The introduction of this Bill presents the Dáil, as the direct representatives of the people, taxpayers and others, with a very serious situation. Conscientiously, each of us is bound to examine this measure very thoroughly and to satisfy himself very fully that the creation of new Ministries is necessary in the best interests of the people, that their creation for bad times as well as good, will not place an undue burden on the backs of the people and that in fact the only feasible manner in which a thoroughly unsatisfactory state of affairs can be rectified is the creation of a multiplicity of new Ministries. There is a danger, particularly in the Parliament of this country, that we plan our expenditure according to the tide of prosperity that is temporarily running into the country and not according to the normal capacity of the people to pay. At the moment and for some years back we have had a flood of wealth pouring into the country, wealth that came from an evil fountain-head. The measure of that wealth was the degree of misery elsewhere and our capacity to produce. The value of our produce was enhanced because of the appalling plight of people elsewhere. It is well for every one of us to remember that the kind of wealth that flows out of a war is a very temporary kind of wealth and that following every war there is a slump. Our plan for expenditure should be based on our capacity to pay and maintain in the years of slump rather than the ease with which we can face the expenditure in the years of opulence.
Here we have a proposal, 25 years after the State was established, when our Civil Service should be far more efficient than it was 25 years ago, when the capacity of each individual and of every section and sub-section to handle more and more work should have grown and developed with experience, when we are catering for a country that has not extended in territory and that has actually reduced in population, to establish three new expensive Ministries, in perpetuity, because the Minister knows and every Deputy knows that it is the simplest thing in the world to establish new Ministries but that once established they are there as firmly planted in the soil as the Rock of Cashel. The Minister says, and says truly, that there has been a certain demand from different quarters for the establishment of new Ministries, for a Ministry of Health, for a Ministry of Social Welfare. There are demands for a great number of things and those demands have not been conceded with the same haste and generosity as this particular demand has been conceded. I do not believe that that demand was very general or very prevalent. I do not believe that that demand came to any extent from the masses of the people. But the demand was made. It was made sometimes by members of the medical profession, at other times by people who were rather disgusted and disappointed at the measure of assistance that we gave through the channel of social services.
The medical profession, or members of the medical profession, occasionally asked for a Ministry of Health and the volume of that demand was the measure of the dissatisfaction they were expressing with the present Department of Local Government and Public Health. The only way out they could see from the strangle-hold of a Department that was crushing the initiative, the life, the enthusiasm and ambition out of the medical services of this country was the creation of a special Ministry of Health. Every doctor felt that with the acromegalous development of the Department of Local Government and Public Health professional opinion was becoming telescoped and submerged; that the lay mind was so rapidly developing that the professional mind was being subordinated and the work of the medical profession was being completely crushed in the way of initiative. The only way they could see out of that hopelessly impossible state of affairs was to suggest the creation of a Ministry of Health in the hope that, inside that new Ministry of Health, the medical minds would be treated as the minds of experts, and that the guidance of those medical people would be accepted, always, of course, subject to the financial requirements and the financial capacity of the State. But they felt that, in a Ministry of Health, the medical mind and the medical advice on medical matters would not be subordinated because any particular rank inside the Department was designated to the medical adviser if there was any other way out than the creation of a new Ministry that would meet the demand in so far as it came from the medical spokesmen.
I am not speaking on a subject that I have not a deep interest in. I am not speaking on a matter that I have not had long experience of. I have been for more than 30 years practising the profession of medicine in different capacities: as a general practitioner, as a dispensary doctor, as a departmental medical director and as a county medical officer of health for a considerable number of years. I practised that profession under two régimes. I practised it under the British Local Government Board, as it was known, and I practised it for the last 25 years under the Department of Local Government and Public Health. My activities to get rid of British control, British domination and interference with the affairs of this country were as great as my capacity to serve. I have no brief for that particular form of rule, but as a medical man, and speaking with that length of experience I do say that the medical profession was free to practise its profession far more freely, and that the requirements of that profession were far more speedily met when the work of the medical profession of Ireland was carried on under that Local Government Board. There was speed and there was ample consideration for its requirements. You were dealing with a medical man who understood medical problems and was in a position to say "yes" or "no". When a medical inspector under the Local Government Board in the past visited any of us in our districts and we required something that medical man would argue it out with us there and then. If he was medically satisfied that the proposal was a sound one he would say: "You can take that as done; I will put that through". The reason was that there was a medical commissioner in that Department who was as high as the highest layman, and he could go directly to the Minister in charge to give expression to the medical requirements of the situation. There were no buffers, laymen, between that medical commissioner and the Minister, who was in a position to say "yes" or "no".
