I move that the Bill be now read a Second Time.
This Bill provides for a large measure of codification of the law in relation to health administration: it is also the first step in the task of general modernisation and expansion of the law and administration in relation to health services. I have no doubt that this latter task will involve the submission of a number of other measures to the Oireachtas as time goes on, but the present Bill contains what I hope will prove to be that measure of reform which is at once most urgent and most practicable.
I do not think it necessary to dwell in any detail on the codification aspects of the Bill: the explanatory memorandum circulated to Deputies sets out the general heads of the statutory responsibilities which have devolved on the Minister for Health in pursuance of the recent Transfer of Functions Order which was made following the establishment of a separate Department of Health in pursuance of the Ministers and Secretaries (Amendment) Act, 1946. The Transfer of Functions Order has been laid before both Houses of the Oireachtas, and Deputies who have examined it must have been struck by the great number of Acts and portions of enactments which had to be cited to give effect to the transfer. There are 46 complete Acts mentioned in Part I of the First Schedule to the Order, and numerous sections of some 14 other Acts are set out in Part II of that Schedule, while there are 21 adaptations of provisions which fall to be exercised severally by the Minister for Local Government or the Minister for Health, according to their respective functions. This gives a fair picture of the voluminous and diverse enactments which have become the responsibility of the Minister for Health.
Now, if Deputies look at the First Schedule of the Bill, dealing with repeals, they will find that some 26 enactments are being repealed in whole or in part. These repeals are possible because the provisions of the present Bill re-enact or replace them in modernised—and, I hope, in improved —form. The result will be that the lists of statutory functions which proved such an arduous and complex task to prepare in connection with their transfer to the Department of Health will be greatly abbreviated and simplified by the provisions of this Bill. The law on the matters with which the Bill deals will in future be available for reference in a readily accessible and modernised form.
As indicated in the explanatory memorandum, the Bill, when enacted, together with the Mental Treatment Act, 1945, the Parts of the Public Assistance Act, 1939, appropriate to the Minister for Health and certain self-contained Acts, will comprise a consolidated series of statutory enactments in relation to most of the Minister's functions and the relevant responsibilities of local authorities. There will remain the need for a separate codification of the food and drugs legislation—although we anticipate that also to a certain extent by special provisions in this Bill.
That is all I need say at this stage on what I might term the legal mechanism of the Bill in relation to the existing law.
I have indicated at the beginning of my remarks that the second objective is the modernisation and reform of the health services. To explain how far we aim at carrying this objective into effect in the present measure, it may be well for me, without going into the detail that is reserved for Committee Stage, to review the proposals in the Bill, Part by Part. Deputies will, I am sure, also expect me to indicate the more important changes which have been made in the proposals which have previously been before the Dáil in the appropriate Parts of the Public Health Bill, 1945.
I might say here, before proceeding to survey the provisions of the Bill and apropos of my references to the Public Health Bill, that, before the consideration of this measure became my responsibility and following very lengthy debates in the Dáil, a large number of amendments had been circulated for consideration on Report Stage of the Public Health Bill. The Ministerial amendments included among these had received very careful consideration and Deputies who participated in the debates and who have studied those amendments will, I am sure, appreciate that they were designed to go a long way to meet a number of the matters which had been the subject of controversy.
In the present Bill, all the relevant amendments then proposed have been incorporated, except where the provisions in question have been otherwise altered, modified or omitted. That fact in itself will, I am sure, help to expedite the consideration of the present measure and procure a moderately harmonious discussion of its contents. I say "moderately" because my proposals are not necessarily perfect and I do not claim to be infallible, but neither should other parties claim either perfection or infallibility for any criticisms or counter-proposals which they may have to make.
As regards Part I, I would draw attention to the new definition of a "health authority". The Public Health Bill contained definitions of a "county authority", "health authority" and "sanitary authority" and it was intended that a health authority might be either a county authority or a sanitary authority. For all the purposes of this Bill, the administrative authority will be the health authority which means the council of a county or the corporation of a county borough. The intention is to rationalise and simplify the administration by making all local functions under the Bill the responsibility of a county or city authority. This in effect means that the numerous urban sanitary authorities who will retain responsibility for sanitary services supervised by the Minister for Local Government will have no responsibility for health services supervised by me.
Part II deals with institutions. Effect has been given to the Report amendments which were put down to meet the criticism of Deputies in regard to the powers sought by the Minister to order the provision or discontinuance of an institution. As agreed on Committee Stage, a local inquiry will have to be held in relation to the desirability of the Minister acting in this manner in any particular case before any Order is made.
