I move:—
That a sum not exceeding £615,590 be granted to complete the sum necessary to defray the Charge which will come in course of payment during the year ending the 31st day of March, 1949, for the Salaries and Expenses of the Office of the Minister for Health, and certain Services administered by that Office, including Grants to Local Authorities, miscellaneous Grants and a Grant-in-Aid, and certain Charges connected with Hospitals.
Before I proceed with a review of the events of the past year and an explanation of the Estimate before the House, I think it is desirable that I should mention a few important items under the head of Vital Statistics.
The number of births registered in 1947 was 68,602, which was 680 more than in 1946 and 1,741 more than in 1945. The birth rate per 1,000 of the estimated population was 23.1, compared with 22.9 for 1946 and 22.4 for 1945. The rates in Northern Ireland, Scotland, and England and Wales for 1947 were 23.3, 22.0 and 20.5, respectively.
The number of marriages registered during 1947 was 16,300—a decrease of 1,225 on the number for 1946 which, however, was the highest recorded since 1878. The 1947 rate was 5.5 per 1,000 of the population in 1946. The rates in Northern Ireland, Scotland and England and Wales for 1947 were 7.1, 8.6 and 9.3 respectively.
The highest marriage rates occur in the cities of Limerick, Cork and Dublin in that order. Counties Dublin and Tipperary had the highest marriage rates in rural areas. The lowest marriage rates occurred in Counties Laoighis, Mayo and Limerick. It should be remembered, of course, that some country weddings are solemnised in the cities and are registered there.
The number of deaths registered during the year was 44,135 or 2,678 more than in 1946. The death rate was 14.9 per 1,000 of the population as against 14.0 in 1946, 14.5 in 1945 and 15.3 in 1944. Deaths from cancer and tuberculosis were among the highest contributing factors. Provisional figures show that the total number of deaths from cancer was 3,773 or 251 less than in the previous year. The total number of deaths from all forms of tuberculosis is provisionally estimated at 3,634, which shows an increase of 244 over 1946.
During the year the number of deaths of children under one year registered was 4,597 as against 4,390 in 1946 and 4,739 in 1945.
Infant mortality has averaged the regrettably high figure of 71.2 per 1,000 live births for the ten years from 1937 to 1946. The figure for 1947 was 67. For 1947 the rate was 53 in Northern Ireland, 41 in England and Wales and 56 in Scotland.
The average rate for the four county boroughs was very much in excess of that for the country as a whole. The infant mortality rate per 1,000 live births decreased in Dublin from 117 in 1944 to 92 in 1946, in Cork from 108 to 61, in Limerick from 123 to 69 and in Waterford from 80 to 66. These figures are still excessive, however, and effective steps must be taken to bring about a reduction.
The number of deaths from diarrhoea and enteritis in infants under two years of age throughout the country as a whole, fell from 1,233 in 1943 to 734 last year while in Dublin County Borough the number fell from 573 in 1943 to 282 last year. It is not possible at this stage to state, with any real assurance, the cause of this decrease, which might be due to a reduction in the virulence of the disease in the past year. It is, however, only fair to state that in recent years there has been an intensification of measures to combat the disease, including, in Dublin, a special gastro enteritis section under the control of the corporation and the provision of special hospital facilities at St. Clare's, under the control of the Dublin Board of Assistance.
During the year 1947 the number of cases of the principal infectious diseases (typhus, typhoid, diphtheria and scarlet fever) notified was 2,697, which represents a continuance of the downward trend in the incidence of these diseases—in 1943 the number of notifications was 7,269. Better still, the number of deaths has declined from 400 in 1943 to 77 last year, of which 55 were due to diphtheria, 16 to typhoid and the remaining six to scarlet fever. For the third successive year no case of typhus occurred.
The number of cases of diphtheria notified was 4,583 in 1943, 5,086 in 1944, 4,177 in 1945, 1991 in 1946, and 851 last year. This fall must, in large measure, be due to the operation of immunisation schemes. Facilities for free immunisation are now made available by all health authorities throughout the country and parents should realise the great life-saving gift that is there for the taking. I regret that, after the great spurt made during the war years, there has been a falling off in the number of immunisations, but I am hopeful that the recent satisfactory settlement with the Medical Association regarding remuneration for this service will bring about a great increase in the number in the current and future years, with a consequent further decline in the incidence of the disease.
A separate Department of Health was established in an attempt to provide the country with a proper standard of health services. I would like at this stage to review briefly the activities of the Department throughout the year.
The Health Act, 1947, was enacted last summer. Certain of its provisions are not acceptable to the Government and it is intended to introduce legislation at an early date to repeal or amend them. Section 25, for instance, provides for compulsory medical inspection of children in certain circumstances. Section 26 gives health authorities power to require school managers to provide facilities for school medical inspection. The remainder of the Act has been brought into operation.
