I move:—
That a sum not exceeding £970,420 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, 1950, 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 reviewing the progress of the Department in the past year and explaining the details of the Estimate, I would like to comment on some matters of significance which come under the heading of vital statistics. I might mention, however, that the figures for the year 1948 are provisional and may be subject to some modifications.
The number of births registered in 1948, 65,584, was nearly 3,400 less than in the preceding year although it was about 4,000 above the average for the previous decade (1938-1947). The birth rate per 1,000 of the estimated population last year was 21.9. The corresponding figures for England and Wales, Scotland and Northern Ireland were 17.9, 19.4 and 21.9 respectively.
The number of marriages registered during 1948 was 16,331—an increase of 41 over the previous year. The 1948 figure was nearly 1,300 lower than the figure for 1946 which, however, was the highest recorded since 1878. The 1948 marriage rate per 1,000 of the estimated population was 5.4 compared with 9.0, 8.5 and 7.0 in England and Wales, Scotland and Northern Ireland respectively.
The number of deaths registered in 1948 was 36,502, or nearly 7,500 less than in 1947. The death rate per 1,000 of the estimated population was 12.2, the lowest rate ever recorded for this country. There is still considerable scope for improvement, however, as the figure for several European countries varies from 7.2 to 9.9.
The need for vigorous anti-tuberculosis and cancer campaigns is emphasised by the fact that, while the all-over picture is definitely brighter, these diseases have once again reaped a heavy harvest. Provisional figures show that the number of deaths from cancer was 3,885 as compared with nearly 4,000 in 1947. The total number of deaths from all forms of tuberculosis is estimated at 3,017, a decrease of 683 on the previous year and the lowest ever recorded. I will deal with the tuberculosis problem in greater detail.
During the year, the number of deaths of children under one year was 3,212 representing an infant mortality rate per 1,000 births of 49, compared with 68 in 1947 and 65 in 1946. The 1948 rate is the lowest ever recorded in this country, but there is still room for considerable improvement. The 1948 rates in England and Wales, Scotland and Northern Ireland were 34, 45 and 46 respectively.
I would like to draw the special attention of the House to the tremendous improvement which has taken place in the death rate in infants under two years of age from diarrhoea and enteritis. Throughout the country as a whole, the number of deaths from this disease was 1,233 in 1943. This figure had fallen to 1,092 in 1945. Since then, progress has been spectacular and is reflected in the figure of 340 for 1948. In Dublin County Borough alone, the figure has been reduced from 573 in 1943 to 80 last year. It is difficult to ascribe this welcome reduction to any particular cause, but it may be significant that measures to combat the disease have been intensified by the local authorities concerned. Instead of drawing any conclusions in the matter, I shall confine myself to expressing the hope that the welcome trend regarding the mortality from this disease will continue. The number of deaths from whooping cough in 1947 was 298 and the number of deaths last year was 196. The number of deaths from measles in 1947 was 106 and last year 61. The total number of diphtheria deaths in 1947 was 56 and last year 31, so it will be seen that measles and whooping cough each claimed many more victims during the last two years than diphtheria. The adoption of protective measures against them is showing promising results. Local authorities have power to provide such protective measures free of charge.
During the year 1948, the number of cases of typhoid, diphtheria, and scarlet fever notified was 4,891. While this showed an increase of over 2,000 on the previous year, the number of deaths was 30 less than the previous year. Of the 1948 total of deaths, 31 were due to diphtheria, 14 to typhoid and the remaining four to scarlet fever. For the fourth successive year, no case of typhus occurred.
The number of cases of diphtheria notified in 1944 was over 5,000. The number last year had fallen to 521. It is reasonable to assume that extensive immunisation against the disease has contributed largely to the decline.
While, therefore, our health statistics for 1948 do not warrant complacency, the figures for the year show that we are gradually improving our position. I would like to emphasise briefly the highlights, in case these points may have been submerged in the statistics I have quoted, viz.:
(a) the infant mortality rate and the general death-rate were the lowest ever recorded;
(b) the total number of deaths from all forms of tuberculosis shows a decrease of 683 on the previous year, and deaths from cancer also showed a decline;
(c) the number of deaths in infants under two years of age from diarrhoea and gastro-enteritis has dropped from 1,233 in 1943 to 340 last year; and
(d) there was a marked decrease in the mortality from the principal infectious diseases.
An important aspect of health services development is the provision of hospital beds. While we have a good nucleus on which to build, the fact that we are far from having adequate accommodation available may be gauged from the fact that when I took up office there were 135 proposals before the Department for the provision of new hospitals and for the adaptation, reconstruction, and repair of existing hospitals. I felt that it would not be conducive to real progress to try to deal in one piece with all these proposals and as I indicated when introducing the Estimates last year, I decided that it would be best to concentrate on a short-term hospital building programme to be completed in seven years. The size of the programme was determined by reference to the availability of materials, of skilled labour and of professional consultants. Local authorities and the authorities of voluntary hospitals concerned have been notified as to the decision reached in relation to each project which had been submitted. In the case of projects included in the seven-year programme those responsible have been encouraged to press forward speedily with the planning and construction work. In an effort to expedite building the promoters of certain voluntary hospital projects and the smaller local authority proposals have been given a free hand to get on with the job without referring detailed plans and documents to the Department for approval once agreement had been reached on the work to be done and on the amount of the grant to be made available from the Hospitals' Trust Fund in cases where such a grant was to be provided.