One of the earliest economies in this State and, as it transpired, one of the most unwise economies, was the abolition of the post of medical commissioner in the Department of Local Government and Public Health. You then found a situation where you had the Minister, the Secretary, the departmental chiefs and the medical inspectors underneath, so that the views of those medical inspectors, no matter how many changes of title took place, were sifted, modified and moulded before they reached the Minister. There were hundreds at first, and thousands in the end, of water-tight, air-tight and sound-proof sub-departments which grew up within the Department of Local Government and Public Health, every one of them being a delaying factor. If I am to talk candidly on this matter I must say that, as numbers increased—and numbers did increase in that Department and increase far beyond the capacity of the country to bear—inside that Department you had increased interference with every professional officer, private practitioner, voluntary hospital and public medical officer in the course of his duties, and the more interference you had the less professional work was done. The more time that was tied up in explanatory correspondence the less time you had to practise your profession. I am stressing that particular point because I firmly believe that, instead of the creation of new Ministries, expensive, extravagant and unwanted Ministries, a little reorganisation, a little simplification inside the Department would remove the impossibly chaotic condition that is there at the present moment.
The Minister based his case, to a great extent, on the complexity of the departmental situation that has grown up inside the walls of the Custom House. He told us that to disentangle the various services that are there would in itself be a formidable task, and would take a considerable length of time. The Minister was rather modest in his description of the complex structure that has grown up there. He was rather optimistic in thinking that it could be disentangled even in the time that he gave to it. Bedlam itself would appear to be a society based on absolute efficiency and harmony in contrast to what has grown up inside the Department of Local Government and Public Health. You have antediluvian dividing walls there that cannot be either scaled or pierced; you have services operating under that Department that are crippled and semi-paralysed by trying to graft the legislation of 1936 on legislation that was enacted in 1856.
You have departments that were operating the enactment of 1856 still sitting rigidly over those old antiques in a pathetic endeavour to adjust them to modern legislation, modern requirements and modern conditions. The result is that any individual working under that machine has got to try to divide himself, his time, his labours, his costs, his duties into so many fractions in order to comply with the various antiquated Departmental sections and sub-sections. Supposing some Minister with initiative, with consideration for the taxpayers, and with an eye to economy, were to say: "This whole code of legislation has become too complicated; this whole code has got into a terrible tangle"— as the Minister himself has said—"let us try if we can blast down all these old impenetrable walls that have been erected around public health over the whole of the last century and see if, thereby, we cannot achieve a greater measure of efficiency, better results and more harmony inside the Department." The first and obvious step to take would be to break down the barrier—the old hoary sub-division— between poor law and public health. That old poor law code has been in existence since about 1864. When this century was reached the whole world suddenly became alive to the importance of preventive medicine as well as curative medicine. When conditions in this country opened the way to us to keep abreast of modern progress in the field of medicine we started our public health services, but we kept the old dividing line between poor law, medical services and public health medical services. We kept the new public health services in such a position that it was impossible, without considerable delay, very extreme difficulty and an immeasurable tact to carry out our duties.
Let me give the Minister a simple illustration. Very often it is the man immersed in a great department who knows least about that department, its working and its inner ramifications. I remember once meeting a friend of mine. He was a technical man, and he happened to be in England at the outbreak of war. He found himself with an appointment in the navy. A couple of years later he came home and I happened to meet him. I said to him: "I suppose you know all about the sea now." He said: "I know less about the sea than when I left here, because I have spent all my service life in a submarine immersed in the depths of the ocean." I relate that story to a Minister immersed in a Department. The fact of being inside that Department may mean that the Minister knows least about it. In every case one sees the structure of a building by standing away from that building rather than peeping at it from the inside.