Much has already been done to provide the services authorised by the Oireachtas under the Act. Part II of the Act which is a consolidation of the law relating to health institutions will simplify to some extent the procedure in dealing with the provision of new sanatoria and other health institutions.
There has been a certain amount of discussion on Part III of the Act, which gives health authorities wide powers to provide health services for mothers and children. While I am satisfied that the main purpose of this Part of the Act should be implemented, I have not made up my mind as to the exact method of providing the mother and child service and am awaiting the outcome of the deliberations of the council which I have recently established to advise me on matters relating to child health. In the meantime, arrangements have been made to continue existing services under temporary regulations made under Part III of the Act.
Part IV of the Act codifies the law relating to the prevention of the spread of infectious diseases and includes new provisions in relation to infestation. Regulations have been made under this Part of the Act to replace all the previous regulations dealing with infectious disease. The Infectious Diseases (Maintenance) Regulations, 1948, also made under this Part of the Act, provide for the payment of allowances to persons suffering from certain infectious diseases and are of prime importance in the fight to eradicate tuberculosis in particular. There can be no doubt that in the case of this disease, lack of means and economic insufficiency have been a major impediment to early diagnosis and effective and lasting cure. As is the case with most new schemes, difficulties have arisen in the administration of the regulations. The whole position will be examined in the light of practical experience.
Under Part IV of the Act, as supplemented by regulations, we shall be in a position also to tackle more satisfactorily the problem of venereal disease. No accurate information has up to the present been available on the incidence of this disease and the readiness of persons suffering from it to undergo treatment. As an experiment, arrangements have been made whereby a medical practitioner who diagnoses a case of venereal disease will notify the chief medical officer of the county without divulging the name or address of the patient. Thus a fairly accurate idea of the number of sufferers from this disease coming to the notice of medical practitioners will be obtained. Three months after notification the medical practitioner must indicate to the chief medical officer whether or not the patient has been adequately treated. This will give some idea as to the willingness of persons to take treatment. This confidential system of notifications and reports will, I hope, enable us to form a better picture of the prevalence of the disease and to make arrangements for its treatment accordingly. It is fully appreciated that there is a delicacy of public opinion and a sensitiveness on the part of patients and full recognition of these factors is being accorded in the proposed arrangements for case-finding and treatment which I have just outlined.
Part V of the Health Act gives the Minister wide powers to arrange for the control, from the health point of view, of the manufacture, preparation, importation and distribution of food and drink intended for human consumption. Arrangements have been made to obtain detailed information on the health control of food preparations, etc., in Great Britain and elsewhere. When the investigations have been completed, it is hoped to produce a set of regulations which will ensure that food intended for human consumption in the home or in public eating-places has been hygienically prepared and handled and is of good quality.
So much for the Health Act itself.
The passing of the Health Services (Financial Provisions) Act, 1947, involved a fairly radical change in the system previously in operation for the making of State grants in aid of the expenditure of local authorities on health services. The full expansion of the health services would have imposed a severe strain on the finances of health authorities if no change had been made. The Act provides that the State will bear the increased cost incurred by a health authority in the expansion of health services over and above the expenditure on recognised health services in the financial year 1947-48 until such time as the State contribution equals the expenditure of the health authority. Thereafter, the cost will be equally borne by central and local funds. The method of recouping health authorities for health expenditure has also been simplified. State grants were hitherto paid from various sources for specific health services to different categories of local authorities. From the 1st April last, a single grant will be paid which will replace all previous grants in aid of expenditure on health services.
I should say a word about the Mental Treatment Act, 1945, which was brought into operation on 1st January, 1947. Among other things it simplified the procedure for the reception of patients, and provided for the reception of voluntary patients and temporary patients as well as persons of unsound mind. The new procedure aims at encouraging patients to seek treatment in the early stages of illness and the results so far achieved are encouraging. The admissions in the year 1947 included 442 voluntary patients and 706 temporary patients. Among the latter class are included 36 "addicts". Discharges during the year included 253 voluntary patients and 279 temporary patients.
I do not wish to extend indefinitely the litany of the various health measures taken in 1947-48 but I feel I should mention the following:—
Measures were taken to empower local authorities to provide for producing immunity from infection with enteric fever.
Rat extermination measures have been under consideration for some time and at the request of my Department the Dublin health authorities have been making a detailed study of the question of control of rat infestation and of measures in operation elsewhere.
Refresher courses were arranged for general trained nurses and public health nurses, while a number of medical superintendent officers of health and county and assistant medical officers of health availed themselves of the facilities provided for attendance at a course of lectures on educationally sub-normal children and mental defectives which was held in London.
