I move:—
That a sum not exceeding £1,564,000 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, 1951, 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.
My speech on the introduction of the Estimate for last year dealt mainly with plans which were then made for the improvement of the health services, notably in the tuberculosis service. Since then, considerable progress has been made in the achievement of these plans. I will later give an account of what was done during the past year and what it is hoped to do in the coming year in the further improvement and expansion of the health services, but, before doing so, I would like to run over the vital statistics for the past year. The figures I give in respect of that year are provisional.
The birth rate per 1,000 of the population for the year 1949 was 21.4. This is less than the figure for 1948, but also less than the figure for the immediate preceding years. It is, however, well above the average for the two decades preceding the recent war. The birth rate for England and Wales for 1949 was 16.7; the rate for Scotland was 18.5, and for the six North Eastern Counties was 21.4.
The number of marriages in 1949— 16,299—was almost the same as in the previous year. The death rate for 1949 was 12.7 per 1,000 of the population. This is somewhat higher than the figure of 12.1 for the year 1948 which was, however, the lowest ever recorded for this country. While comparisons of the crude death rates between different countries may be misleading, it is worth while nothing that the death rates for 1949 for the neighbouring countries were—England and Wales, 11.7; Scotland, 12.3; the rate for the six Northern Eastern Counties was 11.5.
The infant mortality rate, that is, the number of infant deaths per 1,000 births, was 51 compared with 50 for 1948, and an average of 67 for the five years up to 1948.
It is satisfactory to see that the figure for 1948, which was the lowest ever recorded, has been substantially maintained, but our figures give no grounds for complacency. For example, an infant mortality rate as low as 22 has been recorded in New Zealand. The slight increase in the number of infant deaths here in 1949 over 1948 was accounted for largely by an increased incidence of gastro-enteritis. There were 483 deaths from this disease in 1949 as compared with 352 in 1948. The disease did not, however, reach the epidemic proportions of the 1943 to 1945 period, when there were over 1,000 deaths from it in each year. Even at the 1948 figure, the numbers of deaths from this disease were too high and the sharp increase in 1949 makes it abundantly clear that the special measures taken to control the disease must not be relaxed in any way.
As a contrast to gastro-enteritis, there have been spectacular decreases in the number of deaths from most of the other infectious diseases. The number of deaths from tuberculosis in 1949 was 2,651, which was 452 less than the figure for 1948, which was, up till then, the lowest ever recorded for this country. This big decrease is particularly gratifying because it is somewhat of a surprise. With more accurate notification of tuberculosis and certification of this disease as a cause of death, one would have been inclined to expect an opposite trend. It would not be safe at this stage to predict what the figures will be over the next few years. The number of deaths from diphtheria was ten; from typhoid fever, 12; from whooping cough, 131; and from measles, 53, all representing substantial reductions on previous figures. Deaths from scarlet fever increased from five in 1948 to 11 in 1949, and deaths from influenza from 201 to 264.
Deaths from cancer showed a small reduction as compared with 1948. The average number of deaths from this disease over the last five years, however, was almost 4,000. It, therefore, kills more people per year than tuberculosis, and even though it does not attack the younger members of the community as tuberculosis does, the figures emphasise the need for such active measures to be taken against it as the present state of medical knowledge permits.
The general picture presented by the vital statistics for the past few years is one of slow but continuous improvement. It is difficult to say to what extent this improvement is due to improvements in the health services, but I do not think it is unreasonable to assume that the improved services have done much to bring about the better figures at least for infant and maternal mortality and for deaths from the infectious diseases.
In my speech introducing last year's Estimate I explained what I hoped to do in the provision of hospital beds. I mentioned that a short-term seven-year building programme had been worked out and that the planning of the projects included in that programme was being proceeded with as a matter of urgency. Progress on planning has been very satisfactory and in many cases constructional work started during the past year. A substantial proportion of the short-term building programme was under construction by the end of 1949.