The first and most urgent problem was the provision of additional accommodation for tuberculous cases and notable progress in this direction has been made in the past twelve months. As regards building work on general hospitals, maternity hospitals, fever and mental hospitals, clinics and dispensaries, an immense amount of planning has had to be undertaken. Much of this is now well advanced and will be reflected very shortly in the increased rate of construction of these institutions. At the beginning of 1949, hospital building work was proceeding at an annual rate of between £500,000 and £600,000. Since an average annual rate of almost £2,500,000 would be necessary to complete the seven-year programme, it was clearly a matter of great urgency to get on quickly with works which were nearer the point of starting. For that reason works likely to start in 1949 have been given the highest priority within the programme.
The projected building programme for 1949 envisages the stepping up of the monthly rate of hospital building from £45,000 in January to £220,000 in December, or a rate of about five times greater. This rate, if it can be attained, will represent a very considerable achievement. It will mean that by the end of the year a commencement will have been made with £6,250,000 worth of hospital building work, i.e. about one-third of the seven-year programme. So far as we can foresee, there is every indication that this can be done and the replies received from the promoters concerned confirm our anticipations. A difficulty which is envisaged, and which may impede progress is the likelihood that there may be a lack of competition in tendering for the more important hospital works involved. In terms of total volume of output, hospital building work would not represent more than about 15 per cent. of the annual output of the building industry, but when it comes to major projects, hospital works represent a very high proportion of the total number of such works being undertaken in the country.
In the seven-year programme there are 40 jobs which are estimated to cost £100,000 or more, and 20 of these would each cost approximately £250,000 or more, including a number of works which are estimated to cost about £1,000,000 each. The field of competition for major works is limited and in order to ensure that contracts are placed at keen prices it is necessary that as far as possible we should stagger the starting times of such works. In addition to the difficulty of the limited number of building organisations capable of tackling major works, there may be difficulties common to all major building undertakings such as shortage of skilled labour.
Important hospital works, the building of which it is hoped to see started this year, include Ardkeen Sanatorium, Waterford; the new Fever Hospital at Dublin; the Limerick Regional Hospital; Galway Regional Sanatorium and Galway Regional Hospital; the proposed major extension at Portiuncula Hospital, Ballinasloe; the new County Hospital at Manorhamilton; the Children's Hospital at Crumlin and the new hospital at Gurranebraher, Cork. Site works in connection with some of these works have been completed. Others are in progress and it is hoped to commence the site works of the two remaining regional sanatoria at Dublin and Cork by the end of the year.
If the works which it is hoped to commence in 1949 can be got under way, there is not likely to be any holdup which would delay the completion of the seven-year programme as far as planning is concerned.
It has been represented that the short-term building programme is a reduced one. I would like to emphasise that it compares favourably with what has been done on hospitals construction in the period from the initiation of the sweepstakes up to the outbreak of the last war. Approximately 6,800 extra beds will be provided on the completion of this short-term programme and the magnitude of this increase and the important change it will bring about in the hospitalisation position can be appreciated from the fact that the total number of general hospital beds in the voluntary hospitals, county hospitals and district hospitals in the country at the present time is not much in excess of this figure.
Apart from hospital works, the programme envisages the building of new dispensaries and improvement of dispensaries that are capable of improvement, as well as the provision of clinics in each county at which specialist facilities can be provided. Most of the local authorities concerned are already proceeding with the planning of the "county" clinics and it is hoped that most of them will be available within the time allotted to them in the programme.
The amount of money in the Hospitals' Trust Fund, towards which hospital authorities generally will be looking for reimbursement of portion of their expenditure on hospital building, is not as large as we would like it to be. It is hoped, however, that the receipts from sweepstakes in future years will be adequate to enable the fund to meet the amount of grants allocated towards building costs, as well as the deficits on the running expenses of the voluntary hospitals and some encouragement for this hope is given by the return from recent sweeps.
While on the subject of Hospitals' Trust Fund, I must refer to the question of the deficits on the running of the 55 voluntary hospitals participating in the sweeps for this purpose. I mentioned last year that these deficits had been increasing year by year and that the increase gave cause for concern. Nothing which has happened in the past year has helped to allay that concern. The total amount payable on foot of deficits in respect of the year 1939 was £157,000. In 1946 it had risen to almost £238,000. For 1947 it had further increased to £334,000 and I understand that it is anticipated that the figure for 1948 will be as high as £420,000. These increases have occurred despite the substantial increases in maintenance charges levied by the hospitals in respect of patients sent in by local authorities and despite an annual contribution of over £100,000 to the Dublin voluntary hospitals from the Dublin rates. It is obvious that with so large a capital programme depending on Hospitals' Trust Fund moneys some ceiling must be put on the amount of recoupment in respect of deficits and I have been in touch with the Hospitals' Commission about the matter. I hope to be in a position to make recommendations to the voluntary hospitals concerned in the near future.
Deputies are aware that I have devoted a considerable amount of my time since taking up office to the anti-tuberculosis campaign. This disease has been one of our major public health problems for some time and has taken heavy toll of our youth in particular. The death rate from all forms of tuberculosis per 1,000 of the estimated population was 1.25 in 1940, 1.47 in 1942, 1.14 in 1946, 1.24 in 1947 and 1.00 in 1948. The actual number of deaths was 3,017 last year. While the number of deaths last year was the lowest recorded in recent years, we are very far from the stage when we can say that the problem has been reduced from major to minor proportions.