Following a recommendation from the Hospitals Commission, approval was given to the making of a grant to the Medical Research Council of £10,000 per annum from the Hospitals Trust Fund for a period of five years from 1st January, 1948, for general research. The grant previously made was at the rate of £5,000 per annum. Approval was also given to the payment to the Hospital Library Council of a grant of £3,000 in respect of the present year to meet the needs of the council, which deals with the distribution of books to patients in hospitals and sanatoria. The grant paid last year was £2,437.
Under the provisions of Part IV of the Local Government Act, 1941, the Dublin Fever Hospital Board was due for reconstitution before the 27th April of this year. The necessary steps for the restoration of the board were put in train before the expiration of that period and the board held its first meeting on the 12th April last.
I think I should at this stage explain to the House the details of the Estimate for the current year. I should perhaps first say that I had the Estimate as originally framed carefully examined with a view to seeing whether any economies could properly be effected. I found, however, that I could not ask the House to make less adequate provision than had been envisaged. In fact, it is necessary to introduce a Supplementary Estimate to meet the estimated cost of the proposed publicity campaign to which I shall refer presently.
The increases under sub-head A (Salaries, Wages and Allowances) and sub-head B (Travelling Expenses) are attributable to the additional staff which is required at headquarters to deal with the greatly extended functions to be discharged. Sub-heads C and D do not call for comment.
Provision is made under sub-head E for payment of the annual subscription to the International Office of Public Health, Paris (£254). The functions of this office are in course of transfer to the World Health Organisation. Members of the World Health Organisation are the States of the United Nations and such other States, including our own, as have expressed a desire to participate in international efforts to secure the highest possible standard of health. The expenses of the organisation will be met by the member States in accordance with a scale to be fixed. It is, therefore, necessary to make provision under this sub-head towards the sum which later will be levied on this country. In addition, provision is made for the expenses of Irish delegations to meetings of the organisation.
One of the objects of the Food and Agriculture Organisation of the United Nations is to raise the levels of nutrition and standards of living. This country is a member of the organisation and the provision under the sub-head is for the purpose of meeting the expenses of the member of the staff of my Department who is nominated as a member of the Irish delegation to conferences held by the organisation.
A national nutrition survey is at present in progress for the purpose of formulating plans to meet possible deficiencies in the standards of nutrition in different sections of the community and the expenses involved are met from sub-head G (3). The survey consists of a dietary survey and a clinical survey.
The dietary survey commenced in April, 1946, and the field work is being carried out under the supervision of a medical officer of my Department, by a team of 12 specially trained investigators. The survey in respect of Dublin City and the other county boroughs and large towns and certain districts on the western coast is complete, and work is proceeding in country areas. Out of a total "target" number of 2,800 families, about 2,500 have been completely surveyed and I expect that this part of the work should be completed before the end of the year. It is only right that I should here, publicly, express my appreciation of the very generous co-operation of the vast majority of the householders approached by the investigators. The statistical analysis of the information obtained in respect of Dublin County Borough is practically completed and it will be possible to make the results available in the near future.
The clinical survey was begun in February, 1947. It is proposed that about 16,500 children will be examined in addition to adolescents and about 500 expectant or nursing mothers. Considerable progress has been made and I expect that this part of the work will be completed by the end of 1948.
I have already explained the purpose of the Health Services (Financial Provisions) Act which was passed last year. The grants to be paid under this Act will be met from sub-head H and will be paid in respect of expenditure on all recognised health services. They replace the percentage grants for free milk, maternity and child welfare, school medical service, tuberculosis and venereal disease and other special grants which were paid from the local taxation account for health services. The sum included in the sub-head may therefore be divided between replacements of existing subventions and increases represented by the excess of the 1948-49 expenditure over that for 1947-48. The total expenditure on health services for the year 1947-48 is estimated to be £5,280,000. Of this £4,450,000 was met from the rates and £830,000 from State grants. This sum of £830,000 paid from State grants is included in the provision under the sub-head. The total estimated expenditure on health services for the year 1948-49 is £5,976,000. The difference between this and the total for the year 1947-48 (£696,000) is also included in the grant. The total amount payable in respect of the year 1948-49 is therefore estimated to be £1,526,000. As we will not know until after the end of March, 1949, when the accounts have been audited, what exactly is payable to each health authority, it is proposed to pay within the present year instalments amounting to 95 per cent. of the estimated amount due and to pay the balance after the receipt of the auditor's certificates in the following year. The amount included in the sub-head is therefore 95 per cent. of £1,562,000 or £1,450,000. The increase of £696,000 in this year's expenditure as compared with last year's, is accounted for by increases in salaries of local officers, by increased charges for institutional services and by the proposed expansion of the health services, particularly the tuberculosis service.