This Part of the Bill contains provision for the transfer to health authorities of district institutions maintained by the public assistance authority. I do not anticipate that this provision will be utilised except in restricted classes of cases until further legislation, to be explained beforehand in a White Paper, is introduced to alter radically the public assistance basis of institutional administration. In the meantime, the powers sought may be utilised to bring particular infectious disease institutions under the control of the health authority, e.g., fever hospitals at present managed by the public assistance authorities.
There was some discussion, in debate on the corresponding provisions of the Public Health Bill, in regard to the magnitude of the institutional building programme. A figure of £24,000,000 was mentioned for hospitals and reference was made to a further long-term liability of about £10,000,000 for dealing with institutions other than hospitals, for example, county homes. I should like Deputies to be clear that this Bill does not involve, as a matter of course or in itself, the implementation of that large programme. That is a long-term programme which was initiated when the Hospitals Act was passed in 1933. Hospital construction proceeded for some five years up to the outbreak of the war. It is being resumed now and will be accelerated according as funds and materials are available; but it is not provided in this Bill that any particular institution will be built. To give effect to the provisions of this Bill, certain transfers of institutions will be necessary; if they are modern ones, so much the better, if they are not, we must set about improving or replacing them as part of the general construction programme.
The provisions for transfer of any institutions maintained by sanitary authorities are consequential on the removal from those authorities of any responsibility for health functions. The institutions actually maintained by them are relatively few and trivial— scabies treatment centres, disinfestation stations and other centres of that kind.
I now come to Part III of the Bill, which deals with the mother and child service. I have had the provisions on this matter brought forward into one of the initial Parts of the Bill because I regard it as the most important item of reform for which the Bill provides. These provisions are the basis for a comprehensive service for mothers before, during and after childbirth, and for children up to the age of 16 years. It will be observed that, so far as the Minister is concerned, the provisions are enabling provisions. The Minister may make regulations applicable to every health authority or every health authority of a particular class or a particular health authority as to the manner in which, and the extent to which, they are to exercise their powers in regard to: Attendance to the health of mothers; attendance to health of children who are not pupils of schools, and attendance to health of pupils of schools.
Then there is an obligation to submit children to medical inspection unless a registered medical practitioner certifies that the child is unable to attend the inspection owing to illness, or that he has examined the child and will be responsible for any treatment up to the date of the next inspection. Provisions are also included in regard to the affording of facilities for medical inspection of children in schools. I have no doubt that the co-operation of the school authorities will be forthcoming in practically every case. The law has, however, to provide for all cases, to enable the comprehensive nature of the service to be maintained and, for this purpose, school managers are required to give all reasonable facilities on receipt of the prescribed notices, and subject to the consultation which the health authorities are required to have with them.
The purpose of the prior consultation is to enable the inspection to be carried out with the minimum inconvenience to the authorities of the school, but I think that in practice it will be possible to arrange, with the consent of all concerned, for regular inspections at stated times in such a manner as to require very little discussion or preparation prior to particular inspections.
As regards the need for a service such as is proposed here, most Deputies will be aware that both the present maternity and child welfare service and the school medical service are inadequate; that the whole-time public health staff is unable to cope with the demands of a full service, and that there is not proper continuity of attention to the health of children before they attend school and afterwards. It is proposed to establish an integrated service whereby the defects in the present schemes will be remedied and a greatly expanded and modernised service will be provided which will include ante-natal care of mothers, facilities for obstetrical attention and post-natal supervision, and a full medical service for children from birth until the age of 16 years.
In this respect, I propose to pay particular attention to the preventive aspect of the new service. Thus, in addition to medical treatment, the new service will include provision for the early detection and diagnosis of defects in children, their immunisation against preventable disease, care of nutrition, physical development and the promotion of sound healthy habits. It is my aim to use this service to promote a healthy growing generation.
I have given considerable thought to the means by which this service will be implemented, and I am satisfied that it is very desirable that the district medical officers (or the dispensary doctors, as they are commonly called) should be associated with the new service. The service will, of course, deal with various specialised ailments, but it is essentially a basic general medical service such as those doctors are already performing to the best of their ability and resources in their ordinary medical practice, official or otherwise. Some months ago I met representatives of the Medical Association, following which it has been arranged to accord sanction to proposals for increased salary scales for the dispensary doctors up to certain limits indicated to them. Those increases are based on the admitted need for stepping up the remuneration of dispensary doctors in respect of their existing duties. I told their representatives at the same time that I hoped, when this Bill was passed, to be in a position to discuss with them the terms on which they would assume responsibility for increased duties which, in effect, meant this service which I am now discussing.