The death rate per 1,000 of the population in Denmark in 1947 was 0.30, in Sweden 0.51, in England and Wales 0.56, in Scotland 0.79, and in Northern Ireland 0.72. It will be seen that we have a considerable leeway to make up, even though, as I have mentioned, our 1948 rate is estimated at 1.0.
Tuberculosis is not a problem which can be solved merely by the provision of beds and staff. Good housing conditions, adequate nutrition, appreciation of health hygiene and a more rational public attitude towards the disease are essential elements in the anti-tuberculosis campaign. Such measures as utilisation of mass radiography for early diagnosis, B.C.G. vaccination, follow-up of contacts and a greater readiness on the part of sufferers to seek early treatment, will all play an important part, but the first essential is to provide institutional accommodation without a waiting period for persons who are found to need such accommodation. The dangers of the spread of the disease by way of openly infective cases are too well known to need comment here.
I feel that we have achieved quite a lot in the matter of bed accommodation. From February, 1948, to the end of last month 984 additional beds for tuberculous cases had been provided in local authority institutions and 226 in voluntary institutions, i.e., a total of over 1,200 extra beds. The provision of additional accommodation is being pressed continuously and further substantial progress will be made before the end of the current calendar year. The maintenance allowances for tuberculosis patients and increased diagnostic facilities have, of course, had the desired effect of increasing substantially the numbers coming forward for treatment.
Projects in hands, including the provision of temporary accommodation at St. Mary's Hospital, Phoenix Park, Dublin, should reduce the waiting list to manageable proportions before the end of the calendar year—in most areas, including Dublin, long before that date. The latest of these projects is the acquisition and conversion of the former airport hostel at Foynes; a very fine, newly-built structure, to accommodate cases of primary tuberculosis in children and as a preventorium. About 100 beds will be available.
I do not intend to burden the House with a list of all the projects which have resulted, to date, since February of last year, in the provision of 1,200 beds and will result before the end of this year in the provision of a further 800 odd beds. The projects are over 20 in number and Deputies will already be aware of those which relate to their own areas. Some consist of permanent adaptation of existing buildings, e.g., St. Mary's Hospital, Phoenix Park, Dublin, already mentioned. Others are temporary adaptations, the largest of which are the conversion of the District Mental Hospital at Castlerea and the District Hospital at Mallow. They include also the diversion of certain fever hospitals to tuberculosis purposes. In all this, I want to express my appreciation of the co-operation of members of all political Parties and of the members and staffs of the local authorities concerned. In all but a very few cases, that co-operation has been whole-hearted and unstinted.
The longer-term solution of the problem lies in the provision of the three regional sanatoria at Dublin, Cork and Galway, of a sub-regional institution at Waterford and of a children's sanatorium at Ballyowen, County Dublin.
As I have mentioned, site works at the Galway institution are nearing completion and building will commence later this year. Site works at the other two regional institutions will also commence this year. Tenders have been invited for the site and building works at Waterford and the planning of the children's institution is proceeding.
In regard to the last-mentioned institution, it was decided, in order to press forward as quickly as possible with the building programme, to form a company limited by guarantee to erect the 250-bed sanatorium at Ballyowen for children suffering from pulmonary tuberculosis. The sanatorium will be provided on a site which had been previously acquired by the Dublin Corporation. The company will be financed from the Hospitals' Trust Fund to the extent of some £250,000. The eight members of the company— who also comprise the directorate— will not be remunerated for their services. The company has been incorporated and has carried out a considerable amount of preliminary work to date.
The total number of beds to be provided under this longer-term programme will be about 2,000 which, with the beds already provided since February last and the remaining beds which will be available before the end of the calendar year, will bring the total to about 4,000. When allowance is made for the beds lost in institutions which will revert to their former use, e.g., Castlerea and Mallow and certain fever institutions, and in institutions which by that time will have become sub-standard, e.g., Pigeon House, Crooksling, Dublin, the net number of additional beds will be of the order of 3,000 which, on present indications, should be adequate.
Perhaps, I should say a few words at this stage about our proposals for dealing with orthopaedic cases. Discussions have already taken place with local authorities in connection with the need for appointing orthopaedic surgeons and it is hoped that an adequate staff will be available soon. Improved provision will also be required for the hospitalisation of orthopaedic cases, both tuberculous and non-tuberculous. It is contemplated that Woodlands Sanatorium, Galway, will be reserved for orthopaedic cases in the western area as soon as Galway Regional Sanatorium has been provided. Additional units will be added to Woodlands Sanatorium, if necessary. Orthopaedic cases in the southern region will be catered for at the projected regional hospital and regional sanatorium. The possibility of securing 60 beds in the Cork County Home and Hospital for orthopaedic cases is also being examined. South Leinster will be served by the unit to be provided at Kilcreene House, Kilkenny, which has been acquired by the local county council and it is proposed that the accommodation should initially consist of 80 beds, with provision for expansion. The Orthopaedic Hospital, Coole, should cater adequately for the needs of North Leinster where tentative plans for an extension have been implemented. It is intended that the Dublin area consisting of Dublin City and County, Meath, Louth, Kildare and Wicklow should be served by the institutions at Cappagh, Clontarf, Baldoyle and Arklow.