Amongst the more important projects on which building work commenced over the past year or so are two of the proposed three regional general hospitals, namely those at Galway and Limerick, the large new hospital at Gurranebraher, County Cork, the new 304-bed children's hospital at Crumlin, Dublin, the regional sanatorium at Galway and the sub-regional sanatorium at Ardkeen, County Waterford. Site development work for the two remaining regional sanatoria—those at Cork and Dublin—is nearing completion. Site development work for the children's sanatorium at Ballyowen, County Dublin, was completed, and building work was started some weeks ago. Work is well advanced on the provision of infant welfare units at the three Dublin maternity hospitals and the new maternity unit at the Cork City Home and Hospital should be completed this year. Other works which have started are a 100-bed extension at Portiuncula Hospital, Ballinasloe, and new nurses' homes at St. Michael's Hospital, Dún Laoghaire, and the Meath Hospital, Dublin. In all, contracts valued at over £4,800,000 were placed for hospitals in 1949; a further £2,000,000 worth of work has already started this year and further works costing between £2,000,000 and £2,500,000 more are expected to be under way before the end of the year.
The satisfactory results achieved so far have justified the decision, so far as hospital construction is concerned, to concentrate all energies on a set programme and within that programme to give priority to particular projects for which there was greatest need or which could be proceeded with at an early date and so clear the way for other projects rather than to dissipate energy on the detailed examination of a host of projects which there could be no hope of completing in any foreseeable period. Deputies who are concerned with projects which are not included in the short-term programme should be encouraged, by the progress achieved so far, to look with reasonable confidence towards the initiation of the deferred projects before many years have elapsed.
There is, however, one aspect of the building programme which is not progressing satisfactorily. This is the planning of county clinics. These clinics will fill a very great want in helping the early diagnosis of illnesses and in bringing the services of specialists nearer to the people. They should also relieve pressure on hospital beds in so far as investigations can be done there without the admission of patients to hospitals. I am sorry to say that, despite frequent encouragement on my part, many local authorities have been slow in advancing the planning of the clinics and I would ask all Deputies who can do so to help in pushing them on.
One disappointing feature in connection with the hospital construction programme is the very high cost of the projects already started. Although considerably higher costs than before the war were to be expected, the extent of the advance in cost was greater than could have been foreseen. Because of this, and in order to ensure that the funds available are spent to the best advantage, it is essential that all concerned with the planning of hospital projects should secure such degree of economy as is consistent with sound construction and a reasonable arrangement of essential accommodation. Deputies who are members of local authorities or of voluntary bodies concerned with hospital building can give considerable assistance in this matter.
Progress in the provision of hospital beds for pulmonary tuberculosis cases has been particularly satisfactory. Since April, 1948, 2,000 additional beds have been provided. Some of these, such as those in Castlerea Sanatorium and the Mallow Chest Hospital are designed to relieve the shortage until the regional sanatoria are completed. Others, for example St. Mary's Chest Hospital, represent permanent additions to the total number of beds available to accommodate persons suffering from this disease. The total number of beds now available for persons suffering from tuberculosis is estimated at 5,500. There is, however, still need for getting on with the completion of the permanent accommodation in the regional sanatoria as rapidly as possible. Until these sanatoria are completed, the position will be eased by the completion of some smaller projects. A new sanatorium at Killybegs, County Donegal, has just been opened, with a bed capacity of 72. Further accommodation is being provided as opportunity offers elsewhere. The provision of accommodation for 250 child tuberculosis patients in a new sanatorium at Ballyowen, County Dublin, which is expected to be finished next year, will largely solve the problem of institutional treatment for these children.
On this question of bed occupancy and waiting lists there are a few observations I would like to make.
I have mentioned the provision of 2,000 additional beds in about two years, and this might lead to the inference that the incidence of the disease is increasing. It is, however, reasonable to assume that there has been no increase in incidence—the decrease in the death rate provides confirmation of this. What is happening is that due to the payment of allowances under the Infectious Diseases (Maintenance) Regulations and to a more enlightened attitude on the part of the public resulting in part from the extensive publicity given to the facilities for free treatment for the disease in recent years, there is much less tendency to hide the disease than there was formerly, and persons who suspect that they may be suffering from it are availing to a much greater extent of the diagnostic facilities provided, to which I propose to refer shortly.
