Health Bill, 1947—Second Stage (Resumed).

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

The reception which this Bill has received is a tribute to the value of the consideration which the previous Bill got here. The fact that there were so many amendments on the Order Paper for consideration when the last Bill was withdrawn amply demonstrates the useful nature of the discussions which took place here and the advantages which can be derived from discussing, even at length, a measure of this kind. The Minister's introductory speech augurs well for the consideration of this measure and, I may say, augurs well for the schemes that are envisaged in it. Therefore I should like to deal with certain aspects of this Bill rather than anything that preceded it either here or elsewhere.

The most important aspect of the Bill and of the various schemes under it, in so far as it affects people other than the medical profession or patients, will be the cost. So far the Minister has not given any indication of the cost of the particular services which are envisaged in the Bill. I appreciate that it would be difficult at this stage to give anything other than a rough estimate of the total cost but I did hope that the Minister would indicate to the House the personnel and the cost of the particular personnel required for schemes which may be expected to be put into operation in the near future. Many Deputies in considering the Bill have come to the rather rapid conclusion that immediately on its enactment we shall have entirely different health services available. I think anyone who has come to that conclusion takes an optimistic view of the services provided in the Bill or the services which may be provided, but which may not be fully organised for years to come. A few years ago legislation was passed here dealing with regional sanatoria but I think up to the present any work carried out in these sanatoria has been of a very limited character. Some of them have not even been started. I only hope that when this Bill is passed, rapid development will take place on the various schemes.

I should like the Minister to give the House an indication in his reply of the extent to which facilities will be available, assuming that this measure is brought into operation by the end of the year. So far as my information goes, the present supply of medical men in the country—certainly the numbers engaged in local health services or as county medical officers— will be insufficient to cope with the increased services provided under this Bill. I think that some consultation should take place between the Department and these medical practitioners, in regard to the increased work which must fall on them when the new services are in operation. As the Minister is aware the pay and allowances of dispensary doctors are at present on the meagre side and are barely sufficient to enable them to run their cars and furnish them with the smallest amount of necessary equipment. If these men are to operate more extensive schemes, such as mother and child welfare and school medical inspection, they will be called upon to shoulder much heavier responsibilities than they have had to bear in the past. Unless these doctors are suitably provided for by way of increased salaries, it will scarcely be possible to get applicants for these positions as they fall vacant in future.

I think that an indication should be given by the Minister to the profession in general that he has had this matter under consideration, that any views which they may put forward in connection with it will be considered, that a system of consultation will be provided under which the medical officers can make any representations they wish or, alternatively, that some scheme of compensation will be made available for dispensary doctors and other medical officers who suffer as a result of this Bill. So far as I can see, there are two likely results. One is that existing practitioners may find that when these services are instituted, patients they formerly treated will no longer come to them as they will find that their needs may be met by the new services which may be made available. In that way many doctors will lose a considerable portion of their practice. On the other hand, private practitioners who are available at the moment for child welfare and various other services for which this Bill will now cater, will find that their practices have decreased. I think that the Minister must either provide some compensation for these people or make the terms of appointment for new positions so attractive that such doctors will be attracted to them, so that not merely will it not be necessary to compensate any existing practitioners but that they will be able to assist in carrying on the new services under conditions which will take due cognisance of the fact that they had in the past depended on private practice which to a large extent is now being destroyed by the schemes made available under this Bill.

I should like the Minister to indicate what are his proposals concerning the isolation of certain patients. The particular patients I have in mind are those suffering from tuberculosis. As I understand the matter, many of the general hospitals or the voluntary hospitals dealt with all forms of disease but had separate wings or apartments for tuberculosis and other infectious cases. Proper segregation was provided and precautions were taken to ensure that no person suffering from an infectious disease came in contact in any way with other patients. At the same time, in teaching hospitals students were able to carry out a clinical examination of patients in the different stages of particular diseases. They were able to see patients before they were sent to a particular wing or before they were segregated. I understand that it is proposed in this Bill to segregate all cases of infectious disease in separate hospitals. While considerable support may be forthcoming for that particular method of treatment, from the point of view of the teaching hospitals I understand it is undesirable that students should have to be brought into separate hospitals where they know, before they enter these hospitals, that the patients are suffering from a particular disease. If some patients of that type were housed in a general hospital where other patients are also treated, the students could more readily appreciate the difficulties associated with diagnosis. I would suggest to the Minister that permission should be afforded the teaching hospitals to continue the existing system where they think it desirable provided they satisfy the Minister and his medical officers that adequate precautions are being taken to prevent the infection spreading.

The Bill provides ample machinery for school medical inspection and sufficient machinery for informing the school manager that inspection is to be carried out but no provision is made in the Bill for informing parents. There is, of course, the fact that the manager may inform the children and, in that way, the children may inform their parents. The Minister appreciates, as the House must also appreciate, that very often children to not tell their parents, and, if they do tell them, their parents do not heed them. Frequently, although not as frequently now as in the past, parents object to a general medical inspection, and some provision should be inserted with regard to giving adequate notice to parents and with regard to allowing parents who are prepared to have their children inspected or treated separately, the option of doing so, with the proviso that they produce satisfactory evidence that the child has been or will be inspected at intervals as frequent as the normal routine medical inspection in the schools.

The most welcome feature of the Bill is the provision in Section 39 for a maintenance allowance to a patient and the dependents of a patient, in the event of that patient being unable, because of infectious disease, to provide for his or her family. The House is aware that in the past one of the greatest worries of tuberculosis sufferers has been the fact that, while they are ill, their families or dependents were unable to provide adequately for themselves, and in many cases a patient's recovery has been delayed because of worry and anxiety in that connection. In Section 39, provision is being made whereby a local authority can pay either a particular sum, a salary, to a patient or defray the cost of the employment of another person who will carry on the patient's work while he is sick.

I do not know what consideration the Minister has given to the rate of benefits which will be allowed. As I understand from a body which has had close association with tuberculosis sufferers, one of the worries was the fact that up to this no indication was given that there would be a general level standard throughout the country, that the standard might be set by each local authority, and that each local authority would decide for itself the particular rate of benefit. I think it is advisable that a uniform rate of benefit should be payable, with possible provision for the difference in the cost of living in urban and rural areas. Apart from that, there is no case for having one rate payable by one local authority and another rate by a different local authority.

