be providing the service which we in Fine Gael have been envisaging for years and which the Minister is, to some extent, trying to imitate in the programme he hopes to bring in.

There is another disadvantage of the dispensary service which the Minister and the Government do not recognise, because in the White Paper they recognise only one fault, the lack of choice of doctor. The system under which the eligibility for dispensary service is ascertained debases the dignity of both doctors and patients. I do not know how many Members of this House have ever bothered to study the forms issued by some of our health authorities to determine eligibility of people for the dispensary service. The form issued to the investigating officers requires them to obtain information on such matters as: Is the home well-kept or badly kept? Is the home well-furnished or badly furnished? Are the children well-clothed or badly-clothed?—and other extremely personal questions that should not have any effect upon whether or not a person is to get a general service medical card. By those standards these services are only to be made available if you are a pauper or if you are destitute. That is the kind of system which we are asked to enshrine once again in legislation for another decade or so ahead. We are being asked to give a benediction to the Minister to go forth from this House and prepare a Bill enshrining this philosophy. We in Fine Gael say: "No; we are not prepared to do it". We are prepared to vote for a health service which we have categorically stated will cost £8½ million. What the Minister proposes is going to cost only £4¼ million——

Mr. O'Malley

This is a new line of argument.

Mr. Ryan

We have clearly stated what our health services would cost, and where the funds would be obtained. The Minister says his scheme will cost £4¼ million but does not say where it is to be obtained, whether it is by increasing income tax, by reducing the personal allowances or by increasing the turnover tax. We recall that a few short years ago great money was spent, even out of election time, in boasting of the fact that the iniquitous turnover tax was going to be used to improve our health services. The iniquitous tax was imposed but our health services got worse instead of better. I have no doubt that tomorrow, too, we shall have the whited sepulchres giving out a new hope that out of this pollution of a health service and this pollution of a tax system we are going to produce a beautiful new flower.

Mr. O'Malley

Where is the £8½ million coming from?

Mr. Ryan

The Minister will find all the figures in the speech delivered by Deputy Tom O'Higgins on 23rd November, 1961——

Mr. O'Malley

It is not in it.

Mr. Ryan

——at columns 720 to 746, volume 192, of the reports of Dáil Éireann.

Mr. O'Malley

Where is the £8½ million coming from?

Mr. T.J. Fitzpatrick

(Cavan): The Minister is in office and he has not told us in this White Paper where he is going to get the money to implement this policy.

Mr. O'Malley

I am trying to learn.

Mr. Ryan

I wish the Minister would do his homework or his office work for which he is paid, and for which he is paid far too much if he has not read the Dáil Debates of 1961.

Mr. O'Malley

There is nothing about this in it.

Mr. Ryan

The Minister got travelling expenses for attending the socalled Select Committee on Health Services and he has not even acquainted himself with the minutes of the meetings.

Mr. O'Malley

I did not get travelling expenses.

Mr. Ryan

I never believed in that Committee. I was asked three times to be a member of the Committee and I refused, but I seem to know a good deal more about the health services and about the evidence that was given at those meetings than the Minister.

Mr. O'Malley

The Deputy is the greatest thing that ever hit this House.

Mr. Ryan

I am grateful for the Minister's remark but I doubt its accuracy. Having regard to the in-accuracies in his White Paper, I doubt the veracity of anything he might say.

(Interruptions.)

Mr. O'Malley

Tell us about the £8½ million. Do not run away from it.

Mr. Ryan

I shall make my own speech in my own time and I do not intend to make a speech at the whim and dictation and the rude interruptions of the Minister for Health.

Mr. O'Malley

Do not run away from the £8½ million.

Mr. Ryan

The Minister is now clearly showing his colours. He is not the benign, benevolent, smiling person who came through the television cameras. He resents being reminded that it is now five years since the figures, pound for pound, shilling for shilling were given here in this House.

Mr. O'Malley

I hate hypocrisy.

Mr. Ryan

It was not by pretending we were giving figures by the publication of a White Paper which tells us nothing about what is important. The Minister gives no indication in the White Paper where he is going to get the £4½ million.