In previous years, all expenditure from the Vote on mother and child services was met from a single sub-head. In the present year, it has been necessary to make a change because, as explained, all expenditure by local authorities on health services is "lumped" for the purposes of State grant, and the State subvention towards the expenditure of local authorities on mother and child services is included in the provision in sub-head H. Certain voluntary agencies, for instance, district nursing associations, provide, outside local authority schemes, services to mothers and children in respect of which grants are made and provision for these grants is contained in sub-head I.
The grant provided for in sub-head J is a contribution towards the expenses of the establishment and maintainance of a non-profit-making body to provide a national blood transfusion service. An advisory committee established at the end of 1946 reported that immediate steps should be taken for the establishment of a limited liability company to deal with the proposed organisation and that its replacement by a statutory body could be considered later in the light of experience gained.
It is, therefore, proposed to establish a company on a non-profit-making basis to be called the national blood transfusion association. The association will be limited by guarantee and will not have share capital or power to distribute profits. The functions of the association will be to organise and maintain throughout the country panels of donors, both directly and by the provision of financial and other assistance to local committees which can be satisfactorily integrated with the national service; the maintenance of a blood bank in Dublin and the provision of arrangements for the storage of serum; the carrying out of the necessary tests of donors in all areas; arrangements for the payment of donors, and the fixing of charges for whole blood and blood derivatives supplied to hospitals and local authorities. For some time at least the association will probably experience a deficit in its accounts and a grant-in-aid of about £5,500 per annum will probably be needed. The provision made under this year's sub-head, however, includes all the expenditure incidental to the establishment of the company and should be reduced considerably next year.
Provision is made under sub-head L for the payment of grants in recoupment of expenditure by health authorities under approved regulations by way of payment and maintenance and other allowances in the year ended 31st March last in respect of persons suffering from certain infectious diseases. Expenditure by local authorities in the current financial year on this service will be recouped from sub-head H (Grants to Health Authorities).
The remaining sub-heads (M (1) to M (5)) represent anticipated payments of grants in respect of the balances payable to local authorities arising out of expenditure in previous years on maternity and child welfare schemes, free milk, school medical service schemes, prevention and treatment of tuberculosis and treatment of venereal disease.
The last sub-head in the Estimate relates to Appropriations-in-Aid. The major item (£312,000) comprises the payments formerly made from the local taxation account to local authorities in respect of health services and which are diverted to the Vote under the Health Services (Financial Provisions) Act, 1947. As explained in connection with sub-head H, the subvention made by way of these grants to local authorities will be replaced in the grant to be provided under that Act.
This, perhaps, is the appropriate stage at which to refer to some matters connected with the Hospitals Trust Fund. I do not propose to attempt to remove the many misconceptions which have grown up round it and will confine myself to a few observations on the problem of the deficits on the working of the voluntary hospitals, which are met from it, and on its capacity to support an extensive building programme, and then pass to a review of hospital building prospects in the near future.
On the question of deficits, the present position is that 55 hospitals are participating in the sweepstake funds. In 1946 the deficit amounted to £237,624. The amount of the deficits which the fund was called on to meet in 1939 was £156,975, so that there has been an increase of £80,649, or 51.4 per cent. between 1939 and 1946. I understand, moreover, that the figure for 1947 is likely to be in the neighbourhood of £340,000. While I am aware that the increased deficits, or at any rate a considerable proportion of their total, arise from causes outside the control of the various hospitals, the total figure now involved, coupled with the steadily rising trend, is a matter of the gravest concern. Roughly speaking, it is necessary to invest a capital sum equivalent to the total amount of sweepstake moneys at present in hand, in round figures £10,000,000, to produce an annual income sufficient to pay the existing deficits (without making any allowance for further increase) and the other recurring annual charges on the Hospitals Trust Fund. This in itself might not be a cause for anxiety if the annual accretion to the fund represented by the proceeds of the sweepstakes were maintained at a level sufficient to enable us to keep the building programme moving at a satisfactory rate.
The available evidence is that it must be financed by drawing on the capital sum which, as mentioned, is barely sufficient to produce an income equivalent to the present annual charges. The ultimate effect of this process may be that it will no longer be possible to pay annual deficits of unlimited magnitude. The whole position is under examination in connection with the building programme, but in the meantime everybody concerned in the management of institutions whose deficits are met from sweepstake moneys should realise that the utmost economy in expenditure is imperative.
On the question of hospital construction, there are before my Department at the present time, 135 proposals for new hospitals and for the adaptation, reconstruction and repair of existing hospitals. The cost of carrying out these projects is in the region of £27,000,000. This figure does not include any provision in respect of county homes, which, except for the infirmary sections, are not eligible for grants from the Hospitals Trust Fund. It must not be assumed from the fact that I am compelled to exclude them from this review of proposals which can be financed from the Hospitals Trust Fund that I regard them as being in a satisfactory condition. Far from it. I am satisfied that conditions in a large number of them are bad and that the whole problem of making radical improvements in existing buildings or of providing replacements must be faced. The community has a responsibility for the care of the aged and infirm which it cannot escape.