I know that the Minister has altered the original Bill to provide that half the cost may be borne by the State. That is desirable, because under the schemes which will be put into operation, it is obvious that the cost to the local authorities will be quite considerable. I do not know whether the Minister can give any indication on the basis of the number of patients at present suffering from tuberculosis, but in Sweden, for the first six months, the patient suffering from an infectious disease is allowed two-thirds of his salary and, after that, half his salary while incapacitated. I do not know whether these allowances were arrived at after consideration of the cost of living there, but that scheme has been operated in Sweden successfully for quite a number of years, and the Minister might well consider the advisability of adopting a similar scheme or a similar standard here.

One matter on which the Minister dwelt briefly is the necessity for a very large increase in the number of nurses available. I do not think the Minister has any idea as to how sufficient nurses can be provided if this Bill is operated fully and all the schemes envisaged put into operation. Last year certain discussions took place between nursing associations and the Minister's Department. Some of these associations were very perturbed by the possibility that, once the scheme was put into operation, the voluntary nurses or the nursing associations which receive small State grants and which depend mainly on voluntary contributions might find themselves in difficulties. The Minister will realise that, for many years to come, there will be work for these voluntary nursing associations and the Minister should reassure the members of these associations, and in particular the nurses who work under them, that not merely will they be required, but that every assistance will be given to provide them with the necessary equipment and with sufficient salaries to enable them to continue their work.

I refer in particular to the Jubilee Nursing Association. That association was founded many years ago, and, in the western areas, in Donegal and some of the other congested districts, has done very valuable work. There are at present about 260 nurses working. Some of these are members of the Queen's Institute of District Nursing and others of the Jubilee Nursing Association. These titles may at present seem rather out of date, but nevertheless the nurses give the service, and I think their services are appreciated by the people of these districts. Every effort should be made to facilitate these associations in future, and not merely should they be facilitated, but there should be the fullest co-operation between them and the Department. If co-operation can be secured between these associations and the Department, I feel that not only will the future of the nursing associations be assured but the working of the proposed schemes may well be simplified, and the difficulties in many districts of securing nurses lessened by taking into consideration the existing services and, if necessary, extending them, or working these existing services into the new services envisaged in the Bill.

With regard to institutions which may be taken over or set up by local authorities after a local inquiry, the Minister referred to the fact that a local authority could set up an institution, and, on his direction, must set up an institution after the holding of a local inquiry. Many of these old institutions, set up under former régimes in entirely different circumstances from those which exist at present, have far outlived their usefulness. Many of them have been modified, extended and improved, but nearly all have attaching to them the stigma which attached to the old workhouse, and I suggest that every effort should be made to provide new buildings. Some Deputies express surprise that an institution like St. Kevin's should not be acceptable to many people, but anyone with any experience of the old St. Kevin's Institution, with its severe drab buildings and its historical background, cannot fail to realise that there is good reason for that dislike. While rapid strides and great development have taken place there under the commissioner, nevertheless the institution is unsuited to present-day needs. The buildings are depressing and do not lend themselves to easy adaptation and in general the institution has the flavour of the institutions so well described by Dickens. I suggest to the Minister that no effort should be spared to urge on local authorities the necessity for providing modern, up-to-date institutions. It is true to say that some of these institutions can be adapted, at any rate for particular patients or particular types of patients, but, in general, the gathering together of acute and chronic cases, which has been the system at St. Kevin's in the past, is objectionable. Anybody with experience of it must look forward to the day when those patients will be segregated either by providing one institution for acute and another for chronic cases or by providing an entirely new institution.

I should like the Minister to give the House some information as to the personnel of the health council. As I understand, a temporary council is operating at present. Will the Minister continue that council on a permanent basis or will he provide branch councils or an entirely new council? Can the Minister say what arrangements are contemplated for the calling together of members of the council? How frequently will the council meet? Will the calling of it depend on the Minister and will it just consider matters referred to it by the Minister? Or will the council exercise its own discretion so far as general matters of health are concerned and the number of occasions on which it will meet?

The provision concerning food and drink in Part V is welcome. In many cases that provision is, I think, necessary. Part VI, which deals with proprietary and standard medicines, is also welcome. Doctors consider that many of these medicines confer considerable benefit. Some of them are useless but some of them are effective in minor ailments—if only psychologically. The Minister should make regulations under the section providing that the ingredients of these medicines be shown on the container and that those ingredients be available to purchasers. It is desirable to have such a safeguard. Many of these medicines do give on the bottle particulars of the ingredients but many others do not. It should be compulsory on all proprietary medicine manufacturers to indicate to the public the nature and quality of the substance which they produce and sell.

The only other matter to which I should like to refer goes to the root of the public health services. Has the Minister carried out a nutritional survey? While Deputies praise the provision which is being made in the Bill for health services and the provision which was available in the past, I think that much of our trouble from tuberculosis is attributable to lack of proper nutrition. Many of our people are obliged to live to a standard lower than that which would afford them proper food, with the necessary health-building properties. If people are obliged to live to a standard beneath that on which they can properly maintain themselves, it is inevitable that a disease such as tuberculosis will occur. The Minister should, as a prerequisite to consideration of any schemes in the future, hold a nutritional survey and, on the strength of that survey, adopt certain standards. Unless that be done, we are bound to have recurring tuberculosis. While we may provide for that in Bills, we are failing in our first duty—to provide a sufficient standard for the wage-earning families of the country.

I wish to express my appreciation of the welcome which the general principles of this Bill received from the various Parties in the House. There was some criticism of the clauses. Deputies expressed a desire to have some of the clauses amended. I have no objection to that I should like to have the co-operation of all Parties and I promise to give every consideration to any constructive amendment which may be proposed. If we can succeed in bringing the Bill nearer to perfection as we go through the various stages, I shall be very glad, indeed. There is no necessity to dwell on the aim or main principle of the Bill—to improve the health of the people. Naturally, every Deputy agrees that that should be done and that we should make the necessary provision to that end so far as we can. As to what should be done, there is, admittedly, great room for difference of opinion. It would, probably, be impossible to get any two Deputies to agree to every little detail of a Bill of this kind. All I can hope for is to get the general consensus of opinion of the Dáil on the Bill as it goes through its various stages.