Mr. O'Malley

Deputy O'Higgins says he wrote it. Did he or did he not?

Mr. Ryan

The Minister should move cautiously. He knows he was being most provocative in the course of Question Time in which he was claiming credit for things which Fine Gael said ten years ago. Deputy O'Higgins pointed out that these things were said a long time ago by him and he put it this way, that he had written the White Paper. In an hour-long address Deputy O'Higgins made clear what he had written in the White Paper, and the Minister, like all Fianna Fáil people, is a past-master at taking things out of their context. I will make my own speech in my own time. I had hoped to give way shortly to my colleague, Deputy Mrs. Hogan O'Higgins, but if the Minister asks me to give figures, I shall have to give them, or if he is prepared to undertake that even now he will justify the salary he is receiving by reading that debate, I shall be prepared to forgo the pleasure of teaching him. I realise how difficult it must be for some teachers. It must be extremely difficult to teach a dense pupil or perhaps just an obstinate one, but by repetition of these things, there is the hope that in the long run the truth will get through.

I have mentioned the shortcomings of the dispensary service which are not recited in the White Paper, and we shall now come to the third defect of this service which we are told has many merits and but one fault. The third defect is that it produces a very high hospitalisation rate, and that is not surprising. Any conscientious dispensary doctor who is called upon to treat 140 people in a morning, which is a regular thing here in Dublin, finds that the only way in which he can discharge his medical obligation and his moral obligation to patients is by putting them in hospital. The consequence of this is that the hospitals get a large proportion of people who could be treated at home.

By limiting the dispensary service to only a minority of the population, such as now operates, you also compel people to forgo necessary medical attention with the inevitable consequences that the disease or ailment gets worse and will not be treated until hospitalisation becomes absolutely necessary. As a result, we have here the highest hospitalisation rate in Europe and a rate, which instead of decreasing, as one might expect it to do, with the improvement in modern drugs, is increasing and is now little short of double what it was ten years ago.

This is a companion of the dispensary service and it is a third defect. It is a fourth defect if you include the one which has been acknowledged in the White Paper. It clearly indicates the Minister does not accept those things as defects in the dispensary service or if he does, that he is unwilling to admit it. It would be much better for him, and for the future of the health services, if he were to acknowledge those problems. I believe we should look at our problems if we have them and we should try to improve them according to our own lights but there are many people who believe we should determine our social, economic and financial policy by a Micawberlike hope that we may be a member of the European Economic Community by 1970. If we become a member of the European Economic Community in 1970, or at any other time, we will be under very clear and rigid obligations to maintain health and social standards on a level which now operates in the countries who are members of that Community.

We are already a party in respect of some of the clauses of the European Convention on social and medical assistance but apparently we do not accept, in practice, the obligations which already lie on us and which will become unavoidable if and when we become a member of any European community. It is clear that the obligations in the European community are to become common to all countries and we shall have to bring our health services up to the same standards as operate elsewhere.

In Sweden, Denmark and Britain there are free medical services available to 100 per cent of the population. In Germany, France and Austria 90 per cent of the people enjoy medical services without charge. In the Netherlands, Norway, Switzerland and Spain 80 per cent of the people enjoy health services without charge and in Belgium it is 75 per cent. The Minister's proposals involve making the health services available to a small proportion of the population. The present proportion represents on an average 30 per cent. In Dublin city and county it works out at something between 14 per cent and 15 per cent. It is 16 per cent in the city and 13 per cent in the county. We are promised in the Minister's clear, specific undertaking, in black heavy print, in case there is any doubt about it, in the White Paper, that he will not have a large proportion of the people enjoying the health services although all our future companions, the people to whom we are to be bonded tomorrow, have health services available to not less than 75 per cent of the people. This clearly indicates that our health services are not good enough. The minute improvements, which the Minister is now offering, will not permit us to become members of the European community, upon which all our economic and financial hopes are now set.