In regard to waiting lists, it should be realised that even if there were unlimited beds available for treatment, there would still be waiting lists. Tuberculosis is a long-term disease and most persons in whom the disease is diagnosed, realising that they must spend a fairly long period in hospital, particularly if, as is often the case, they are not acutely ill, like to have a week or a fortnight or even longer in which to make arrangements in regard to their affairs before they will accept hospital or sanatorium treatment. A waiting list of, say, 200 to 300 in relation to a bed capacity of 5,500 would not be unreasonable.
There is the further consideration that the flow of discharges of patients in the 2,000 beds provided in the last two years is not yet as great as in beds longer established. When large numbers commence treatment at roughly the same time, the beds are immobilised for the full treatment period and it takes some time before the flow of discharges events out.
Two other factors affecting this question remain. One is of a temporary nature. It relates to persons whose condition after a normal period of treatment becomes stabilised as "chronic", and who are discharged from the sanatorium because they have derived the maximum benefit from their stay there. Many such persons have been brought back into tuberculosis institutions to avail of the surgical procedures now provided and this backlog of cases has affected the turnover of beds for "new" cases. The second factor is that earlier diagnosis and treatment facilities, which have now become available to a greater extent than formerly, result in a shorter stay in the sanatorium and the effects of this, on a large scale, are now only beginning to be felt.
Apart from the provision of extra accommodation, other sides of the tuberculosis service were developed. Two thoracic surgeons are now working in institutions in Leinster, Munster and Connaught. Operating theatres, equipped for the provision of the most modern treatment, are available at St. Mary's Chest Hospital, at Rialto Hospital, at Mallow Chest Hospital, at Castlerea Sanatorium and at the Limerick City Home and Hospital for these surgeons.
Further steps were taken to improve the diagnostic service. In October last a circular was sent to all the health authorities recommending them to make arrangements to enable private doctors in their areas to get free chest X-rays for their patients. This service is now in operation and the attention of doctors and the public has been drawn to it by wide Press publicity sponsored by the Department. Early diagnosis of tuberculosis gives a much better chance of recovery and permits steps to be taken to prevent the spread of infection. It is most important that this service should be used as much as possible. I would appreciate any help given by Deputies in publicising this service to their constituents and correspondents.
In addition, mobile X-ray units will be used to provide a mass radiography service. Such a unit has been successfully operated by the Cork County Council since April, 1949. It consists of a van in which the X-ray apparatus is housed and which has accommodation for a doctor and the persons requiring X-ray. It has been found a most convenient way of providing a mass radiography service and from April, 1949, up to the end of March last approximately 11,000 miniature radiographs and about 2,000 larger plate films were taken by this method in the county. One hundred and four new cases of tuberculosis were diagnosed. It is hoped to provide six of these units in other areas in the near future. The Dublin Corporation mass radiography unit at Lord Edward Street, Dublin, continues to function, but I feel that it is still not working to capacity. I have referred to this in a recent reply to a parliamentary question.
A new high-powered X-ray set was installed at the corporation's dispensary, Charles Street West, in July, 1949. The installation of this equipment should enable a first-class diagnostic service to be provided at this dispensary, which is the corporation's principal chest clinic for the city.
Courses of study were organised by the Department last year in Wales, England and Denmark, for medical officers engaged on tuberculosis work in this country. Eleven medical officers took the Welsh course which lasted eight weeks. Two took the English and six the Danish course. The special feature of the last-named course was the study of B.C.G. vaccination.
The scheme of cash allowances under the Infectious Diseases (Maintenance) Regulations, 1948, continued to operate satisfactorily. It was found necessary to make some minor amendments of the regulations to enable allowances to be paid in respect of domestic help rendered in certain circumstances by relatives of patients.
Last year I referred to the question of the rehabilitation of tuberculosis patients.
Vaccination against tuberculosis with B.C.G. has been part of the Dublin Corporation's tuberculosis service since 1948. Vaccination is offered to uninfected contacts of persons suffering from tuberculosis, to children in residential institutions, to infants born in the city maternity hospitals where there is a family history of tuberculosis, and to some other groups who are subject to special risk.