I was asked whether or not we had consulted various interests before bringing in this Bill. A Minister is in a difficulty in doing that. I did consult the medical profession on certain principles of the Bill at one meeting. I had to explain to them that I was not at liberty to circulate a copy of the Bill, that members of the Dáil must be the first to see a Bill. I was, therefore, not in a position to go into great detail but I did explain to the medical gentlemen I met what I thought we should aim at and what, roughly, were the proposals we were putting up to that end. I had their views. It might be said that they differed on some of these matters, just as we differ here. On the whole, I think I might say that the medical men would take much the same view as the members of the Dáil. They all agreed that we should do everything possible to improve the health of the people but they, probably, would not agree on the various clauses we were inserting in the Bill. Some of them might agree to some clauses and others might disagree. One of the points of which I took note at the conference was raised here by the last speaker, Deputy Cosgrave. I shall refer to it later.

Having got agreement on the principle at which we should aim, we draft a scheme for dealing with people and their health. It is a simple thing to say that everybody comes under a certain scheme and, if we depart from that, we must give some sort of reason why we stop at a certain stage. Take mother-and-child welfare. We might say that it applies to those who are not able to afford to look after themselves. In a scheme of that kind, it is extremely difficult to apply a means test. From the administrative point of view, it is much simpler to say that they are all entitled to free treatment. We go a bit further in this Bill and say that, if they satisfy the medical officer of the district that they have looked after themselves by employing a private practitioner, then we are satisfied—for the moment, at any rate.

As regards infectious diseases, there is a principle to be determined. We all start off by agreeing that it is desirable to stamp out infectious disease, but how far we should go in interfering with individual liberty in our efforts is something we have to decide. I am not very much impressed with the talk of certain Deputies about individual liberty, as it is just whatever we are accustomed to that we put up with. For instance, if a man goes mad and becomes a menace to himself or to his neighbour or to property, the law is that he can be put into an asylum and kept there by compulsion and I suppose we all agree that that is a good law. None of us would have the temerity to propose that the law should be changed and that that man should have his individual liberty and be allowed to kill himself or his neighbour or burn his neighbour's house if he so desired. That is because it is a long established practice and we all agree with it. If, however, a person gets a very infectious disease like typhus, we say we must deal with that person, if he is unreasonable and is not going to protect himself, as he will die from typhus if he will not take treatment. We say we must not allow that person to spread typhus to his neighbours as he will not stay in the room where we want to isolate him, neither can we allow him to do damage of any kind; and we say we must apply compulsion where necessary.

I cannot see very much difference between a person suffering from typhus or a man who has become a lunatic, as if the sufferer from typhus is not reasonable and does not take advice from the medical profession, he is just as great a menace to himself and his neighbour as the lunatic. We have to deal with them and the question is how far we should exercise compulsion. Every Deputy will agree that we should try to have the dangerous case of infection isolated—and isolated in his own house, if possible. If he is agreeable to that, I do not see any necessity for any powers to remove that man from his own house and put him into an institution against his will. If there is no opportunity of isolating him in his own house and if he is unreasonable and negligent of his own life and that of his family and his neighbours, the question is whether we should have some powers to deal with him or not. That question of compulsion is one that arose more in the discussion than any other and I may come back to it again when I am dealing with the points made by individual Deputies.

The Dáil lays down the principles and I have to make as good a case as I can for the powers I need to deal with the problems coming before us in this Bill. If I can persuade the Dáil to give me certain powers, then it is for me and for my Department and for the medical officers acting under this Bill throughout the country to use those powers in a sensible and a commonsense way. I met the medical profession and discussed with them certain principles in the Bill, but I could not deal with the details. I explained to them that when the Bill was passed, its implementation would be done mostly by regulation and, the Bill having been published and everyone having seen it and the Dáil having given its imprimatur to whatever final form may be agreed upon, I would be quite free to come to the medical profession and say I would like to discuss the regulations with them. I am sure they will be only too willing to help me as far as they can and that we will get co-operation on the regulations from the profession and from any other interests that may be concerned.

In my speech on the Second Reading, I spoke of the method of implementing this Bill. If it is passed through both Houses, the next steps I will have to take will be to find how far I can give effect to the approved policy of the Oireachtas through the machinery we have at the moment. Then we will have to make up our minds as to what changes may be necessary in that machinery. I told the House, when moving the Second Reading, that there is a survey being made of the dispensaries throughout the country. That survey has been undertaken by the Department of Health and when the report comes in we will be in a very good position to make up our minds whether the existing machinery is adequate to carry out the principles laid down in the Bill or whether it must be amended, or whether we must add new machinery. Having decided on that and having made whatever changes may be necessary, a very big cog in the whole machinery will be the medical profession.

Several Deputies spoke about the salaries paid to dispensary doctors and other members of the medical profession and I think it was the general opinion that they should be treated a bit more generously, if possible. Naturally, I will have to meet the medical profession. I said on the Second Reading that I had met them and agreed that I will sanction an increase in the salaries of dispensary officers and other classes of the profession working in the public service up to a certain percentage over what they had pre-war but I pointed out to them that that was merely to compensate them for the increased cost of living and that, if and when the Health Bill was passed and if additional duties were being put on their shoulders, I would meet them again and discuss with them what increased remuneration would be fair to cover the increased duties they would have to undertake. Deputies need not be unduly worried about the medical profession—like most of the other professions, they are able to make a good case for themselves. The only fear I have is that I may not be able to deal with them on my side as well as they are able to deal with their own case.

It must be remembered that this is largely an enabling Bill, enabling the Minister to do so-and-so and enabling local authorities to do so-and-so, and most of the clauses will have to be followed by regulations. There is no doubt that it will take a long time to implement all its provisions. When moving the Second Reading, I pointed out that we had to go on with this Bill with the implements we had at our disposal. I am not satisfied and neither are the officials of the Department of Health that the institutions we have are adequate for all purposes. None of us is satisfied with the dispensary buildings throughout the country. I think we are all agreed that we must have more medical men than we have in the dispensary service at the moment to carry out the additional duties along with what they are doing at present. As was pointed out by many speakers, including the last speaker, Deputy Cosgrave, we must have many more nurses, but the fact is that we have not got ideal buildings, or the fact that we have not got, or cannot get maybe, the number of nurses that we would like to have, should not prevent us from going on as well as we can with the implements at our disposal and gradually improving the service until we have all the buildings and all the personnel that will be needed for the new service.