On page 9 of the White Paper there is a reference to the need for improvements and then there is reference to the fact that expenditure on development in the services could not, in any event, be undertaken in the existing financial circumstances. Unfortunately, we know that to be true. It is not the only necessary thing which is being postponed in the existing financial circumstances but we are entitled to say that those minute improvements are coming late. They could have come into operation, even under existing administration, at any time in the last nine years. The Government deserve to be criticised because of the fact that in days when they said finance was plentiful they failed to bring in even the miserable improvements which are now proposed.

The Minister also indicated in the White Paper that he will not leave in future an atmosphere of uncertainty regarding eligibility for health services. While there are merits in putting an end to all uncertainty there are also dangers. We know the many hardships which can arise in our social welfare legislation. The difference of as much as a penny can mean getting a service and not getting it at all. The danger of bringing in a means test by ministerial regulations rather than by administrative decision is that we will close the door to many people who now, by process of argument or production of evidence of the burden of costs, can get in. We, therefore, express the hope that there will be some kind of way left for grading those benefits so that people will not find themselves excluded by small amounts from all benefits, compared with their neighbours who, by having a minutely smaller income can get all the benefits. If one is to be specific as to the levels of eligibility, it becomes impossible to deal with the variations as between families. There will have to be considerable grounds for manoeuvre if we are to have any kind of a just system.

We are told also in the White Paper that at present no service is designed so that the person must show dire want before he can avail himself of it. That is a quotation from page 16 of the White Paper. Further on in that paragraph we are told:

Eligibility for hospital and specialist services, which are likely to be much more costly, has been extended to a far wider group of the population and, in general, those outside the group statutorily entitled to the services can use them if they can show hardship.

Does the Minister even know what his present health service is doing? In one part of this paragraph he says there is no need to show dire want and further in the same paragraph he says that you must show hardship. It becomes extremely difficult to accept the bona fides of the White Paper which contradicts itself in the one paragraph.

Mr. O'Malley

Surely there is a difference between dire want and hardship?

Mr. Ryan

I should love to know it.

Mr. O'Malley

It is hardship for me to have to listen to Deputy Ryan speaking in this manner. It is not for dire want I am sitting here.

Mr. Ryan

It is clearly for dire want of information which you are paid to get and which you have refused to collect.

Mr. T.J. Fitzpatrick

(Cavan): Are the Government suffering from dire want when they go to New York and from there to Germany for money?

Mr. Ryan

That is only a case of hard-upship.

Mr. O'Malley

Deputy T.J. Fitzpatrick was not here in 1956.

Mr. T.J. Fitzpatrick

(Cavan): We were not kicked out of New York.

Mr. Ryan

There is no difference between dire want and hardship. What are the consequences of these tests which we now apply and which we also will be applying in the future? People make an application for a general services medical card; they are perhaps not as skilled as others might be in expressing their case and because they are unable to prove dire want or hardship, or the two of them, they then trot along to some politician and the politician makes representations on their behalf, and sometimes the representations might not be as clear as the original application. In other cases, more information is extracted from the applicant and an appeal is lodged. I am happy to say that in the majority of cases the appeals are successful but what really angers me is that in due course you get a letter from the health authority, the envelop of which is marked "confidential" and the letter itself bears at the top the word "confidential" telling you the highly confidential information that So-and-So has been given a blue card. But we oblige people to go to politicians to disclose their family income, to disclose their circumstances, to disclose a disease from which they or their family suffer. We oblige them to throw confidence out the door and then the irony at the end of it when we get a confidential letter saying because the people have broken confidence and because we have exposed them to the indignity of disclosing their family circumstances, they will now get a confidential blue card. Apparently the Minister proposes to have something similar in future and, unless people disclose all these things, they will not be eligible for the blue card; unless they disclose all that they will not come within the limitations set by the Minister.

On page 23 of the White Paper the Minister says:

The maximum use of out-patient services will be essential.