In June, 1949, a group of medical experts in close touch with the tuberculosis problem agreed to the Minister's request to form a special committee called the National B.C.G. Committee for the purpose of extending the B.C.G. vaccination service at St. Ultan's Hospital to serve the country generally until the various health authorities are in a position to provide this type of vaccination as part of their tuberculosis service. The committee's vaccinators work in close contact with the medical officers of the various health authorities which have adopted B.C.G. schemes. The vaccinators are now working in 15 counties. Up to 31st May, 6,600 vaccinations and 20,500 skin tests (preliminary and post-vaccinal) have been carried out.
I would like to record my appreciation of the work of national importance, in the field of preventive medicine, being performed by the members of this committee whose services have been given voluntarily. During the short period the committee has been functioning, there has been splendid co-operation on the part of the health authorities and the general public with the trained staff of vaccinators, and this co-operation augurs well for the integration, in the near future, of this valuable protective scheme with the health services operated by local authorities. It has been established that the use of this type of vaccination on a wide scale in other countries had produced a high degree of immunity from tuberculosis in the community, and it is gratifying that this country has made a good start in adopting this valuable preventive measure here.
The service to control and prevent other infectious diseases continued to operate quietly and effectively, and the incidence of most of these diseases give no cause for alarm.
I wish to express appreciation of the efforts made by all in this campaign and I hope that they will keep the good work going.
To conclude this account of the fight against infectious deseases, I would like to emphasise again that all health authorities provide free treatment and diagnostic services for tuberculosis and other infectious diseases. These services are not perfect, but efforts are being made to improve them as rapidly as possible. The public should realise that if they are suffering from any infectious disease they are entitled to free treatment for it by the health authority and that it is their duty to their families and to the community to avail of this treatment. It is also the duty of the health authorities to provide these services promptly, courteously and conveniently.
A survey into the nutritional condition and the food habits of the people which commenced in 1946, has now concluded and a number of reports on the results of the survey in urban and rural areas have been published.
I referred last year to what was then being done to bring the various parts of the Health Act, 1947, into effect. I will now give an account of the progress since then on these matters.
The progress made in regard to the introduction of the comprehensive free mother and child service visualised in the Act is not as great as had been hoped.
Discussions are in progress between the Dublin maternity hospitals, the corporation and the Department regarding maternity services and a neonatal infant service for Dublin and district. I have already referred to the steps taken to provide accommodation for the hospital side of the lastmentioned service. Works has been proceeding on the preparation of a draft comprehensive scheme for the country at large. A tentative scheme has now been prepared, and it will soon be considered by the Irish Medical Association. In these circumstances, I am sure the House will agree that it would be better that I should not furnish details of the scheme here now.
The food hygiene regulations, which have been under consideration for some time, were sent to various trade organisations—retailers, wholesalers, importers, manufacturers, trades unions, etc.—to the representatives of the medical profession and to local health authorities. Many helpful suggestions were made by these bodies and they have now been considered and, where desirable, are being incorporated in the regulations. The draft is now being put into its final form, and it is expected that these regulations will be made very soon. I had hoped that they would be made sooner, but the regulations represent a very comprehensive and complicated code and required careful drafting. Because of their importance, I am making every effort to expedite work on them.
To enable persons affected by the regulations to study them and, where necessary, to put their houses in order so as to comply with the regulations, they will not come into operation until some months after they are made. The proposed regulations were generally welcomed by the various trade interests as well as by the general public.
During the year further measures were taken to improve the medical services provided under the Public Assistance Act for the more needy classes of the community. Up to the present these services have been handicapped by the fact that persons requiring specialist attention were often obliged to travel to the larger cities in order to obtain it. It is the intention that, in future, all possible treatment will be given locally. To enable this to be done, the services at the county and district hospitals are being improved. Attractive conditions of service for county surgeons have been sanctioned and it is hoped that these conditions will ensure the maintenance of a high standard among appointees as county surgeons. It is proposed also to recommend to local authorities that they should, as opportunity offers, appoint whole-time county physicians and county obstetrician-gynæcologists in each county. These physicians and obstetricians will be highly qualified and it will be possible for them to provide treatment at specialist level in county hospitals. Regional specialist orthopædic surgeons have been appointed to serve most parts of the country and it is hoped to provide this service for the entire country soon.