I would like to deal now with some other aspects of our anti-tuberculosis campaign. Early diagnosis is most important and I have requested health authorities to take steps to improve and equip any health clinics which were not up to standard.
A mass radiography unit has been operating in Dublin since 1946. Approximately 8,000 persons were mass radiographed by this unit in 1948 and of these, 175 were found to have pulmonary tuberculosis and in 165 cases it was deemed desirable to keep the persons concerned under observation. With the provision of full X-ray facilities at the Dublin Corporation's reconstructed and extended tuberculosis clinic at Charles Street, to be opened next week, it should be possible to make more extensive use of the mass radiography unit in future. A mobile X-ray unit has commenced operations in Cork City and County and the experience gained in this area will be useful in the extension of mobile X-ray facilities throughout the country, a matter which has already been taken up with local authorities generally.
During the latter part of 1948 a new scheme of chest surgery for tuberculosis patients in local authority institutions was initiated. Operating theatres containing the most up-to-date equipment and facilities have been provided in the new sanatoria at Castlerea and Mallow and a thoracic surgeon was appointed to carry out operative procedures at each of the institutions referred to and at St. Kevin's Hospital, Dublin. This is a most important development of our tuberculosis schemes, providing as it does, a first-class service, free of charge, for patients requiring chest surgery. When additional fully - equipped operating theatres are available in the very near future in Rialto Hospital, Dublin, in St. Mary's Chest Hospital, Dublin, and in the proposed enlarged tuberculosis unit of the Limerick City Home and Hospital, the existing scheme of chest surgery will be expanded and two additional thoracic surgeons will be appointed. A suitable division of work between the three surgeons will then be made.
It is essential that tuberculosis medical officers should keep abreast of current developments elsewhere and it is part of our policy that they should visit other countries and study techniques and problems there. Arrangements have already been made for a number of medical officers engaged in the local authority service to undertake an eight weeks' course in Wales, covering field and institutional work. Five medical officers have already undergone the course. Four medical officers have completed a course in Canada and one has finished a course at Cheshire Joint Sanatorium. Further courses are visualised.
A scheme of training of probationer nurses for the new grade of sanatorium nurse was initiated during 1948 with the co-operation of the General Nursing Council. The rules of the nursing council under which sanatorium nurses would be trained were approved and steps are being taken to provide training facilities at various sanatoria. Probationers are already being trained at the sanatorium at Castlerea and at Peamount and Newcastle. It is a matter of regret that delay in the provision of accommodation has delayed the recruitment and training of probationers in the Dublin and Cork local authority services.
It is a generally accepted scientific fact that persons who have successfully passed through the primary stage of tuberculosis are much less vulnerable to the ravages of the secondary and later forms of the disease than persons who have not passed through that stage. The effect of having passed through the primary stage successfully can be produced by B.C.G. vaccination, a procedure not more painful and little more elaborate than ordinary vaccination against smallpox or inoculation against diphtheria.
Schemes of B.C.G. vaccination have been initiated by the Dublin Corporation and the authorities of St. Ultan's Children's Hospital. A committee representative of St. Ultan's, the Corporation and Department of Health has been set up to supervise the extension of the scheme operated at that hospital. The hospital authorities will, in the first instance, offer vaccination to susceptible groups of the population, including students (particularly medical students), hospital nursing staffs and children who are in contact with open infective cases of tuberculosis. They will make B.C.G. vaccination available to health authorities and will train the medical officers of those authorities in B.C.G. vaccination. This vaccine is offered to negative reactors to tuberculin tests and we hope it will be a factor of considerable importance in reducing the incidence of tuberculosis in adolescents.
Under the Infectious Diseases (Maintenance) Regulations, 1948, a scheme of monetary allowances was brought into operation on the 1st March, 1948. The scheme applies to sufferers from specified infectious diseases who, by reason of illness or of taking precautions in certain circumstances, are unable to maintain themselves or their dependents. The regulations have proved to be of considerable benefit to eligible persons—particularly in the case of sufferers from tuberculosis, where the period of treatment is sometimes prolonged. The regulations were amended in September last so as to extend eligibility for a domestic help allowance to a married woman receiving institutional treatment, whose husband is unable to make proper provision for the care of their family. The regulations have now been further amended so as to permit of the payment of the domestic help allowance in the case of certain patients whether they are undergoing domiciliary or institutional treatment and whether or not a relative is employed as the domestic help.
All local authorities maintaining institutions, i.e. district, tuberculosis and mental institutions, have been asked to adopt special measures to protect the staffs against contracting tuberculosis.
The consultative council on tuberculosis is considering the question of rehabilitation of patients. This problem presents many difficulties and a practical solution will not be easy to find. Due to the generous action of Senator R. M. Burke, in placing Toghermore House, Tuam, at the disposal of a local voluntary committee a splendid opportunity has been given of gaining practical experience of the operation of an experimental rehabilitation scheme. Patients discharged after sanatorium treatment are already engaged, under medical supervision, on suitable rehabilitation treatment at Toghermore House,
There is a wide field in tuberculosis institutions for the employment of expatients in suitable posts and with suitable safeguards. I have recommended that course to health authorities and I hope that they will respond generously. I have also been in touch with trade unions about the matter and I hope that they, also, will co-operate.