As I have already indicated, the proposals in the Bill are enabling provisions, as far as the Minister is concerned. The local authority is required to implement them according as regulations thereon are brought into force by the Minister. Furthermore, while most anxious to implement this service, we can only do so with the implements at our disposal, improving those implements, of course, as rapidly as we can. To ascertain precisely what facilities will be at our disposal immediately and what new facilities should be provided, a comprehensive national dispensary survey is being conducted at present. A conference of all the county medical officers of health has also been convened to discuss various public health matters, and the proposed mother and child service is an important item on the agenda.
With the aid of these negotiations and conferences I hope to attain a workable and agreed basis for the co-operation of the dispensary doctors with the whole-time county health staff in the operation of the service. The chief medical officer in each county and his assistants will be expected to supervise the service, to check up on child health and on infantile and maternal mortality, to constitute in brief the headquarters staff which will direct the implementation of the scheme, inspect it in its operation, assess its results and be answerable therefor to the health authorities and to the Minister. The present schemes are inadequate and unsatisfactory, precisely because a small health staff is required to get around every school in the county and to provide for followup treatment without any clear coordination of their machinery with the functions of the institutional and dispensary medical officers who treat the general maladies of the people. The matter is obviously one in which the co-operation of all sections of the medical profession is essential.
There is one other aspect of the service to which I wish to refer before passing away from it, and that is, the objections which have been voiced to the compulsory examination of children. I must say that I am not very much impressed by these objections. My experience of any beneficial service affecting health, or social welfare generally, which is made available, is that it is criticised by the people more on the score of its inadequacy than on the fact that they are compelled in some way or another to avail themselves of it. The people of this country for the past 150 years and, in particular, since they were made the proprietors of their own holdings, have been anxious to improve their status and their houses and property and to educate their children above the standards which existed in former times. There is also a growing degree of enlightenment on the need of greater attentioto health.
Medical treatment, including specialist treatment, is intelligently and insistently sought for by the vast majority of the people. But just as we need compulsory school attendance for the children of those who value education least but require it most so do we need compulsory ascertainment of disease and defects in relation to the children whose parents are least keenly aware of the need for medical attention. An ill-educated child may become a menace to the community in his later years, but the danger is much less than that of an infected child who may infect his companions and there is the added possibility that unless his condition is diagnosed and treated he will grow up, if he grows up at all, a burden on the community through some kind of constitutional infirmity.
It is, therefore, the people who are not sufficiently well aware of the need for medical attention whose children are likely to be most in need of inspection and who may have to be required by some procedure, other than mere invitation, to present themselves for inspection. But I do not anticipate that compulsion, if you can call it compulsion, will amount to absolute dragooning. As I say, the number of people likely to present difficulty will probably be very small, and side by side with the clinical aspects of the service there will, in due course, be a domiciliary nursing service which will be available for giving advice to expectant and nursing mothers and the mothers of young children. That will, I hope, still further reduce the numbers who fail to appreciate the value of the service. I hope that the domiciliary visitors will prove a very valuable medium of health propaganda and that their peaceful persuasion will prove in most cases an effective alternative to compulsion—in other words, that they will be able to coax the lazy ones on with something more gentle than a stick.
I need not stress the advantages of the service from the personal, public health, social or national aspects: these are self-evident. But to put the matter on its most material level, there is grave economic wastage from the loss of young lives and from the undue proportion of children who grow into adolescence and adult life with their economic potential diminished or destroyed by avoidable infirmities. There is the economic waste of the children who are reared and then lost through death, and there is the further economic waste of chronically infirm persons who have to be supported by their relations or by the State or both. In the matter of mental defects, in the absence of a comprehensive scheme to ascertain them and deal with them, backward children are allowed to remain or recede into idiots when early training of a specialist kind would advance them, never perhaps to normally adult mentality, but would at least make them amenable to progressive improvement.
For families who do not wish to participate in the scheme generally applicable and who may have some preferences for private treatment of their children's ailments and some objection against compulsion based on more than mere aversion, inspection of the children is not compulsory if such people can satisfy the health authority that they are providing adequately for their children through the employment of private practitioners.