We in Fine Gael could not agree more with him. We believe this will be for the benefit of the patients, and we are primarily concerned for the benefit of the patients, but we are also satisfied that the maximum use of out-patient services will bring benefit to the medical service in general, will make it possible for the doctors to give better service than they are giving at the moment. If we accept this as essential, we must also accept the clear obligation of improving the out-patient services available in our hospitals. It is deplorable that in this day and age, in this city of Dublin—and I suspect in most other urban centres—we have not got a system of appointments for outpatients. The result is that people without influence are obliged to go to the out-patients' departments of our hospitals at 8.30 a.m. and consider themselves lucky if they get medical attention by noon, one or two o'clock. Some years ago I had ocassion to go to a hospital in the city to get an X-ray taken of a fractured wrist. I joined a queue of such unfortunate people and sat for three and a half hours, time which I could not afford as I was then a Member of this House and had other obligations as well, but I was interested to see what would happen. At the end of that three and a half hours the X-ray was taken and then I was asked for my name and address. When I had given this, I was severely criticised for not having disclosed my name and status beforehand because I would have got immediate attention. But I expressed the view that I did not wish to have attention given to me which was not available to everybody. I made an exhaustive study of other hospitals and inquired from many other injured people and found that this practice applies in practically all the hospitals in Dublin. It may not be the case in them all but in any I have heard of this practice of obliging people to wait for hours in out-patient departments operates.

I asked the Minister to do something about it. I asked his predecessor to do something about it. The Minister replied in the House and said it was not his responsibility, it was up to the people to make their own arrangements or for the health authorities to see they are looked after.

Mr. O'Malley

I did not give that reply.

Mr. Ryan

That is what I got from the Minister.

Mr. O'Malley

I did not give that reply.

Mr. Ryan

That was the answer I got from the Minister in the House but, within a few weeks, the Minister was speaking in a place he has probably heard of and remembers being there— Limerick—where he then disclosed himself as the new Florence Nightin-gale, the person who was going to improve the out-patient departments. I was delighted; I said a prayer in thanksgiving.

Mr. O'Malley

You are full of crawthumpers over on that side of the House.

Mr. Ryan

The truth is getting home. I would not make any personal claim on having got through to the Minister's conscience. I would imagine that it would be impossible but, nevertheless, he did express concern then about the inadequacy of our out-patient services. We need a radical improvement in this particular service and I think we should bring it about here and now. The way to do it is to have an appointments system breaking up the appointments by half-hourly or hourly periods. There was a time in our district courts in Dublin when there was no hour fixed for the hearing of cases, other than the commencement of the court in the morning at 10.30. I am glad to say that over the years this system has been changed, a certain number are fixed for the 10.30 list, others for the 11.30 and so on. The result is that a great deal of frustration has been avoided. People do not as a rule have to resort to the law courts as frequently as they do to out-patient departments for medical attention. On that account it is imperative that we introduce an appointments system. It is clear that it would be easy to do it and there is no justification for delaying it. I say that out of knowledge of my own experiences but there are some people who would not regard it as possible unless it is in existence elsewhere. I would remind everybody that it is in existence across the water.

On page 29 of the White Paper the Minister mentions that at the moment dispensary doctors—flatteringly called district medical officers in the White Paper—act as registrars of births, deaths and marriages in their districts. I have advocated in the House that this system should be done away with; that this is something which does not require legislation. The Minister has indicated that all it requires is an amendment of regulations by him and I would beg of him to do so without delay. Again, speaking from personal experience, if one's child is not born in one of the general maternity hospitals, one of the parents must attend at the local dispensary to register the birth and there join a queue of, again, maybe 140 people who are looking for medical attention. You join a queue of people, some with bottles, some without; some with pills, some without; some highly contagious, some not; some with broken limbs, some without; and at the end of a long wait—unless you have exerted influence—you arrive at the medical officer, if he is present, and you hand him a form which you filled in in the office outside and he accepts it from you. You are totally unknown to him. Thus a great event has occurred in registering the birth of another Irish citizen.