So much for tuberculosis, the most prevalent and most costly of our infectious diseases. I would like to say a few words now about some of the other infectious diseases.
In January last each health authority was requested to furnish a report from the chief medical officer on the practical operation of the infectious diseases regulations in their area with particular reference to the provisions relating to vaccination, immunisation and the notification of cases of tuberculosis and venereal diseases.
It was rather disturbing to find that in some counties no schemes of vaccination against smallpox were in operation, while in others schemes were operating only to a limited extent.
I am glad to say that the number of full immunisations against diphtheria carried out in 1948 appears to indicate that the decline which had become noticeable in recent years has been arrested. The number of children fully immunised during 1948 under schemes administered by health authorities was nearly 80,000 compared with 49,000 in 1947 and 42,000 in 1946. In the odd case where the disease is contracted by a person who has been recently immunised, the course of the disease is generally light and the death rate among children who have been fully immunised is almost negligible. Of the 31 diphtheria deaths in 1948, only one death occurred among children who had been immunised.
Health authorities were advised during the year to have all infantile paralysis patients examined by an orthopædic surgeon before discharge from fever hospitals and to make arrangements for any follow-up examinations considered necessary and for the provision of local facilities for physio-therapeutic treatment in suitable cases. Considerable progress has been made by health authorities in the organisation of this necessary service and a number of health authorities have already made suitable arrangements for the after-care of patients.
Health authorities were also urged to press forward with measures for the control of enteric fever, to sustain their efforts in the extended use of D.D.T. preparation in the fight against vermin-carrying diseases and to improve the facilities provided in urban areas (other than the county boroughs) for the treatment of scabies. (The facilities provided in the county boroughs are regarded as adequate.)
A revised scheme for dealing with venereal disease is under consideration at present and will be communicated to health authorities as soon as some difficulties have been cleared up.
In concluding the review of the fight against infectious diseases, I want to emphasise that all services provided by health authorities in connection with these diseases are free of all charge to the recipient. They are of a high order already and are improving rapidly and failure to avail of them in appropriate cases is a disservice to the entire community.
When introducing last year's Estimate I gave a resumé of the provisions of the Health Act, 1947. That Act and the regulations and Orders made under it are intended to codify and bring up to date the law dealing with public health. Further regulations were made during the year now under review and initial steps were taken in the preparation of others.
A draft set of regulations dealing with food hygiene has been prepared and sent to interested outside bodies for their views. This draft has received a certain amount of publicity and Deputies will probably be aware of the general purport of the regulations. The intention is that the sale or importation of unfit food will be prohibited and that all premises where food is normally manufactured, prepared or sold for human consumption should comply with certain structural and hygienic standards. There are also provisions in the draft regulations dealing with the registration of food premises and special articles are included to ensure the safety and cleanliness of ice-cream and shellfish— foods which are particularly liable to suspicion as vectors of infectious diseases.
This draft has been welcomed by the traders and other organisations interested in the food business who have been consulted. Many of the bodies to whom the regulations have been sent have suggested amendments in the details of the scheme. All these suggestions will be fully and sympathetically considered and will, where feasible, be accepted. It is intended that the officers of local authorities, whose duty it will be to enforce the regulations, will furnish advice and guidance to food traders regarding compliance. Progress and improvement in food handling conditions can, it is felt, be best achieved by such advice and guidance but, of course, local authorities will also have adequate power to enforce the regulations by prosecutions. Apart from the advice and guidance which will be given by health officers, it is very desirable that food workers should, in their apprenticeship, be trained in the fundamentals of food hygiene. A step in this direction has been taken in Dublin, where the City Vocational Education Committee have, with the co-operation of trade organisations, established a course for persons in the grocery trade.
When the food hygiene code has been brought into operation it is proposed to consider, in consultation with the trade and other interests concerned, further regulations to deal with the separate, but related, problem of standardisation of certain foods, that is, the prescription of the nature, quality and proportion of the ingredients which may be included in these foods so as to ensure that proper nutritional values are maintained.
The retention in the medical assisttance service of some of the features of the old poor law system is a serious defect in our health services. One such feature is the "red ticket" system. Accordingly, it is proposed to amend the existing regulations regarding the provision of medical assistance so as to provide that persons who are eligible for such assistance under the Public Assistance Act, 1939, will, upon application to the appropriate public assistance authority, be furnished with a medical card which will entitle them to medical assistance either in the dispensary or in the home of the person, as the case may require without the ad hoc ticket required at present.
While on the subject of the medical assistance service I would like to say a few words about county homes. Many of these institutions fall far short of minimum standards of comfort. For many reasons connected with the development of the county home system and the lack of suitable alternative accommodation we find old persons, unmarried mothers, children, mental defectives and destitute persons sharing the same institution. This situation must be brought to an end. In order to expedite this matter the Government has decided that an inter-departmental committee should be established to advise on the problem. When this committee will have completed its work I hope to be in a position to formulate concrete proposals but as an interim measure, I recommended to public assistance authorities that existing conditions in the homes under their charge should be surveyed and that they should draw up proposals for effecting improvements in sanitary accommodation, bathing facilities, cooking and dining arrangements, segregated accommodation for children and mental defectives, dietary scales to ensure properly balanced and varied diets, general cleaning up and painting.