Furthermore, treatment of the children following the ascertainment of defects is not compulsory for any class. But the public conscience has reached a stage at which the health authority must at any rate take cognisance of defects in children who are not otherwise medically provided for and bring these defects to the notice of the parents in the interests of the individual children and of the coming generation generally. The parent then becomes the arbiter of the child's destiny and he is free to determine whether a recommended course of treatment will or will not be availed of—with this exception that where a case of infectious disease is ascertained on inspection the health authority has a further obligation, by virtue of their responsibility for the public health, to safeguard the rest of the community.
This brings me to the next Part of the Bill. Part IV deals with infectious disease and infestation. The provisions on this matter in the original Bill were debated at considerable length and following detailed consideration of the provisions on Committee Stage amendments were prepared for introduction on Report which were intended to modify considerably the major points of contention. These amendments have been incorporated in the present Bill.
They include the guarantee that infectious disease regulations will not prescribe compulsory surgical treatment. I may say that I have had considerable doubts as to the wisdom of accepting this amendment even though it is provided in the definition section that "surgical treatment" does not include hypodermic injection, inoculation or other processes of immunisation or the taking of blood or other specimens for examination or test. Take the case of a child who may have to be compulsorily isolated for treatment of diphtheria. Most Deputies will be aware that the operation of tracheotomy is often necessary in such cases to preserve the child's life. If consent is not forthcoming, then, under this provision, the child must be either allowed to die or the surgeon will have to break the law. Consent is usually required at present as a matter of course. But it is a very different matter to provide by law that consent is essential.
I put it to Deputies to consider this matter and to let me have their views. In my opinion the idea that surgical treatment of an unnecessary or illegal or immoral nature would ever be undertaken by responsible medical officers in this country is entirely fanciful. The suggestion is a slur on the profession. And if, which God forbid, concentration camp conditions were ever to develop here, the mere prohibition in an Act of Parliament would not deter those responsible from indulging in activities which, as far as I can see, must have occurred to the minds of Deputies from a too close proximity to a time in which conditions abroad were abnormal and which we hope will never again recur.
If, therefore, I have a general expression of willingness from Deputies to delete this proviso against compulsory surgical treatment I shall move an amendment to that effect on Committee Stage. Otherwise the provision will have to stand.
Another amendment of the Public Health Bill embodied in the present Bill is the modification of the provisions in relation to the duty of parents to keep children from school and the giving of lodging in dwellings and the use of public conveyances. These provisions were formerly applicable to persons who were probable sources of infection. They will now apply only to persons who actually have any of the infectious diseases to which the provisions are applicable.
Another, and I think a very proper amendment is the provision that, before a person who is a probable source of infection is detained or isolated, he must be actually inspected medically. Previously it was, I think, contemplated that it might be necessary to get after, for instance, a group of itinerants and detain them without individual medical inspection. We will take the chance that our service will be sufficiently effective to permit of individual inspection. A further safeguard of personal freedom which I have had included will ensure that the practicability of detention at home will be considered before a person is compulsorily isolated in a hospital or other place.
I do not wish at this stage to go over the detailed provisions in relation to compulsory isolation and treatment. I shall be prepared to discuss them in detail on Committee Stage, but I wish to say now that there may perhaps have been a certain delicacy or reticence as to the matters for which the provisions are primarily intended, a delicacy natural enough but capable of giving rise to considerable misunderstanding. I now say that one of the first and most important conditions which these provisions are intended to counter is the spread of venereal disease contracted from prostitutes soliciting in the streets. That statement is not, I think, capable of any misunderstanding. It is not the business of the State or the health authorities to enforce the codes of public morality which are infringed by these conditions but so long as these conditions exist it is, I submit, the duty of the State to ensure as far as possible that the resulting spread of disease will be countered and as far as possible eliminated.
Venereal disease, like some of the more natural diseases of children to which I have referred earlier, is a process of physical and mental rot which may pursue the unfortunate individual throughout his life. But, worse still, it can produce another generation of unfortunate innocent children who may be congenital syphilitics. Many unmarried mothers are found to be infected. Successful treatment of such cases is surely an objective which would justify the procedure proposed.
I have felt obliged to state the position thus briefly and plainly, in the hope that the discussion which will follow and any consideration of these provisions on Committee Stage will advert to the terrible consequences of letting this menace go unchecked.