I have on the majority of occasions during my visits of inspection throughout the country criticised the sub-standard conditions which, in my opinion, exist in these county homes. Equally, however, I have paid tribute on each occasion to the extremely high standard of equipment, staffing, care and attention which exists in the county hospitals which I have seen up to the present, and it is also only just for me to give credit where credit is due. I have pointed out how very very impressive were the hospital buildings themselves, my only criticism being that they appear to be rather too small for the population groups which they serve. My hospital building programme is conditioned by two main factors, shortage of materials and shortage of skilled and unskilled labour. This makes it inevitable that hospitals can be built only in competition with other pressing housing needs of the community.
I am conscious that good housing is a prerequisite of good health and that money and effort devoted to building up a positive health service while slum conditions, overcrowding and bad housing remain is largely waste. In these circumstances I have come to the conclusion that I would not be justified in approving of the full programme before my Department. I have concluded, reluctantly, that what should be done is to proceed on the basis of a limited programme of hospital construction over the period of about seven years. I have fixed at £15,000,000 the cost of the work which I will endeavour to have brought to a conclusion within that period. Included in this figure are the works which I feel are the most essential. The decision to proceed on these lines has not been an easy one for me to take because I have had to decide that certain works must be deferred. My Department is in the process of notifying the promoters of the projects which will have to be deferred. I know the notifications will result in grave disappointment which I have done my utmost to avoid but I can assure the House that I have examined the question dispassionately and without regard to political considerations or to local affiliations and that my decision has been taken purely on grounds, not of need, but of the greatest need. A review of the programme will, however, take place as soon as there is any material change in conditions in the building industry and, in any event, in the next three years.
I should perhaps say a special word about Dublin. The Dublin area already has a number of excellent and well-run hospitals, and while the need to provide more modern buildings with greater bed accommodation to replace these institutions does undoubtedly exist, I think we must agree that there is a greater need elsewhere.
The division of the £15,000,000 among the various types of treatment centres is as follows:—
|
£ |
|
|
General Medical and Sur gical Hospitals |
5,900,000 |
|
Maternity and Children's Hospitals |
1,600,000 |
|
Tuberculosis Hospitals |
3,800,000 |
|
Clinics and Dispensaries |
500,000 |
|
Mental Hospitals |
1,500,000 |
|
Fever Hospitals |
1,250,000 |
These total £14,550,000. The balance must be reserved for spending on small works, unforeseen at present. It is clear that no margin is left for any major project.
It will be seen that there is a very substantial provision included for tuberculosis hospitals. These are particularly badly needed because there is in tuberculosis the factor that each sufferer, so long as he is not receiving the proper treatment away from his family and friends, can spread the infection and I am sure every member of the House shares my anxiety that every tuberculosis sufferer in the country should, if he wishes to avail of it, be given the facilities for isolation, rest and proper treatment, which are necessary for his recovery and the protection of his family and associates.
I feel that if the country can succeed in getting £15,000,000 worth of hospital construction carried out within the next seven years, we will have gone a good way towards solving the institutional side of our health problems, but the programme can be carried out only if there is general acceptance that it is the only reasonable decision and I am allowed to get on with the job and the time of the officials of my Department is not taken up in examining proposals which there is no hope of putting in hands or completing within the next few years. I would like to join with the Minister for Local Government in appealing to our workmen—bricklayers, carpenters, plasterers, painters and all the other skilled and unskilled workers at home and overseas—to give us their unstinted assistance and co-operation in the Government's building drive which they will have the satisfaction of knowing will provide houses for the healthy and hospital and other health services for the sick of all sections of the community, particularly the workers themselves and their families.
A noteworthy development is the readiness of the central health administration to avail itself of the accumulated knowledge of experts in different spheres of medicine. In the National Health Council set up by my predecessor we have the first advisory council on health matters which has been specifically provided for by Statute to give to the Minister, when so required by him, advice on matters relating to or incidental to the health of the people. This most desirable development should be a factor of great importance in the efforts to expand and improve the health services. The council has been established and has already given valuable advice.
In addition to the National Health Council, a number of consultative councils have been established under the Health Act.
In order to keep abreast of modern developments I have established a Consultative Cancer Council to examine the existing facilities for the diagnosis and treatment of cancer and for research work in relation to cancer in this country and to submit recommendations as to—
(a) the further facilities to be provided;
(b) the nature of the organisations by which such facilities should be provided; and
(c) the staffing, equipment and suggested stages of development appropriate to any organisation or organisations recommended.
The council is composed of bacteriological and cancer specialists and persons familiar with the administration of public health services and held its first meeting on the 22nd April last. I have especially requested the council to advise me, in the first instance, on any immediate steps which I might take to improve the diagnostic and treatment services in the early future, and, secondly, to submit a long-term plan designed to deal as fully and exhaustively as possible with all phases of the problem.