One of the first matters which engaged my attention last year was the unsatisfactory condition of many of our public assistance dispensaries. The lack of proper accommodation was not only a cause of bringing the medical assistance service into disrepute, but, more important still, it rendered the provision of proper medical assistance in dispensaries very difficult. The standard of accommodation and necessary amenities for patients is, in general, very low. Public assistance authorities were urged to take early steps to ensure that their dispensaries should be brought up to a reasonable standard and that where such was not possible, new dispensaries should be provided. They have since surveyed the dispensaries in their areas and are taking steps to improve them. The solution of the problem is not easy. A large number of dispensaries are not capable of reconstruction and it will be probably necessary to replace them. This must, of necessity, be a gradual process, but everything possible will be done to ensure that no undue delay will occur.
Since the field of medicine is wide, it would be folly not to avail to the full of the accumulated knowledge of experts in different spheres of medicine which has been so generously placed at the disposal of my Department through their membership of the various consultative councils and committees which have been established. In addition to professional interests, we have had the benefit of the services of representatives of administrative bodies concerned in health matters.
The Consultative Child Health Council was established in May, 1948, and, at my request, directed its energies in the beginning towards the production of a short-term plan for reducing infant mortality. As the problem in Dublin County Borough was easily the most serious in the country they considered this area demanded prior attention. The council have submitted their report on this matter and the necessary examination and discussions have been proceeding since. The problems involved are considerable as will be appreciated when it is borne in mind that the service will have to cover about one-third of the community. Integration of the projected service with the existing medical assistance service is another of the difficulties.
One of the most important elements in the projected service is the making of arrangements for care of sick infants in the neo-natal stage. The council put forward certain recommendations in this matter and it was decided that it would be best to have it fully discussed between representatives of the three maternity hospitals, the Dublin Corporation and my Department. It was gratifying to find that not only had we unanimity on the need for co-ordinated vigorous action but a large measure of agreement also on the manner in which the problem might be solved. The authorities of the hospitals are considering the problem now in greater detail with a view to the evolution of a practical working plan. Considerable progress has already been made.
The council have not been idle since the furnishing of the Dublin County Borough Report. They have submitted recommendations as to how a service might be organised for Cork County Borough and a report covering areas other than the county boroughs. These reports are now being considered in my Department.
As I have already mentioned when dealing with vital statistics, cancer is one of our most serious problems and, consequently, the work of the Consultative Cancer Council is of prime importance. I expect that the council's report conveying their long-term recommendations will be available shortly. The problems involved in a cancer campaign are many. Early diagnosis and treatment are essential and efforts at public and professional education must be intensified. The availability of beds, highly-trained staff and equipment will be important elements in the fight against this disease. The manner in which a national cancer service might best be organised will also need careful consideration.
I will lose no time in having the council's report examined and I am sure that it will be of considerable assistance to us in formulating our plans to reduce the death rate from this disease.
This brings me to the position of St. Kevin's Hospital, Dublin. Following consideration of the report of the committee which was set up to examine the existing facilities in the hospital, certain decisions, which I feel will have an important influence on the standard of local authority medical services, have been taken.
The public will have noticed advertisements which appeared recently in the Press inviting applications for the positions of director of medicine, director of surgery and director of pathology at St. Kevin's Hospital. These appointments represent the first major step in the carrying out of the policy of which I have approved, for the improvement of the standard of service to be provided at St. Kevin's Hospital and in the local authority service.
In order to improve the standard of medicine in the local authority service generally, it is proposed to establish in St. Kevin's a post-graduate school of medicine. The school, which will be established if the necessary legislation is enacted, will provide post-graduate courses in medicine, surgery and pathology for members of the local authority medical service. Each of the three branches of the hospital and of the school will be under the supervision of a director, who will be a man of the highest professional qualifications and who will be paid a salary commensurate with his qualifications. In order to attract the very best possible material, the salaries and emoluments of the posts have been fixed on a scale considerably in excess of those ordinarily applicable in the local authority service.
In addition to their responsibility for the organisation of the post-graduate school, the directors of medicine and surgery will be responsible for the treatment of patients in St. Kevin's and shall, when necessary, provide such treatment. It follows from this that the standard of treatment for patients in St. Kevin's Hospital will be at the highest specialist level and that the best, and only the best, treatment will be provided at that hospital. In order to assist the directors in their work, it is envisaged that each will ultimately have the help of an assistant director. All this flows from the adoption of a policy for the provision throughout the country of the best possible medical, surgical and pathological facilities for those sections of the community who are unable to provide them from their own resources.
The gastro-enteritis advisory committee is compiling its final report, which, I expect, will be submitted in the near future.
Last year I mentioned that the new procedure provided for under the Mental Treatment Act aimed at encouraging patients to seek treatment in the early stages of mental illness. Statistics for 1948 encourage us to hope that this fundamental aim of the Act will be realised. The number of voluntary patients admitted to mental hospitals in 1948 was 501 compared with 376 in 1947. The number of temporary patients admitted increased from 773 in 1947 to 995 last year, while the number of persons of unsound mind admitted totalled 2,752 in 1948 as compared with 1,929 in 1947. The total number of admissions in 1948 was 4,248 compared with 3,078 in 1947—an increase of 1,170, but the total number of discharges in 1948 was 2,875—an increase of 1,009 over 1947. This total comprised 430 voluntary patients, 657 temporary patients and 1,788 persons who had been committed as of unsound mind.