That brings me to the point that Deputy Cosgrave raised with regard to these nursing organisations throughout the country. I think we would be very foolish not to try to get these organisations to co-operate with us in implementing the provisions of this Bill. In view of the fact that there is a scarcity of nurses at the moment, and probably will be for some years to come, we would be only too delighted to meet these various organisations, and make use, as far as we can, of their staffs in carrying out this Bill. We can go along with the means we have at our disposal, making the best changes we can at the moment and making regulations to deal with the position as it comes in our way. The Bill gives us an opportunity of being flexible in the application of the provisions because we foresee, naturally, that it is not possible to have the buildings, the equipment, the trained personnel and so on that will eventually be necessary to carry out the full provisions of the legislation.

One of the points that was more discussed probably than anything else was the compulsory inspection of children and the compulsory detention of children. I can quite well understand Deputy O'Higgins holding the opinion that he does—that he was able to carry on in the County Meath and never needed that power of compulsion. He gave us some instances of how he was up against difficulties and how, in the end, he succeeded in getting a child to go to an institution— that it was happy in going in—and how he got the parents to agree. Well, now I feel, whether I am right or wrong, that if I was in charge like Deputy O'Higgins neither would I ever use compulsory powers, but still I do not see why we should not have these powers if they are ever necessary. They will not be used unless they are absolutely necessary. Deputy O'Higgins suggested that they might be made adoptive, that is, that they might be applied to certain counties where the position was difficult. That is the idea in the Bill. It is laid down in the Bill that a provision like this can be applied either to the whole country or to certain counties or to a number of counties, so that we need never probably apply its provisions to a county like Meath if Deputy O'Higgins does not wish to have it. We can apply it to any county if the county medical officer of health says that it is necessary and that he cannot get on without it. I would be very glad indeed if the provision were not necessary. I want to say this to Deputies that, if they agree to this power being maintained in the Bill, it does not mean that they will lose entire control over any supervision that they would like to keep on this particular section, because this power will have to be extended to counties by regulations and the regulations will have to be laid on the Tables of the Houses. Therefore, any Deputy can raise at any time an objection to the application of a regulation which proposes to extend this power to any county or to the whole country as the case may be.

Deputy O'Higgins said on this point that he was quite satisfied with the way in which children were presenting themselves for medical inspection in the schools, and quite satisfied with the way in which parents were sending their children along. I asked for the reports of the medical officers of health from all the counties and I find that a number have complained and that they do not agree with Deputy O'Higgins. A number of these county medical officers of health have complained about the laxity of parents, in certain cases, in not presenting their children for inspection. Some have complained that the percentage which is presented for inspection is far too low, and they make the point that, usually, it is the children of parents whom they would like to examine that are not presented: in other words, the children of parents whom they might suspect would be likely to be found with disease.

I think that, if one were to make up his mind on the reports of the county medical officers of health, he would inevitably come to the conclusion that there should be a residual power there for compulsory school medical attendance, at least in certain areas at certain times. While I say that, I am very much in favour of a persuasive system as far as we can possibly go with that. I mentioned, when moving the Second Reading of the Bill, that we hoped to have nurses appointed in all the districts. When I speak of a district I mean, roughly, a dispensary district, although some of these may be slightly changed in area, but as time goes on we hope to have a nurse allocated for each district. One of the duties of that nurse will be to visit the houses in it. The nurses will use persuasion with the parents and try to reason with them as to how valuable and important the school medical inspection is. They will try to get these parents to send their children along for medical inspection. I think when we have the scheme in full operation that the compulsory power will be very seldom needed, but the fact that it may be seldom needed is perhaps the greatest argument why it should be put into the Bill, because if there were only a few people left in the country who were not ready to comply, one would like to see that they were made toe the line under a scheme which practically everybody approves of.

As regards these compulsory powers, the next question that arises is one that relates to detention for infectious diseases. Again, many Deputies spoke against this power of compulsion. I do not see why a person suffering from an infectious disease should be permitted to continue to be a danger to himself and his neighbours if he becomes recalcitrant and will not agree to have himself properly isolated either at home or in some institution. I think that Deputies are allowing their hearts to get the mastery over their heads when they talk about the freedom of the individual in cases of that kind. The peculiar thing, though, is that many Deputies while regretting the necessity for, as they called it, dragooning people into compulsory detention, compulsory immunisation and compulsory detention as regards infectious diseases, also regretted the fact that we were repealing the vaccination laws. Under this Bill we are putting vaccination against smallpox on the very same level as vaccination or immunisation against any other infectious disease. We are very lucky in this country in that we have had no smallpox for many years. We have had many deaths here from, say, diphtheria, and if we were to go on statistics alone here of the number of deaths from diphtheria and the number of deaths from smallpox there would be an overwhelming case for having compulsory immunisation against diphtheria and not bothering about smallpox at all. We are not going that far in the Bill. We are only going this distance: we say that all the infectious diseases—diphtheria, scarlatina, tuberculosis, smallpox— are all on the same level, that we can make regulations if necessary, to have everybody vaccinated against smallpox in a particular area where there is danger as we can make regulations to have everybody immunised against diphtheria under similar circumstances. If any Deputy has a feeling that we should not interfere with individual liberty to the extent of vaccination or immunisation against a particular disease, we are making provision for that in the Bill. As a matter of fact, we are allowing a certain amount of individual liberty there but, surely, a person who has a conscientious objection to vaccination or immunisation has just the same objection whether it is against smallpox, diphtheria or any of the other diseases and it is only fair that they should all be put on the same level.

An Leas-Cheann Comhairle took the Chair.

While saying that, I do not want Deputies to come to the conclusion that we are in any way forgetting the terrible danger of smallpox if it should occur. We are leaving the facilities for vaccination against smallpox there. We will encourage medical officers of health of the county and of the district to try to get everybody to agree to be vaccinated against smallpox. We will do that just as strongly as we would encourage them to try to get everybody to agree to immunisation against diphtheria and we will try, if we can, to get the practice carried on of vaccination against smallpox as it has been carried on in the past.

This Bill contains adequate powers for enforcing the necessary vaccination against smallpox or diphtheria as the case may be. So that those Deputies who have regretted the abolition of the Vaccination Acts need not have any fear because any Minister for Health at any time can enforce vaccination under this Bill just the same as was done in the past, if he so desires.