Now, in the first place you had this dividing line between public health and poor law. You appointed your public health service in every county. That service was responsible for certain things—tuberculosis, infectious diseases, the supervision of midwifery, and so on. But no one engaged in that service must cross the dividing line into the field of poor law. You are responsible for tuberculosis cases; but if your tuberculosis cases go into the county institutions they immediately become poor law cases and you have no right to follow them through the doors of the institutions. You are responsible for infectious diseases. They are treated in the county fever hospitals, but the county fever hospitals are poor law institutions and you must shed your responsibility at the doors. You are responsible for midwifery and maternity work but you have no contact with the medical officer because he is a poor law medical officer. If a man starting on his day's work visits in turn a tuberculosis case, an infectious disease case, a school, and supervises a midwife his expenditure for that day has got to be regulated under four different headings of expenditure. The cost of his travel has to be apportioned as between the length of time taken or the mileage covered in each particular case. A whole field of accountancy has grown up around that complicated system, making work down below, making worry down below and making work and worry at the top. That was further extended when tuberculosis grants came into force and when food and clothing were to be given to the tubercular, when one child in a house might be getting treatment under a specific medical service scheme and another under a tuberculosis scheme.
There is a multiplicity of channels of accountancy. There is a multiplicity of sections and sub-sections under which you are queried with regard to every activity. That results in such a complicated system inside the Custom House that no one person could control it. My suggestion is that all this work could be simplified from within if, instead of making a multiplicity of grants to the various local bodies—one grant under the heading of school medical service, another under the heading of tuberculosis treatment, another national health block insurance, another for child welfare and maternity schemes, and another for free meals— all that were averaged out and one comprehensive grant made to every administrative area, with one system of accountancy for its expenditure. In that way the whole matter could be simplified and the complication that present existing would be removed and the necessity for the establishment of three new Ministries might never arise.
I hold that in the best interests of the taxpayers of this country we must, first of all, find out if the system cannot be remedied by a simplification of the machine and an internal reorganisation of the already existing system. The Minister in his speech and in his White Paper points out developments that have taken place in the last 25 years— immense developments and remarkable progress both in the field of social services, curative medicine and preventative medicine. If we had a sensible administration on top that immense and spectacular development would have resulted in less work at the top and not more. In the old days under the Local Government Board the medical service was just the hospital service and the dispensary service. If there was an outbreak of infectious disease it was the duty of the dispensary doctor to treat the sick. He had very little time and very little opportunity to grope for and search out the origin and the cause of the outbreak. The Local Government Department had to send down in those days investigators and inspectors who would follow up the outbreak of that infection. They might cover up to six, seven or eight dispensary districts further away before they found the source and eliminated the cause.
With the development of public health services all that work was done centrally in each county or by co-operation between the county public health service in one county and in the next and you had the pooled information and the combined efforts of the new public health services in every county, working either individually or co-operatively. You had a great amount of work that previously had to be undertaken and investigated from on top, done locally. But with the greed of the bureaucratic mentality for expansion and further expansion, the more work that was being done below, the more sub-departments or sub-sections and sections grew up within the Custom House. First of all, you had the public health nucleus in each county. No sooner did they begin to inspect schools than a school section developed in the Department. No sooner did they begin to aim at central notification of births or infectious diseases than that was duplicated on top. No sooner did they embark on schemes, within their administrative areas, of maternity and child welfare, than a duplicate section started on top. In other words, the more work that was done below and the greater responsibility that was undertaken by the services functioning down below, the more the overhead staffs doubled, quadrupled, increased and expanded.
Having got the staffs, what is the result? Every one of these sections must keep files alive. They must keep writing, putting their queries. They must keep interfering, so that the body that started out to do professional work found itself so glutted with these queries and interrogations that in the end they found themselves doing less and less professional work. You had highly-paid professional men becoming third-rate clerks and the greater portion of their time doing a job that could be and should be done by clerks. With the growth on top with the numbers not mattering, with costs not mattering, any one of these men who should be field-men down below would not succeed in getting sanction for as much as one auxiliary typist to deal with the work below. Those men who were field-men for five days a week are now field-men for only two days and office-men for the rest of the week.