Clinics for affording advice and preventive and curative treatment in cases of mental disorder, including cases of suspected or incipient mental disorder, have been established by the majority of mental hospital authorities in view of the importance of the provision of facilities for early treatment of mild cases.
During the year, a branch of St. Augustine's Colony, Blackrock, County Dublin, was opened at Drumcar House, Stamullen, County Louth, for male mental defectives and Moore Abbey, Monasterevan, became available for female epileptics. Schemes for providing additional accommodation for about 800 mental defectives have been approved and planning is proceeding. I have also been giving attention to the broader aspects of the protection and care of mentally deficient persons and legislation to deal with the position is under consideration.
I feel that too much stress cannot be laid on the importance of fair living and working conditions for all our nursing staffs. Adequate remuneration alone is not enough. Proper amenities and adequate recreational facilities are also of primary importance and during the year the attention of local authorities was drawn to the matter. In many districts considerable improvements have taken place and progress is being made towards the introduction of a 96-hour fortnight. Some counties are experiencing difficulty in introducing the shorter working hours owing to the absence of residential accommodation for the extra nursing staff which is required, but efforts are being made to provide the necessary accommodation, and in some cases arrangements have been made to allow the staffs to live out. In order to relieve the existing overcrowding of our training schools and to ensure a more liberal supply of nurses, I have urged the public assistance authorities responsible for some of our larger county hospitals to endeavour to fulfil the requirements of the General Nursing Council in order that they may be recognised as training schools. As already mentioned, a new grade of sanatorium nurse was instituted during the year.
Health authorities were encouraged to appoint further health inspectors, where required, to meet the demands of the public health services and courses in sanitary science were held at University Colleges, Dublin and Cork, which afforded persons desirous of being appointed as health inspectors an opportunity to obtain the necessary technical qualifications.
The local authority medical services have been handicapped by the non-availability of specialist services outside the larger centres of population. Hitherto, persons who required specialist attention could not, generally, receive such attention in the areas in which they reside and were, therefore, obliged to travel to Dublin, Cork, Limerick and Galway. It is essential to have the services of specialists more widely available throughout the country. Discussions have taken place between officers of my Department and county managers and county medical officers with a view to finding an early solution of this problem. There seems to be general agreement with the view that the specialist services should be brought to the people and that local authorities should make appointments, or combine to make joint appointments, of wholetime officers. An enormous improvement in the health services at relatively little cost would be achieved if orthopædic, ophthalmic, obstetric and ear, nose and throat specialists were available regularly at the county clinics or smaller clinics in a county as required and in the local hospitals. The saving in human suffering would be very appreciable and I hope that before the year is out considerable further progress will have been made.
The availability of a complete range of laboratory services is another essential element. It is hoped to provide a full range of pathological and bacteriological services in each region, with county laboratory services to deal with routine work not requiring more specialist intervention.
The pattern of medical service which is evolving should now be apparent. The general practitioner is obviously the basic unit in that pattern and he will have as backing the local pathological services to which I have referred, or, alternatively, the specialist clinic to which he can refer his patients. The clinics in their turn are backed by hospital beds of the appropriate kind in the district hospital or the county hospital or the local sanatorium. These hospitals are in turn backed by the regional hospitals or other specialist institutions, including the regional sanatoria, orthopædic centres, etc. Outstanding in this pattern must be the position of St. Kevin's Hospital, Dublin, where, as I have already mentioned, not alone will there be a medical service second to none for the patients, but refresher and other courses will be provided to enable the medical staffs of local authorities to improve and to bring up to date their knowledge and to ensure that the highest possible standards are maintained at every level of the service.
In regard to all this, I would like to emphasise that it is my desire that treatment up to and including a high specialist level should be available to every patient as near to his own home as possible and that the processions of ambulances from the furthest corners of the country to hospitals in Dublin and Cork should become more and more attenuated.
I now come to the details of the Estimate before the House. The increase under sub-head A—Salaries, Wages and Allowances—is attributable to the additional staff required in my Department and the payment of increased remuneration to civil servants arising out of the recent revision of Civil Service salaries. The additional provision under sub-head B— Travelling Expenses—is necessitated by the increase in the inspectorial staff at headquarters and also by the fact that the amount of inspection and supervision work will be greater than in previous years, due to the expansion of local health services.
The main provision under sub-head E—Expenses in Connection with International Congress, Etc.—is for the payment of this country's contribution towards the Budget of the World Health Organisation for 1949. Ireland's contribution has been fixed at 0.34 per cent. of the total budget which amounts to about $5,000,000. Our contribution for 1949 amounts to £4,280. Sub-head F (2) makes provision for the payment of expenses connected with the activities of the different consultative health councils which have been established. I have already explained in some detail the work done by these councils in the past year.
Deputies will note that greatly increased provision has been made under sub-head F (3)—Dissemination of Information and Advice on Health. I regard publicity measures as a vital part of any campaign for the inculcation of health habits among our people. If we can fully awaken the community to a well-balanced appreciation of the need to safeguard health, we will have taken a very big step forward in the ceaseless struggle against ill-health and towards the attainment of a healthy community.
Sub-head F (4)—Miscellaneous Expenses in connection with the Health Act, 1947—is a new sub-head. I have already referred to the regulations which it is proposed to make in the near future. It is unlikely that any considerable expenditure from central funds in connection with the administration of these regulations will arise for discharge during the present year, but a token sum of £10 is being provided under this sub-head.