As I mentioned earlier I have also set up a Child Health Council. The council has been given responsibility for advising on the measures which may appear to be likely to prove most effective for the improvement of the health of children generally, or of any particular class or classes of children, and, in particular, for the reduction of infant mortality.
The problem of tuberculosis is one of major concern and a matter which will need the combined and sustained efforts of the whole community to alleviate the present grievous position, and I have established a special tuberculosis consultative council to advise me from time to time on matters relating to the prevention and treatment of tuberculosis.
While the consultative bodies I have mentioned are the first statutory bodies of their kind in the health sphere, they are by no means the first bodies of experts in the medical and kindred professions which have given the benefit of their experience or knowledge to the central health administration. My predecessor in office also established a committee to examine, in relation to projected health reforms and any developments in the standard of medical education elsewhere, the present system of undergraduate and post-graduate medical education in this country. The value of any health service depends largely on the efficiency of its personnel and the nature of the health services of the future will demand that medical education must keep in step with progress in the realms of medicine and with the needs of the community for doctors possessed of the highest standard of skill and knowledge. I understand that this committee has already made substantial progress in its task.
Apart from the general question of raising the standard of knowledge and skill of medical graduates there is also an urgent need for obtaining at least a skeleton staff with all-round medical and public health post-graduate training for the health services in advance of any general examination of the major problem of medical education.
In the circumstances it is proposed to establish a post-graduate medical school for the training of local authority medical personnel in St. Kevin's Hospital, Dublin. An advisory committee was established to examine and consider the existing accommodation and facilities at the hospital and to make recommendations as to the measures necessary and immediately practicable for enabling the proposed school to be established and to function satisfactorily. I gather that this committee, also, has made considerable progress and that its report will soon be available.
While on the subject of professional education I should perhaps refer to an ancillary matter, the training of nursing personnel. I have been considering the present system and may find it desirable to bring before the House legislation governing this matter. Arising out of that, there have been discussions with representatives of the nursing profession on the question of the desirability of establishing a new national nursing board which would absorb the General Nursing Council and the Central Midwives' Board. This proposal would facilitate the integration of the different branches of the nursing profession and the provision of the steady flow of nurses and midwives that will be needed for many years. I have also had discussions with the General Nursing Council on a scheme for the institution of a new grade of sanatorium nurse.
Training and organisation are only two aspects of the nursing problem. I feel that too much stress cannot be laid on the importance of insisting on fair living and working conditions for all our nursing staffs. We will need hundreds of nurses for our extended health services and if we are to get them we must offer them attractive terms. Adequate remuneration alone is not enough. Proper accommodation and adequate recreational facilities are also of prime importance.
Before passing from this question of medical and nursing personnel I would like publicly to thank the many medical practitioners and representatives of professional organisations who have so generously put their time and experience at my disposal through their membership of councils and committees and in discussions.
Adequate and well-trained medical and nursing staffs are not in themselves sufficient to improve health standards of the community. The community must itself co-operate and among the matters to which I gave early attention was the initiation of a programme of education for the public generally in the fundamental principles of health and hygiene. I felt that this most powerful weapon in a positive health campaign had been rather neglected and I, therefore, took immediate steps to remedy the position. A publicity and intelligence section has been established in my Department and an experienced officer has been put in charge. By availing ourselves of the potent media available—the Press, the radio and films—we will endeavour to convince the people that they can reduce the incidence of disease and illness by availing themselves of the health services at their disposal, by the adoption of a positive attitude in health matters, by compliance with the elementary principles of hygiene and by a realisation of their responsibilities towards the community in general.
I propose to make use of Press advertisements, booklets, leaflets, films, exhibitions and radio talks. In co-operation with the Minister for Education and the National Film Institute arrangements will be made for the showing of health films in schools and, in addition, it is hoped to purchase copies of health documentary films for distribution to the film renters for screening in cinemas throughout the country. I believe that the additional expenditure involved in such publicity will be money well spent and that the nation will reap rich dividends in the way of healthier citizens. A Supplementary Estimate to provide the necessary funds will be before the House immediately after the Health Estimate proper has been disposed of.
For large sections of the community, the first link of the individual with the medical services is his local dispensary. One of my aims is that existing dispensary buildings should in the majority of cases be replaced by properly equipped health clinics which will, as far as practicable, be located in the most convenient centres from the point of view of the population of each district. Where possible, existing buildings will be converted for use. As far as I can see, the demands of this section of the health services will be heavy on money and materials, but as they are one of the corner-stones on which the health services structure will be built the effort will be well worth while. The existing dispensary service must, of course, be dissociated from the poor law tradition.