The development of work and responsibility down below should not lead to a consequential expansion up above. It should, in fact, if there was a sensible administration, lead to a reduction in the numbers on top. Neither the present Minister nor any other Minister can build up little sections, little cells, without these little sections and little cells becoming active. They do not like idleness, and the degree of activity is measured by the extent of interference with people who are competent to do their job and who are doing their work competently. Walk into any of the old established, internationally famous hospitals in the City of Dublin, hospitals that made a name for Irish medicine hundreds of years ago, hospitals that attracted ambitious medical men from the Far East and the Far West to come here to learn their profession. What is the complaint inside the doors of every one of those hospitals? It is that they are driven distracted by the intensity and continuity of interference in petty matters by the Department of Local Government and Public Health. But you cannot have officers in idleness. The multiplicity of officers appointed inside that Department in recent years will find something to do, and it does not matter if that something is putting queries to a busy surgeon who would be better employed in the operating theatre than sitting at a desk to answer queries with regard to the number of overalls laundered per annum from his operating theatre, or some such question. I have seen it go to the extent of querying the time taken by a specialist to do a certain number of cases and asking what steps would be taken to ensure that that specialist took a minimum length of time for his cases.
When I referred to this practice as outdoing bedlam, I was speaking with knowledge and with absolute sincerity. There is no man inside the Department but knows the degree of chaos that has been created by over-staffing and by the jealousy to hold on to whatever happens to be there at the moment. A little fluidity of the staffs and less established sections would lead to a much smoother movement of the whole machine of medicine. A little fluidity and the breaking down of these old barriers would lead to harmony between the centre and the periphery. But in order to accomplish that, it is not necessary to create a number of new Ministries. The medical mind that has been telescoped in the Department should be put back—rank or pay are not my consideration—where it was under a Government that had centuries of experience behind it.
The new departure was a legitimate experiment, but it was only an experiment. It has failed dismally. The Minister's advisers will tell him the extent to which it has failed. He need not think, when I make these statements, that I do so because I speak from the Opposition front bench. If the Minister asks his own medical people whether medical work, curative and preventive, would not be simpler and more efficient if medical views could be expressed directly to the Minister and not through departmental chiefs, no matter how elevated or glorified, it would be much better.
If the Minister in charge of a Department dealing with health finds there are blocks or obstacles or buffers between him and those responsible for advising on health matters, then every one of those buffers should go. That is what is required and not the creation of a new Ministry of Health. Such a thing would mean the creation of another horde of officials, another army that will keep themselves busy by correspondence to and from health workers throughout the State, correspondence to and from the hospitals and the treatment centres—and the more correspondence and interference the less efficient the work done.
The Minister, in the course of his speech, which I read with interest, remarked on the necessity to keep the best brains in the profession of medicine at home. What do we see across the water? We see, right enough, a tug-of-war between the Government and the medical profession, but what do we see there, where there is a Ministry of Health? The responbility for the direction and control of the health services in the various regions is carried out by the medical profession, not interfered with by laymen on top, or even by qualified men on top. There are committees of regional doctors, appointed by the doctors themselves and managing the work in each region. In this country, we have all the advantages which flow from the Appointments Commission machine, we have the measure of each man taken for the standard of appointment he is seeking, we have people going into appointments highly qualified and well experienced in their work, we have a special system of selection and we have achieved excellent results. Yet we have more supervision, more interference, and more direction, the more we have competent people in the job.