The provision made under sub-head G (3)—Expenses in Connection with a Survey of Human Nutrition—is greatly reduced from last year as the field work arising from the survey has been concluded. The nutrition survey, as Deputies are no doubt aware, consisted of a dietary survey concerning selected families in various areas throughout the country and a clinical survey concerning thousands of school children and some adolescents and expectant mothers and nursing mothers. A report of the methods employed in the dietary survey generally and on the results of the dietary survey in Dublin in particular was published last February. Deputies will recall that the survey indicated that, with the exception of calcium, the intake of nutrients was, broadly speaking, satisfactory at all levels of income, food expenditure and family size. The deficiency in calcium was found to be considerable in some groups, due to the low consumption of milk and cheese.
The statistical analysis of the returns received from the nutrition investigators in respect of the congested districts has been completed and it is hoped to publish a report on this portion of the survey at an early date. Analysis of the dietary returns in respect of the remainder of the country, and of the clinical returns, is in progress and it is hoped that the work will be completed by the end of the current year.
We now come to sub-head H—Grants to Health Authorities—which is the largest item in the Estimate. I explained the principle underlying the Health Services (Financial Provisions) Act, 1947, in my statement on last year's Estimate, but perhaps a little recapitulation may be helpful.
The Act provides that the State will bear each year the difference between the net expenditure of each health authority on health services and the net expenditure of that authority on such services from local funds in the year 1947-48, (i.e. the standard expenditure) until such time as the State contribution equals the expenditure of the health authority. Thereafter, the cost will be borne equally by central and local funds. The method of recouping health authorities for health expenditure has also been simplified and a single grant replaces all previous grants in aid of expenditure on recognised health services.
It is not expected that any health authority will, in the current financial year, reach the point where its expenditure will be equal to twice its standard expenditure. Consequently, the costs, excluding capital costs, of any new developments of the health services in the present year, together with any increases in the cost of the old services, must be met in full by the Exchequer.
The ascertainment of the standard expenditure in each case must await the audit of the local accounts, but it is estimated that the aggregate standard expenditure of all health authorities is in the region of £4,731,000. The aggregate expenditure of health authorities on recognised health services for the year ending 31st March, 1950, is estimated at £6,915,000, as detailed in Part III of the Estimate, and the difference to be borne by the Exchequer is, therefore, £2,184,000. Of this amount it is expected that 95 per cent., or £2,075,000, will actually be paid within the year, the balance to be paid on receipt of the auditors' certificate. A further item of £85,000, contained in sub-head H, is to pay the balances of grants due in respect of the year 1948-49 which will fall due as the accounts of that year are audited.
The total disbursements by health authorities on health services for the current year are estimated to exceed the disbursements for the year ended 31st March, 1948, by £1,273,000. The corresponding excess of expenditure for the year ended 31st March, 1949, over the preceding year's expenditure is estimated at £859,000.
Sub-head (I)—Grants to Voluntary Agencies for Child Welfare, Schools for Mothers, etc.—shows an increase of £500 on last year's estimate of expenses. The provision under this sub-head is for grants to voluntary agencies, such as district nursing associations, which provide, outside local authority schemes, services for mothers and children in the forms of boarding out, nursing homes, etc.
The Grant-in-Aid provided for under sub-head J—National Blood Transfusion Service—is a contribution towards the expenses of the establishment and maintenance of the non-profit-making body, a company, limited by guarantee, set up in August last to organise and administer a blood transfusion service on a national basis. Suitable premises have been acquired by the company and the medical director has already taken up duty. It is hoped that effective progress towards the establishment of an adequate transfusion service will be made in the present year.
Sub-heads L and M (1) to M (5) provide for balances of grants payable to local authorities arising out of expenditure in years previous to 1948-1949. Expenditure by health authorities on the corresponding services in respect of subsequent financial years will be recouped from sub-head H—Grants to Health Authorities.
In conclusion, I would like to say a few words about further plans. Some appear to think that progress is reflected in the production of grandiose schemes, attractive in theory but not capable of early implementation. We must build on a solid foundation. Widely-available health services would soon fail if they had not the backing of hospital and specialist facilities and ancillary medical and nursing personnel. We must first concentrate on providing these facilities before we impose an undue strain on the health services by too great an immediate widening of their scope.
My main concern is the provision of facilities designed to eradicate weaknesses in our existing services, and when this has been accomplished gradually to extend their scope. The provision of beds to relieve the pressing needs of the acutely ill, the successful prosecution of an anti-tuberculosis campaign, the provision of an improved mother and child health service, the raising of the standard of the medical assistance service by the provision of post-graduate courses, specialist teaching and suitable premises, the organisation of an adequate cancer service, the provision of proper care for mentally deficient persons, the organisation of a clean and nutritious food campaign, and other projects to which I have already referred, form the basis of our short-term plans to give the country a better health service. The bringing of the plans I have outlined to a successful conclusion will need the whole-hearted co-operation of local health authorities, the public and medical and nursing personnel. I feel that such co-operation will be forthcoming, as we are all at one in agreement to improve the health services, and once we have the will, the removal of any difficulties and the smoothing out of any disagreements on the means or methods to be adopted should not present too serious a problem.