Deputy Dr. O'Higgins referred to the incidence of diphtheria in the County Meath, which was higher after immunisation against diphtheria had been carried out than it was before. That is possible. But I think Deputy Dr. O'Higgins may have given a wrong picture of the situation or may have given rise to a wrong inference being taken from the case he made. For one thing, the statistics show that in this country, since 1935, there has been a gradual and a marked decrease in the incidence of diphteria. That is subject to correction but, taking it as a whole, since 1935, there has been a big decline. 1942 was exceptional. There was a bit of a jump in 1942 and in 1944-45 there was what amounted to an epidemic but that epidemic was common to the whole of Europe, excluding Great Britain. That epidemic in 1944-45 was particularly severe in the City of Dublin and the City of Dublin is very close to the County Meath and the County Meath may have suffered from this world epidemic in 1944-45. I would like to draw attention to a question which I answered in the Dáil on the 24th April. A question was put down by Deputy Larkin with regard to the number of cases of diphtheria, the number immunised, the number of deaths. The reply was very detailed and occupied some columns of the Official Report but if any Deputy cares to study the figures given in that reply he will find a convincing argument for immunisation against diphtheria, because the number of deaths was negligible practically in those that were immunised while it was comparatively high in those that were not immunised.

Another thing that we should remember is that for some time after immunisation against a certain infectious disease commences there is quite a number of people who are not immunised and who will get the disease if it comes along. It is only when immunisation is in operation for some years that we may expect to get the benefit and I am quite sure that that will be found in this country as years go on.

I need hardly assure the House that on that point also I mean to keep in touch with the medical profession as regards the efficacy of immunisation against the various infectious diseases and I do not think that there need be any fear that we are going to embark on any sort of new-fangled ideas in this country unless they are fairly well established by the medical profession in general. Deputy Dr. O'Higgins thought that we should wait, as he said, until the thing was tried on the big fellow before we apply it to this small country. That is generally what we are doing, but, on the other hand, we should not discourage our own medical men if they are anxious to make progress—not at the expense, of course, of our people—in the medical profession in general.

Deputy Dr. O'Higgins said that compulsion and medicine are completely incompatible, which is quite true. Anything in regard to health must be done practically entirely on a voluntary basis and by persuading the people that it is good for them and getting them to adopt it, but it may be necessary to deal with a few recalcitrants that are causing a great deal of harm in the country and, therefore, these compulsory powers must be got. Deputy O'Higgins must find it hard to reconcile his views on vaccination with the view he expressed that medicine and compulsion are incompatible.

Deputy Dr. O'Higgins made a suggestion that we should make the provision for compulsory detention of a person suffering from infectious disease adoptive, that is, it should be applied to each county as the county may require it. That is not easy in this particular case, I am afraid. There have been compulsory powers of this kind vested in the Minister for Local Government and Public Health and then in the Minister for Health under an Emergency Powers Order made in 1940, and since that 38 Orders have been made under that particular Order and these Orders covered 14 different counties—counties as far apart as Kerry and Sligo, Galway and Dublin, Roscommon, Westmeath and Wexford, so that you cannot say that this thing is necessary only, say, in the north-west or the south-east or in the big cities. It appears to be necessary in a great variety of places—in fact, practically everywhere. There is no large region which one can say is immune and, therefore, it would be impossible to say that we will apply this to certain counties and not to others.

A better way to approach it if we want to keep it as confined as possible, would be to say: "Well now, let us not confine it on the geographical basis but let us try to confine it on the number of diseases to which it might apply." I think Dr. Ward, when speaking on the Public Health Bill last year, said it was proposed to apply it to typhus, typhoid and paratyphoid, smallpox, scarlet fever, diphtheria, acute anterior poliomyelitis, which means infantile paralysis, encephalitis lethargica (sleeping sickness), cerebro spinal fever or what is usually called meningitis, anthrax, tuberculosis, venereal disease, dysentery. I think we could cut that down a good bit. I think for a start we could cut it down to five or six—smallpox, open tuberculosis, venereal disease, typhus, enteric typhoid, diphtheria and infantile paralysis. It would be very difficult to remove any of those I have mentioned in this smaller list because any one of those could become a terrible menace to a whole area if we did not control the outbreak with the greatest possible despatch. I just mention that list for Deputies to consider, as I am sure this matter will be raised in more detail when we come to the clause on the Committee Stage.

Deputy Commons suggested that appeals from persons compulsorily detained should be considered by a consultative council. Deputies will remember that if a person is detained compulsorily under this section he can make an appeal and that appeal goes to the Minister and the Minister either says that the appeal is granted or that it is turned down. Deputy Coburn thinks that appeal should go to the consultative council. I do not agree with that at all—whether he means the present consultative council or the health council which I mean to deal with later, it is just the same as far as my arguments are concerned—because for one thing, there would be people on these consultative councils from all over the country, many of them very busy men, to whom we must really feel grateful for giving us a day of their time as often as we may require them, say every two or three months and we could not possibly expect them to come along in a judicial capacity every time an appeal is made under this section. Apart from that objection I think it is essentially a matter for the administration to decide rather than anybody else; that is, that it must be decided by the Minister because the Minister is the person in particular who knows the gravity of the situation that exists and whether very drastic steps will have to be taken or not.

Listening to this debate by the Deputies in this House about personal liberty and so on, reminds me of a position I was in five or six years ago, as Minister for Agriculture, when there was an outbreak of foot-and-mouth disease. I remember and Deputies will remember it too—if not they should go back and read the debates which they will find very interesting—that I was vehemently attacked because I did not take sufficient measures to stop the outbreak. I remember being pressed on more than one occasion by Deputies to stop football matches. I said I was advised by my technical advisers that there was no danger of the spread of foot-and-mouth disease by people going to football matches. Deputies wanted them stopped, anyhow. I did not stop them. I think the experience of every Minister is that when he is bringing a Bill to the Dáil he has arguments from Deputies saying that he is taking too many powers but when he is up against a crisis they tell him to go and do the thing whether he has the powers or not, and they do not bother about powers. I am sure there would be very little talk about personal liberty if there were an outbreak of smallpox in this city. I think Deputies should not be in any way apprehensive of allowing this power of detention. It will be very seldom used—only when it is absolutely necessary.