I want to tell the Minister that a doctor has his professional conscience and I want to warn him of a tendency that has grown up of late, by circular letter and by direction, presuming to tell a doctor how he will treat a case and what particular material he will use on a case. That is violating the very first principles of conscience in association with medicine. No doctor would hold his diplomas for 24 hours, if he took direction or orders from anybody else as to how he treated a case under his care. Yet that has happened. Even in the Army Medical Services, it has never been attempted. The staff in the Department of Health is certainly perfectly free to advise—and is bound to advise—as to the modern treatment or the latest materials which have been found satisfactory elsewhere. But to presume to direct is a thing that no professional man of any standing would tolerate from a Department of Health or from anybody else. There is no member of the medical profession in this or any other country who would ever presume to direct another qualified doctor as to what particular drug he should use on any particular case. He might advise and say what good results he had with it. But with the growth and the development in the Department and the necessity for doing something each hour of each day, it has developed even to that extent.
We see in this Bill, as far as the ordinary person can see, an attempt to go in two opposite directions. Only a few years ago, we introduced the managerial system, to centralise within each administrative area the various fields of work, medical, engineering, housing, etc., under one individual. That was a step in the right direction. If the scheme fails, it is the failure of individuals. At least in theory, the scheme is a step in the right direction. However, having centralised down below, we fractionise up on top. At the moment, we have bodies working in the various administrative areas under one Department with one set of bosses. Now we propose to have them working under three Departments. Which Department will be the master of the manager? In regard to the public health services, he will function under at least two Departments. Presumably, in so far as the manager is a pivotal officer in the housing schemes, he will function under three. To which of the three Departments will he be most responsible? Obviously, he must be responsible to each of the three, according to the field of his activities.
On the face of it, the proposals in this Bill bear no evidence of any serious consideration having been given to them. The line of least resistance has been taken. Perhaps the most spectacular road to take is to create a multiplicity of Departments and to say to anybody interested in any particular subject: "Oh, that will be fixed all right by the new Department of Social Welfare". That Department has grown out of a perfectly sensible and perfectly obvious suggestion made by various Parties in this House, namely, that it was ridiculous to have a multiplicity of inspectors calling at the same little cottage on different days in the same week, each one of them giving out a little ticket or dole, ranging from 1/- to 2/6. We suggested that those services should be co-ordinated and amalgamated into a central stream, so that there would be one inspector, one investigator, one payee and one payment. However, if the only way amalgamation or co-operation could be carried out is by the establishment of a new Department, surely that is bankruptcy of all intelligence and bankruptcy of any capacity to understand that a Government has no money to spend unless it gets it out of the pockets of the people?
Taxation is so stupendous that we can only keep up the rate of spending by looting the pockets of the very poor. When we propose three new Departments, we must measure the capacity of the poorest to pay their whack towards the expense. New Ministries mean new Ministers; new Ministers mean new staffs; new staffs mean new sections; new sections mean new sub-sections. Let anybody look at the Book of Estimates. The population is smaller, the area just as big, but look at the growth of departmental services, in cost and in numbers, over the last 15 years. Is there any one of them that has not doubled itself in numbers, trebled itself in cost, carrying the same functions for a smaller number of people? Now we are going to multiply, not only the number of officials but the number of Ministries. I took just a glance at the numbers and cost of the Minister's Department, starting with the period 1931-32. The cost of salaries and wages of officials, within the four walls and having nothing to do with grants in any direction outside the four walls, in 1932 was £99,000 odd.
The number of persons doing the work for a larger population than we have at the moment was 236. Five years later, for the same area, for the same or a lesser number of people, the cost had jumped to £127,000 and the numbers had jumped to 359—an increase of one-third in numbers in a few years. That was in 1936. This year, the cost has bounded up to £188,000 and the number of officials to 467. The number of officials over the period mentioned has just doubled. The cost has also doubled. And the Minister complains of the complexities of that Department and tells us that it will take hard work and many months to untravel and disentangle the various pieces there. You have 200 extra tanglers taken on over that period of years. The solution is the beauty of the whole thing. Not only increase the numbers further, so as to create a number of more tangles, but multiply the number of Ministries and increase the cost to the taxpayers. It is no wonder that the Taoiseach said elsewhere that the proposals contained in this Bill will lead neither to greater economy nor to greater efficiency. How could they lead to greater economy? How could they lead to greater efficiency? There is more co-operation between one Government Department in this country and another Government Department in Paris than there is between any two Government Departments in this country. There is more co-operation between any two Government Departments in this country than there is between any two sections within a Department. There is where you get the delay, the irritations, the cost and the inefficiency.