Some months ago, as an interim measure, the attention of all public assistance authorities was drawn to the unsatisfactory conditions in the many dispensaries where accommodation and amenities provided for patients fall far short of what is desirable. Since it will not be possible to provide for the replacement in the near future of more than a proportion of the inadequate or unsuitable premises, I have urged the responsible authorities to take early steps to ensure that existing premises are kept clean and in a proper condition, that adequate seating accommodation is provided for waiting patients, that the examination room is properly equipped and that before next winter reasonable heating provision is made. I would urge Deputies who are members of local authorities to take a special interest in this matter and to urge on their councils the necessity for seeing that the important health work done in dispensary premises has not to be performed under conditions which at present are primitive in many cases.
These are only two major matters with which I propose to deal at this stage, the problem of tuberculosis and the question of future health developments; but before I pass to them, I would like to mention two other matters.
No adequate measures have been taken so far on a sufficient scale to provide for the training of mentally deficient persons who are capable of being educated or for proper institutional care for other mental defectives. Magnificent work is being done by various voluntary bodies already in this field, but their efforts must be supplemented if the problem is to be adequately dealt with. The entire position is under review and I hope later to introduce a Bill dealing with this matter.
A big contribution to any health campaign would be the ensuring of a supply of clean milk. With this end in view my Department is in communication with the Department of Agriculture concerning the recommendations made by the Milk Tribunal that the production of highest grade milk should be fostered and that other milk should be pasteurised.
With regard to tuberculosis, the death rate from all forms of tuberculosis per 1,000 of population in Ireland in 1940 was 1.25, in 1946 was 1.14, and last year was 1.22.
As I have just said, our rate in 1946 was 1.14. In Denmark the figure was 0.44, in Norway 0.53, in Sweden 0.56, in England and Wales 0.63, and in Northern Ireland 0.94. Even ignoring the lesser incidence here of the effects of the war, these figures afford us no consolation. They prove conclusively how serious, relatively and absolutely, our problem is.
The number of cases treated by health authorities here was 20,622 in 1945. The figure in 1946, at 19,565, was lower than in 1945 but was still substantially in excess of the figures in earlier years.
The figure for notifications was 3,864 in 1943, but in each subsequent year showed a reduction. The figure for 1946 was 3,380.
Accommodation is provided by health authorities in 19 tuberculosis institutions. There are, in addition, four voluntary institutions which cater solely for pulmonary tuberculosis cases. Patients, however, are also accommodated in county hospitals, county homes and district hospitals and beds are made available as conditions permit. Other voluntary hospitals also play an important part in relieving the demand for beds, particularly as regards non-pulmonary cases.
The number of beds at present provided in health authority tuberculosis hospitals is 1,600 and the voluntary tuberculosis hospitals can deal with 650 patients. This total of 2,250 beds represents the number provided by institutions devoted solely or mainly to the treatment of tuberculosis. In addition, some 980 beds are made available by the remaining local authorities and voluntary hospitals. The total is thus about 3,230 beds and represents, approximately, 1.28 beds per death.
Steps are being taken to increase the number of beds, as a matter of urgency. It is intended that an initial provision of approximately 1.5 beds per death should be the first objective, to be extended to two beds per death should conditions so demand. It is not easy in present circumstances with shortages of money, materials and labour to achieve that result. As a first step, existing institutions are being extended or adapted. Thus, four of the voluntary institutions will soon have provision for over 300 more patients. The recently built Castlerea Mental Hospital has been handed over temporarily for use as a sanatorium and opened last week. By the end of the year it should have 420 beds and full treatment facilities, including a theatre for thoracic surgery and homes to accommodate over 100 nurses and 30 domestic staff. The new District Hospital in Mallow is in a similar position to Castlerea, but the number will be approximately 60 to 80 patients. Arrangements are in train for the taking over by Dublin Corporation of Coláiste Moibhi in the Phoenix Park. This institution will ultimately accommodate approximately 350 patients.
Before I leave these three projects, I wish to express my sincere appreciation of the whole-hearted co-operation I have got so willingly from all sides of the House, from the local authorities concerned, from the Ministers for Education and Defence and from the Most Reverend Manager of Coláiste Moibhi. That co-operation has, in many cases, involved great sacrifice. I would like to particularise, but this statement has already been lengthy and I will have later opportunities to do so.
As a result of the extensions and acquisitions to which I have referred, some 1,650 additional beds will ultimately become available. This would give a total approaching 5,000 beds, which is not far short of 1.5 beds per death. These extra beds will not all become available for some time, although it is hoped that about one-half of them, so far as it is possible to judge at the moment, will become available during the current year.
We are by no means within sight of the desired position so far as beds are concerned, however, because some of the existing institutions are most unsuited to the treatment of tuberculosis and a number of them will have to be closed down as soon as an alternative can be found. Long-term plans are, therefore, in preparation and will be pressed ahead with all speed. These include the provision of large sanatoria on a regional basis.