Many Deputies spoke of financial implications. These new services will be financed practically altogether on the basis of 50-50, that is 50 per cent. from the local authority and 50 per cent. from the Department. I should say, first, that capital expenditure will to a great extent, as in the past, come from the hospitals fund, so that the local authorities will not have to bear any bigger share than they have borne in the past, as far as capital expenditure is concerned. Deputies are more concerned with the year-to-year charges. Section 23 provides for a grant of 50 per cent. of the cost of mother and child services. Whatever they cost, 50 per cent will be recouped to the local authority. Section 39 protratio vides for a grant of 50 per cent. of the cost of maintenance allowances for persons and dependents suffering from infectious disease. That clause has been referred to by some of the speakers. The dependents of a person who is ill with an infectious disease will be looked after by the local authority and the local authority will get 50 per cent. of the cost. I intend to say something more about that clause too, later on.

There is another point which is not mentioned in the Bill upon which I might reassure Deputies, and that is the cost of tuberculosis services, including the cost of the actual operation of the tuberculosis scheme which will be administered under the provisions of this Bill in local institutions which will include regional sanatoria, when they are ready—that is, under the 1945 Act. The cost of that scheme will be recouped to the local authorities on a 50 per cent. basis. The three big items in this Bill will be recouped to the extent of 50 per cent. I do not know what the complete programme may cost. I did give figures that were already mentioned with regard to the building of all institutions that are still required in this country. We may leave that capital sum aside because we are not concerned with it for the present. As regards the three matters I mentioned, I think Deputy O'Higgins is probably about correct when he assumed that the mother and child welfare scheme, when it is fully operating, would cost about £500,000 a year. The estimate that we made in the Department for allowances to patients or to dependents of patients suffering from infectious disease is that it will be about £300,000 a year.

Does that include tuberculosis?

It includes all infectious diseases, of course, but particularly tuberculosis. The third item—extension of tuberculosis schemes with regard to regional sanatoria—may cost another £500,000. It is very difficult to give any sort of a firm estimate for any of these cases at the moment. The estimates I am giving now apply to the scheme when it is fully working. Of course, it will not cost nearly as much as that for the next year or two because it will take a few years to get these schemes into full working order.

Deputy O'Higgins stated that this Bill bore the evidence of being prepared by people who were working at a desk rather than in the field. I do not think that is fair criticism, because I think everybody knows that, so far as the medical staff in the Department of Health are concerned, they know a great deal about the field work. Some of them were doing field work before they came into the Department, but, whether they did or not, they know a good deal about it. The same applies to the administrative staff. In preparing these Bills, we invariably get the advice of men who have experience of field work in order to get their opinion on the various provisions. As I said already, it is an enabling Bill, and before regulations are drawn up under any of the sections the field staff will be consulted as well as members of the medical profession in general.

Before I leave this question of compulsion, I must say that personally I am very much against it in the medical line as well as in everything else. But I do see the necessity for having the residual power there to deal with people who are so unreasonable that they will not fall in with what is for their own good as well as for the common good. You must keep in mind that individual laxity—it is called individual liberty by some people—may be a great menace to the community and we may have to deal with it. We are dealing now with what is known as public health or, as it is called by some people, social health. In dealing with that we must remember that we are looking to the future and trying to lay down a good foundation for the health of the coming generation as well as the present one, and we cannot have people being so lax and unreasonable that they will not fall in with some parts of the scheme. I have no intention whatever, nor have I any wish, to dragoon either the medical profession or the general public in a scheme of this kind.

Deputy Cogan referred to Most Rev. Dr. Dignan's plan. That plan, which I do not intend to go into fully at this stage, dealt with both public health and social insurance. I informed the Dáil a few days ago that I hoped to have a White Paper on social insurance prepared within the next 12 months. Of course, the preparation of a complete social insurance plan is a very big job. That White Paper will deal with social services so far as this Government can foresee the future. I also promised that a White Paper dealing with public health will be presented very much sooner, probably within a month or two.

Deputy Davin said that he had always advocated a contributory scheme for health services, but I do not agree with that. I think that health services will have to be freely put at the disposal of people and that we can leave contributions out of that. On the other hand, so far as social services are concerned, I believe they should be contributory so far as we can possibly make them so, so that we will have a very clear divorce between the health and the social services. Public health or the prevention of disease is quite a different thing from sickness benefit, which is a social service and should go with such things as unemployment, widowhood and all these other things.

If a person is insured and contracts tuberculosis can he get medical benefit?

Certainly. At the present time, as the Deputy knows, there are medical benefits attached to the national health insurance scheme. I think these will disappear, because I think that when a social insurance scheme is properly co-ordinated and our health services are properly built up everybody under a certain income will be entitled to these medical benefits which are now applicable to national health insurance members. I do not see why national health insurance members should pay for benefits that are free to everybody else. Therefore, they should get the same treatment so far as that goes. These are matters to be dealt with in the White Papers which I expect will be prepared—one on health and the other on social insurance. They are matters for the future.

Deputy Burke asked for a provision for after-institutional care. Where dependents of a person in a sanatorium or a fever hospital are getting a certain allowance from the local authority while he is in the institution, Deputy Burke made the point that when that person came out of the sanatorium or fever hospital he was not in a position to work, perhaps, for a few weeks and that this payment should continue. Deputy Burke is quite right there. As a matter of fact, we did intend to include in the Bill the period of rehabilitation but, through an oversight, it was not covered. We will, however, deal with that on the Committee Stage.

Deputy Burke also asked about the training of mental defectives. There is a scheme being hatched, if you like to put it that way, but it has not come to maturity yet, to deal with this whole question of mental defectives. First of all, we must get the buildings and then we must get the personnel to look after the patients. They will have to be a highly-trained personnel to look after these mental defectives. The scheme is being considered both by the Department of Education and the Department of Health. We mean to do something about it as soon as we possibly can.

Deputy Hughes referred to the wide powers taken to make regulations dealing with infectious diseases. As a matter of fact, the powers that I have at the moment under the 1878 Act are wider. I did not know that until Deputy Hughes made the point. I looked it up and I said: "Why did I change it, anyway? I should have left it as it was." We had wide powers under the 1878 Act. There are wide powers taken here, but there are limits put to them, because the regulations have to be laid on the Table. However, I do not mind having surrendered, if you like, a certain amount of power to the Dáil. But there is that difference anyway, that the regulations must be laid on the Table and the Dáil will have power to object to them if it likes.