The proposal outlined by the Minister is to increase all those factors. The only solution is three new Ministries. Let us be logical about these things. If we are to be logical and if four, five or six subjects have to be dealt with in any Department, why not follow the line laid down here? Why not have four, five or six Ministeries? Why not have a Ministry for every little phase of activity which has to be supervised? Here we have a Ministry that, 16 years ago, was headed by a Minister. There was no Parliamentary Secretary. The Department grew because there was more work being done down below. It developed into a Minister with two Parliamentary Secretaries. Now, it is to sub-divide itself like an amoeba and multiply itself into three brand new Ministries. If we wanted a startling and striking example of the fact that what is wanted is to blast down all the internal walls, to have a general flow of knowledge, general freedom of conference and general understanding in one room of what is being done in the next—if we wanted a clear, striking, memorable example of the failure in that very elementary procedure with regard to efficiency, harmony and success, we had it in the Public Health Bill. We had the Public Health Bill coming out of that Department and put before the Dáil as a matter of vital, national urgency—so vital that we were threatened with sitting throughout Holy Week to deal with it. Then, outside circumstances got the officer in charge of the Bill into trouble and he resigned. Another officer from the same Department reads the Bill and drops it completely. There is no urgency about it, good, bad or indifferent. The fact is that there were things in that Bill that whoever is Minister for Health would never stand over. It had come before us as the considered policy of the Government when it was not even the considered policy of the Minister for Local Government. There is an example of water-tight, air-tight, sound-proof Departments that have grown up inside that particular institution. I say: break down all those walls, let there be fluidity when people are dealing with common or allied subjects, and it will be found that one Minister with a sensible outlook, one Minister with a desire to cut his cloth according to the measure of the taxpayer, to place the burden according to the capacity of the shoulders to carry it—that that Minister, approaching the matter with a desire to reorganise and simplify, would get the services carried out with much greater efficiency and much greater expedition without this new and extravagant proposal for the multiplication of Ministries.
So far as has been indicated to us, the case for Ministry No. 3 is the control and supervision of social services. Is it our ambition to make this little island a nation of soupers or a nation of paupers? Is it the vision of the Government that there is to be so alarming an increase in pauperisation that that particular service can be rendered only by the creation of a special new Ministry such as has never been required during the past 25 years? If there must be a Ministry of Health, could there not be persons inside that Department who would account for the necessary payments for those social services? If those social services are allied to anything, they are allied to health. You have blind pensions—a health disability. Old age pensions—a natural disability, if you like. Tuberculosis grants under various headings —a health disability. National health insurance benefits—again a health disability. You are going to put the making of those payments into a Ministry over there. You are going to have health dealt with by a Ministry over here. Is it not obvious that those services, so closely allied to health, should, at least, be carried within the health service?
Taxation, expenditure, pomp, ceremony and extravagance have reached such a point here that the worms are beginning to turn and that it is not just a case of "Ask and you shall receive". If the proposals contained in this Bill are necessary, a case will have to be made for them. Remember, the Taoiseach previously pointed out that no such proposal would be made to the Dáil, or come before the Dáil, until Deputies had been made familiar with the case as it exists and the requirements of the situation, through a White Paper—a White Paper that would have to state coldly, calmly and precisely why the present structure had failed and why three new structures were necessary. What has become of that White Paper? Is it that a case cannot be put down in black and white? Is it that there is no case to make? Is it that the only case that can be made is to point the finger of failure at the political head of the Department of Local Government and Public Health for the last 15 years? If things got into a mess, either through lack of intelligent supervision or because there was not proper co-ordination, it is not fair to turn to the taxpayers and say: "There is one mess already; give us three more messes and pay for them." Is not the obvious remedy to get someone to look into the internals of the machine that has gone wrong and see if it cannot be lubricated and repaired rather than to say: "Leave us the machine that has gone wrong and, if you can pay for it, give us two other machines that will do the work that should be done by one?"