The main centres at which tuberculosis is diagnosed are the tuberculosis clinics, of which there are 278 throughout the country. Many of these centres are unsuitable and, as an interim measure, the authorities concerned have been requested to improve them as a matter of emergency in so far as the re-equipping and redecorating may be effective, pending the erection of new structures. Fluoroscopic apparatus is available in practically every county. A mass radiography unit has been in operation in Dublin since 1946 and over 12,000 persons have already been X-rayed. It is proposed to extend this service throughout the country by providing additional units, including mobile units.
Two medical officers of health authorities are at present in Canada on a six months' course of study in modern methods of diagnosis and treatment of tuberculosis. It has been arranged that four such officers will each year, throughout a period of five years, undertake a similar course.
Nursing personnel are also catered for by the provision of a course of study in tuberculosis work, for which a diploma is awarded by the General Nursing Council to successful candidates. In addition, as I have already mentioned, arrangements to train a special category of nurses, to be described as sanatorium nurses, are under examination.
A commencement has been made in the provision of a national thoracic surgical service. A whole-time thoracic surgeon has been appointed and is about to take up duty. Owing to lack of suitable theatre facilities in local authority institutions, it would have been impossible to bring the scheme into operation in Dublin for several months but for the co-operation of the Commissioner administering the affairs of the Dublin Board of Assistance, who made available first-class operating facilities at St. Kevin's Hospital, pending the provision of permanent facilities at Rialto Hospital. Full theatre facilities are available at the new Mallow Hospital and, as I have mentioned, full facilities will shortly be available at Castlerea.
A scheme of immunisation with B.C.G. under the auspices of the local authority has been instituted in Dublin. I am investigating the possibility of introducing a scheme under which the health of young persons from school leaving age will be supervised. Such a scheme, if introduced, should reduce the incidence of the diseases, including tuberculosis, so often contracted during the dangerous years of adolescence.
I have already referred to the appointment of a consultative council to advise me on matters relating to the whole problem of the diagnosis and treatment of the disease, and to the introduction of the maintenance allowance scheme by my predecessor, Dr. Ryan.
Deputies will have noticed that I have confined my review to the question of diagnosis and treatment and that I have made little reference to prevention. The tuberculosis problem cannot be solved until good housing, good school and working conditions and adequate nutrition are available for all, but these are not within my province on this Estimate. I can and will, however, supplement the national effort to bring about conditions repugnant to the spread of the disease by publicity as to the elementary precautions which every citizen can take to lessen the risk of infection in his own home, in his place of employment and in his place of relaxation and amusement. Another important object of the publicity will be to get the public to adopt a rational attitude towards the disease so that no longer will the infected person be ashamed of his ailment or the person who has been lucky enough to avoid the ailment feel superior. If only people would regard tuberculosis as they regard rheumatism or cancer or any other ailment, we would have advanced considerably towards the eradication of the disease.
I have not so far referred to rehabilitation. Not every person who has been cured of the disease will be fit to resume his former occupation. For those who will not be fit for heavy labour, as a result of the disease or of infantile paralysis, some special provision must be made. The problem is a big one and I do not propose to enlarge upon it now. I will only say that it will be examined carefully, considerately and with expedition.
As regards future developments, the position is that I have found it necessary, since I assumed office, to devote a large part of my time and energies as well as those of my Department to dealing with the prodigious number of problems which I found requiring immediate attention. I felt that until these had been disposed of the amount of time which could be devoted to long-term plans was necessarily limited. So far as the ordinary citizen is concerned, the provision of facilities designed to relieve immediate and pressing needs is of much more importance than plans, which, however attractive they may seem in theory, are not capable of early realisation.
Any worthwhile development of our services must, of course, be within the financial capacity of the community as a whole and, moreover, cannot have any reality without the necessary diagnostic and treatment centres and adequate medical, nursing and midwifery staffs.
On this question of future health services, I would like to say a word to the medical profession. Very few people would welcome State interference in our medical set-up. In the ultimate, however, the State has a duty to the public and it will be incumbent on the medical profession to demonstrate its readiness and willingness to co-operate in providing an adequate service with the minimum of State interference. With a universal spirit of goodwill, there is no adequate reason why we should not build, on the present foundations, a worthy health service within a comparatively short time.
I should like, in closing, to pay a particular tribute to all the members of my staff in the Department of Health. I think that it should be a source of great encouragement and considerable gratification to us all that the greatest loyalty, efficiency and hard work should be evident from the civil servants in our Departments. That these qualities should be forthcoming to the appointed Minister of the State irrespective of whatever Government may be in office should be publicly acknowledged and to a great extent to them must go the credit for the effective carrying out and the realisation of our endeavours to provide a service which we feel that our people so richly deserve.