Put them in the Bill, which is the right place for them.

To put all the things necessary to be covered by regulations in the Bill would, I am sure, take 1,000 sections. It would be very difficult to have the matter dealt with in that way. As I explained already, we must have a flexible procedure, because you do not know what you may be up against. You may be up against a desperate situation from time to time in a particular area and you want wide powers to deal with that desperate situation and authority to withdraw the powers from the medical men concerned and to allow them to carry on in the normal way afterwards.

Another point made by Deputy Hughes was that of choice of doctor. That will not be easy in a country place. The Deputy knows that in a country place at the moment you have no choice. There is one doctor there and, so far as the people are concerned, he is the medical man and they have to put up with it. It would be very difficult to alter that under any scheme, because you cannot maintain two medical men in a country place. There is only a living for one, only work for one, and it would be extravagant to pay two of them so that the people could have a choice. There are other instances where people have not a choice. There is a growing practice of going into maternity homes amongst women. They go into these homes knowing that there is no choice of doctor. The person dealing with maternity cases in that institution is the person they must go to and they cannot go to anyone else.

They choose the home and that means choosing the doctor.

They have as good a choice under this scheme as they have at present. It has been put to me by the medical profession that there are certain practitioners who may suffer under this scheme. I have undertaken to examine that and, if it is possible to fit these men in, or to fit in some of them—I do not know whether or not it is possible—it will be done. In that way, in towns there may be a choice, and in fair-sized villages, if it is a populous area; but in the sparsely-populated rural areas there will be no possibility of giving a choice.

Deputy Bartley asked about nurses for the Gaeltacht area. There is a scheme for training girls in nursing in the Gaeltacht and that will be continued. We will need to have a number of these girls trained for our schemes in the Irish-speaking districts when those schemes are being put into operation.

Deputy Roddy raised a question about borough corporations and he thought the health administration should be left to them, because it was so very efficiently carried out in boroughs like Sligo. There are a number of boroughs in the same position as Sligo, for instance, Dún Laoghaire, Kilkenny, Drogheda, Galway, Clonmel and Wexford. There is this point to be considered, that they had only the powers of an ordinary urban district council and I think, so far as the few powers they have are concerned, it is not worth while leaving them there. It is much better to have a uniform scheme under which the counties and county boroughs will administer all the health services.

It was Deputy Roddy who asked if the health authorities could be consulted with regard to health regulations. That would be a difficult matter. There will be 31 health authorities and it will be difficult to consult them all. In practice it would mean sending down a copy of a proposed regulation to have it discussed at the meeting of the health authority, and it would be very difficult to know whether it was approved or not. The medical officer of health will be consulted and he will know the local conditions better than anybody else.

Deputies Roddy and McCann said they thought it was a pity that charges should be made in these institutions against people suffering from infectious diseases. So far as the public assistance authorities are concerned, they have been circularised to the effect that no charge should be made. We saw that there was no necessity to make a charge in the case of people going in with an infectious disease. Deputy McCann apparently had in mind Cork Street Hospital. That is in a different position. It is not under a public assistance authority. Its expenses are very high and they are trying to make ends meet as well as they can. There will be something done about that as soon as possible. Section 15 provides for this charge and we do not intend that it should be construed harshly against any patient.

Deputy Cosgrave referred to the desirability of a nutritional survey. That is proceeding as energetically as possible and it is proceeding successfully. We hope to get a great lot of information through this survey and to be able to base advice and instructions on the data gathered. The Deputy also asked about St. Kevin's Hospital. I spent half a day there recently and I was very impressed with the accommodation for acute cases and with the service the staff are giving there. We intend to give all the assistance we can to the commissioner to improve the hospital for acute cases even more and there is no reason why it should not be made at least as attractive as any of the voluntary hospitals; both from the point of view of the accommodation there, the nursing and the medical attendance, it should be just as attractive as the voluntary hospitals and quite as good work should be done there. I think we can reach that position before very long.

As regards the chronic patients, in what might be described as the county home part, I am very much in favour of removing those patients to another place which would be more congenial. I do not like the institutional atmosphere that those old people have to endure for the rest of their lives. It has the old workhouse form of architecture and I would like very much to get those old people to a more open site where there would be buildings scattered all over the place, where they could have fresh air and, let us hope, a bit of scenery. We are working towards that end, to get those people changed from that particular institution.

It would be a welcome change for them.

Deputy Cosgrave asked about the personnel of the health council. The consultative council is a medical consultative council and it really deals with medical matters, matters that the medical profession would be personally interested in, particularly with reference to their own conditions. Constituted as they were, I consulted them about certain clauses of the Health Bill. The health council would be a different body. I did not give it as detailed thought as I hope eventually to be able to give it, but the intention is that the health council will consist of all the interests concerned—medical, dental, nursing and other professions of that kind—and on the administrative side there will be representatives of the local authorities and the voluntary institutions. We must keep in mind the total number; that must be kept within reasonable limits, but we must try to have representation of all those interests.

By election or selection?

It will be by selection. In the case of the medical profession there are a couple of organisations and we shall ask them to nominate a panel. In the other cases we can do that as far as possible.

Deputy Cosgrave asked how would the rates of maintenance for the dependents of patients be determined. It is laid down in the section that the Minister could prescribe minimum and maximum standards. What I was afraid of—and I would like to be frank with the Dáil—was that some local authorities might look on it as just a public assistance service. I do not want it to be regarded as an outdoor relief scheme. It is much more general than that. On the other hand, there might be some who would go far and away above the other counties and say that a man would be entitled to his full salary. As regards a person earning a substantial salary, that would be going too far. Keeping those two extremes in mind, I put it in the Bill that I could fix minimum and maximum limits.

Deputy Cosgrave raised a question as to the necessity of notifying parents in regard to school medical inspections. I think that is fairly well provided for. Advertisements can be issued, school teachers will be told, so that they can make announcements to the children and I think in most cases the teachers will probably send word to families whose children are not present on the particular day on which the notification arrives. Of course, when nurses are appointed in the various areas that is the sort of duty which we can rely upon the nurse to discharge. She will look up families that may not have got word and endeavour to have the children present when the inspection takes place.