Why is such a parent not permitted to complete the form and return it by post to the Custom House? Possibly the officer in the Custom House may know as much about the applicant as the local dispensary doctor. I beg the Minister not to delay any longer in making this very necessary amendment. On another occasion when I raised this matter with the Minister he said—I may be wrong; I am open to correction—that only 25 per cent of the people had to register births at the local dispensary, and that would be in respect of births in people's own homes or in nursing homes, but even this 25 per cent should not be called upon to perform this ancient and ridiculous rite of attending before an official at the local dispensary who had no idea as to the veracity of the information given to him.

The law requires that this form should be handed personally to the district medical officer, but I have had the experience—and I know other people who had the experience—of attending such a place for the purpose of handing in the form within the stated hours, and the medical officer did not arrive in time, and perhaps not for half an hour or an hour after the appointed time, and a sympathetic official who had no right to accept the form said: "If you give it to me, I will pass it on to the doctor". That practice is rampant and again it is evidence I adduce of the necessity to amend these regulations and allow births to be registered by direct information to the Custom House.

The White Paper throws out for comment the question of the system by which doctors are to be paid for services to be rendered under the new medical system. I have spoken already of the fact that an inevitable and unavoidable companion of the existing system is a high hospitalisation rate, because doctors must in conscience reduce the burden upon themselves by getting people into hospital where they can get better attention. If we have a capitation rate, it is almost certain that some doctors will have a very high case rate because of their popularity, because of their skill, because of their good reputation, and such doctors, particularly during an outbreak like a flu epidemic, will not be able to handle all the patients they are expected to handle under a capitation scheme, and as a result they will refer their patients to hospital, and by referring them to hospital apparently they will not lose anything because the capitation fee will still apply.

Clearly we would have a better system if we related the fees to be earned by the doctors to the services provided by them. So far as I know, in all the countries which I recited earlier where there is a national health service, in only two is payment by means of a capitation fee. Those are Britain and the Netherlands. The other countries found it possible to have a system of paying for services given. We think the interests of the patients dictate that we should have a system of payment for services rendered rather than a capitation system. We note that the White Paper says that a capitation system seems the most practicable. From what point of view? I strongly suspect it is from the point of view of administrative convenience and not the excellence of the service that should be given to the people who avail of it.

In paragraph 49 of the White Paper, we are told that doctors are to be limited in the drugs which they prescribe. We are very worried about this. We appreciate that it is undesirable to encourage the prescribing of luxury drugs and medicines if there are perfectly adequate alternatives, but we fear the consequences of a bureaucratic arrangement under which in some cases non-qualified people will determine whether or not a doctor's prescription is one which ought to be met. Dispensary doctors will tell us, and patients who are compelled to attend at dispensaries will tell us, that at present it is not infrequent for a doctor's prescription to be altered by the dispenser.

Several serious cases have arisen in which alternative medicines and drugs which were not prescribed by the doctor have been given out by the chemist and the consequences in some cases have been extremely serious. I have been informed by a doctor in general practice—he is not a dispensary doctor—that he has had the experience of being called to treat a coronary case which had arisen by reason of the fact that the dispenser at the local dispensary had given a drug as an alternative to the drug prescribed by the dispensary doctor. This is an extremely serious situation. We know that doctors can bury their mistakes, and apparently the bureaucrats can also bury them, if it is a case of life or death. We are alarmed that the drugs and medicines services are to be limited by the bureaucrats who have not got the professional responsibility which morally lies upon the doctor.

We are also concerned that the further development of our health services as proposed in the White Paper will give us a continuation of a class service. This is spelled out in several parts of the White Paper. We are told at page 10 that our present health service is the system operated by the poor law guardians. On page 12 we are referred to the classes which were entitled to benefit under the Health Act, 1953. On page 13 we are told that so far as the medical services are concerned, we have three different classifications, the lower-income, the middle-income and the higher income. These are called groups, but calling them groups does not get away from the fact that they are classes, with all the unsavoury relationships which that word has. On page 34 we are referred to classes. We are to have a classification not only in our medical services but also for the drugs and medicines to be provided and we think this is a most unsuitable basis on which to plan for the future.

Progress reported; Committee to sit again.