Another serious infectious disease to which the provisions of detention and isolation will be applicable is typhoid. Typhoid carriers may be of two kinds, persistent and intermittent. To treat them so as to eradicate the sources of infection is often a lengthy and tedious business. Those people may not be aware of any illness or discomfort and in fact their condition is not dangerous to themselves but here again they represent a class which, all unwittingly, is a menace to the community, and it is for this reason that their detention for treatment and cure is proposed.
Section 39 contains a revised set of provisions in regard to the maintenance of the dependents of persons suffering from infectious disease. I should mention that "infectious disease" there, of course, includes tuberculosis. The former provisions contemplated that the full cost of maintenance should be met from the rates. I went into this matter personally and, after consultation with the Minister for Finance, I have included a provision for half the cost being met by way of State Grant. Side by side with this new provision I propose to take power to regulate the rates of allowances where necessary. Such rates may be fixed either too high or too low, and it is to achieve some uniformity in the rates which will be applicable over the country as a whole that I am seeking this permissive power of regulation. The section is being tightened in other respects, as many Deputies very properly considered that, as formerly drafted, these provisions might be open to abuse.
I have made other modifications in this Part of the Bill in the respects mentioned in the Explanatory Memorandum, including giving persons an option not to undergo immunisation (except in the case of serious epidemics). I anticipate that immunisation schemes will be very fully availed of when an effective service is in operation, and in that event the people who opt out, some of them, such as Christian Scientists, on conscientious grounds, will be a danger only to themselves.
I have had the requirement that a medical officer should notify infestation deleted, while extending the provisions to articles of clothing, etc., as well as to persons.
The sections about precautions to be taken in relation to schools and public conveyances are also being omitted. These are matters of administrative detail which can be provided for in regulations.
I think that Section 110 of the former Bill was not discussed in any detail in the Dáil but there were numerous amendments down in relation to it. It proposed to take very wide powers of regulation and control of the uses to which institutions might be put. I am absolutely in favour of a system of rationalisation of institutions by reference to their specialised functions and regionalisation of many of them by reference to appropriate areas of the country, but such a process could not be effectively undertaken without including the voluntary hospitals in it. I hope in the more comprehensive proposals which I shall publish in a White Paper to outline a scheme of this nature which would be contingent on full negotiation and agreement with all the interests concerned. Meanwhile, the section which replaces that section in the present Bill, viz., Section 40, is related only to the treatment of infectious disease in institutions. It has been found by experience to be absolutely necessary to prevent the spread of infection or cross-infection. For instance, it would defeat the whole policy of segregating infectious disease cases if we were to allow open tubercular cases to be treated in the same wards as non-tubercular patients. It is to remedy such conditions that the present provisions of the section are designed and limited.
I may briefly describe the purposes of Part V of the Bill as being for the protection of the public from danger to health arising from careless or unsafe preparation of food and to standardise foods which are especially important to the public health. The powers sought replace and supplement existing powers which have been found to be inadequate.
The need for the powers sought in this Part is evident. While many food establishments in this country maintain an adequate standard of cleanliness, I am sure that all Deputies will agree that there are also many which leave much to be desired. It is necessary that public health administrators should be able to stop the dangerous and careless practices which often give rise to illness and epidemics and from the point of view of nutrition to control the extravagant claims sometimes made for very useless compositions. Standardisation of foods will only affect economically those at present dealing in sub-standard products. I am sure that the control will be welcomed by the honest manufacturers, traders and caterers as eliminating an unfair economic advantage at present enjoyed by those who do not incur the expense of taking proper public health precautions.
The form of the regulations made under this Part will be settled after full consultation with the trade and other interests concerned. It is hoped that, with their help, a code of food laws will be evolved which will be capable of harmonious and efficient operation.
Part VI contains somewhat similar powers of control over medical and toilet preparations and certain other articles. Here again the intentions are to prevent danger to health, from the use of certain preparations and articles, and also to control the sale of preparations purporting to have medical or tonic qualities which in fact they do not possess.
The opportunity has been taken to repeal the Rag Flock Act to re-enact and extend its provisions to other filling materials. The intention is to enforce appropriate standards of cleanliness for bedding of all kinds.
The remaining portions of the Bill have, I think, been adequately explained in the memorandum issued with the Bill. I have provided in Part X for the establishment of consultative councils on the lines proposed in the previous Bill and in amendment thereof.
I have omitted the section which defined the health functions of the Minister. They added nothing to his legal powers and, as Minister for Health, I am seeking and will continue to seek from the Oireachtas all the statutory additions to the legal powers already transferred to me which I may consider necessary for the proper implementation of a progressive health policy.