One point raised by Deputy Cosgrave was also mentioned by some members of the medical profession. A section of the Bill gives the Minister power to compel hospitals to refuse to take certain types of cases. The point made by Deputy Cosgrave, which, as I say, was also made by some medical men, was that a hospital should have some say in the kind of case it would accept, especially the teaching hospitals. The Deputy mentioned that some of these hospitals had special wards for dealing with infectious diseases. I am afraid that, as the section stands, it may not be possible to make a regulation that would fit the position by allowing a certain ward to be set aside for dealing with a particular disease. It may be necessary to amend that section on the Committee Stage.

You take power to ensure that only special diseases would be treated in certain hospitals. That might give rise to difficulties.

Power is taken to prohibit hospitals from taking in infectious diseases. There is very good reason for that. Hospitals may not be able avoid it in certain cases but they will have to try to avoid it, so far as they can. There have been instances, probably very few, where hospitals took in open tuberculosis cases and put them beside surgical cases. That is a very dangerous thing. I think hospitals in general would welcome a provision of this kind because it would enable them to refuse cases which they did not want to take in. There was one instance of a children's hospital which took in a case of gastro-enteritis without isolating it. That is a very dangerous disease amongst children and is very infectious. Grave damage might be done by taking in children suffering from gastro-enteritis and putting them alongside other children in the same ward. We require powers to deal with cases of that kind.

Some Deputy stated that he did not think that it was a good idea to make the dispensary doctor the medical officer of health. I think it is a splendid idea because everyone is aware of the difficulties mentioned by Deputy Dr. O'Higgins. For instance, Deputy O'Higgins mentioned the inconvenience associated with dragging a medical officer from town to town when there is a prosecution under the Public Health Acts. The dispensary doctor, however, will not have to leave his own district and he will not have to under-go the inconvenience mentioned by Deputy O'Higgins. He will have to deal only with his own district and prosecutions will be heard in the nearest court area to that district. That will be one advantage. Apart from that, I think that it will be helpful when we can say to a medical man: "There is your area; you must not, as far as you can prevent it, allow any disease to come into it, and if it does come in, you must get rid of it as soon as possible. That is your responsibility". That man knows that he has nobody to fall back upon. If things are not done as well as they should be, he knows that he alone is responsible.

Again the dispensary doctor will have an opportunity of inspecting the children in his area fairly frequently. Usually there are only five or six schools in a dispensary area and it should be no great trouble to a doctor to inspect these children two, three or four times a year. As we know under the old system, the county medical officer of health could get round to each school only every few years. Under the system now proposed the doctor can visit each school two or three times a year at least and he will be able to look after the health of the children more closely than in the past. He is responsible for seeing that the children are reared in a healthy manner and for guarding them against infectious disease by providing for immunisation, or any other measures that may be necessary. If disease breaks out in spite of his efforts, he is the man responsible for trying to stamp out that disease and for seeing that it is kept out. It may, of course, be said that everybody is not bound to come to him. People, if they like, can go to a private practitioner. If they say they are going to a private practitioner and that they are getting the necessary service from him, the dispensary medical officer must accept that statement, and these people are exempt from the obligation of going to him.

I think this is a really good scheme. So far as I know no other country has a scheme of this particular kind because no other country has had the opportunity of adopting it. They had not the foundations to build on that we have. I think that on the whole we were very fortunate in having the dispensary system on which to build this scheme. I have every confidence that the scheme will be a success when these new district medical officers have the authority that this Bill gives to them.

The Minister's remarks seem to suggest that it will be necessary to increase the number of dispensary doctors considerably. It may be necessary to employ 300 or 400 more doctors. Do I understand that new dispensary districts will be created, or that in some existing dispensary districts it may be necessary to have two doctors? Will all the doctors in these districts be directly responsible to the Minister? If that be so, what will be the function of the county medical officer of health and his assistants?

The dispensary doctor will become the district medical officer. There is the fact that certain dispensaries are too big. In the cities, they are very big, and it may be possible to put extra men into some of these dispensaries. In many country places, however, it will not be necessary to employ a second man but it may be that a bit will be taken off, say, three dispensary districts to create a new dispensary district. If we find that we shall have to employ additional doctors to provide necessary staffs, they will be employed. As I said, each district medical officer will be responsible for the health of his district. The county medical officer of health will, as it were, be the general in charge. After all, he is the link between these men and the Department.

So that the county units will remain?

Yes. I explained that matter very fully on my Second Reading speech, as reported in column 1953.

If you appoint a second man in a dispensary district, I think it would be necessary to define the work which each man will have to do so that you will not have the two doctors at variance.

The Deputy may not be aware that in Dublin City at present there are sometimes two or three doctors in one dispensary district. The duties are theoretically divided between them. We shall probably have to intensify that system. If we put up clinical buildings, it would be much better to have a building where, say, four men could attend than to have four separate buildings. The same thing will apply in fair-sized country areas.

Arrangements will have to be made for their private practice.

Each man will have his own area, or, as an alternative, we might have a man with an assistant in a town, because it has been advocated that experience as an assistant would be a good thing with which to start a young man off, and that he could get a dispensary afterwards.

Is it intended to utilise the services of the private practitioner under the mother and child welfare service or to compensate him if the scheme injures him in his practice?

That is a matter which would require a lot of discussion and it took me quite a long time to discuss it with the medical profession. There are various aspects of it. I could argue, and, I think, fairly convincingly, that the private practitioner will not lose by this scheme, because if every child must be inspected every quarter, the parents will probably avail of his services and so he will get more work instead of less. The same applies to immunisation. If children must be immunised, the parents will probably avail of the private practitioner's services also.

They will work on a fee basis?

He will get more private work under this scheme than he got in the past. If it turns out otherwise, we shall have to discuss what is to be done.

The Minister has not made the position clear to me. If there is a man designated for the particular work of the mother and child service and paid on a salary basis, does the Minister anticipate that a very big number of people will decide not to avail of that service?

I think so. The Deputy must realise that in, say, the City of Dublin, there are numbers of doctors doing private work at fairly low fees. They are making their living entirely from people who are entitled to free medical service, but who do not avail of it. When you go higher in the scale, to the people with £1,000 and £2,000, they are entitled to free maternity treatment, but they will not avail of it. They must, however, get the necessary certificate, so that the scheme will put more, rather than less, money into the pockets of the private practitioner.

Question put and agreed to.
Committee Stage ordered for Thursday, May 22nd.