During last year it was found necessary again to circularise local authorities requesting them to take immediate steps to improve the public assistance dispensaries, not only as regards their structural condition, but also in relation to the equipment and the amenities provided for patients and staff. It is admitted that this is a very difficult problem as a large number of the dispensaries which are not capable of reconstruction must be replaced. Elaborate premises are not required, however, and all local authorities should take energetic steps to bring their dispensaries up to a decent standard. The Minister hopes that in every county an immediate start will be made to replace those buildings which cannot be made satisfactory by reconstruction. I would urge those Deputies who are members of local authorities to cooperate in this effort.
I referred last year to the condition of the county homes. In some counties considerable improvements have been made in these institutions, but many of them still fall very short of the standards which are desirable. The interdepartmental committee which was established to advise on the measures which should be taken to reconstruct or replace these is continuing its work and its report is expected to be furnished soon.
Further measures were taken to improve the medical services provided in St. Kevin's Hospital, Dublin, by the appointment of a specialist visiting gynæcologist and a visiting ophthalmologist specialist. Hitherto, surgical operations were carried out in St. Kevin's on three days per week. Arrangements for the performance of daily operations are well advanced, and will be completed very shortly. In addition, the appointment of directors and assistant directors of surgery and medicine and a director of pathology should shortly be made which, as well as providing a better service for the patients there, will bring the establishment of the proposed post-graduate medical school a step nearer.
On the subject of St. Kevin's, I should perhaps say that at long last a start is about to be made with the much-needed structural improvement of this, the largest of our Irish hospitals, to bring it up to modern standards.
In accordance with the recommendations of the Consultative Cancer Council a central body, known as Comhlachas Ailse na h-Éireann (The Cancer Association of Ireland) was recently established. The association has been constituted under the Companies Acts and will be financed from the Hospitals Trust Fund. The directors of the association, all of whom are willing to act without remuneration, are members of the medical profession with special knowledge and experience of cancer work, representatives of the medical schools and local authority medical services, laymen with administrative experience and a representative of the Department of Health. It is intended that the association shall be an authoritative body and it has been given wide powers to enable it to ensure a full service on a national basis for the prevention, diagnosis and treatment of malignant diseases and diseases of the skin.
It is expected that this new organisation will receive the co-operation of local authorities and of the other bodies and institutions which, up to this, have done much excellent work in this field and that the present cancer service will be co-ordinated and considerably expanded. As the new body will be the primary national agency for the development and improvement of the cancer service, it will be responsible for advising and assisting the Minister on all matters relating to any aspect of that service. It is hoped that the association, with the help of the local authorities and other bodies engaged in the service, will succeed in providing, within the financial and other resources available, a modern cancer service with up-to-date facilities for diagnosis and treatment adequate to the needs of the people. It is understood that the new association has acquired extensive premises and property in Dublin capable of development as a fully equipped centre for the treatment of cancer.
Before dealing in detail with the demand for moneys for the health services contained in the Estimate now before the House, I think it is appropriate that I should say something about the other great source of funds for hospitalisation, that is, the Hospitals Trust Fund.
The House will be aware of the very disconcerting rate of growth of the deficits of the voluntary hospitals. They had reached, in respect of 1948, the last completed year for which audited figures are available, a total only £2,000 short of £400,000. It would, of course, be reasonable to expect that, with the fall in the purchasing power of money during the war years, the deficits would rise, but the progression from £116,000 in respect of 1938, the last pre-war year, to almost £400,000 in respect of 1948 is, to say the least of it, extremely steep. In reply to Deputy Briscoe's question on 4th instant, I gave very full information in regard to certain of the steps taken to remedy the position, and I do not wish to occupy the time of the House now by repetition in detail.
Briefly, these steps may be summarised as follows: The amount which will be paid in deficits in respect of each of the years 1950, 1951 and 1952 will be £400,000, which, as I have mentioned, is the approximate amount of the deficits in 1948. The payments on foot of deficits will be made at a much earlier date than at present—as much as 12 months earlier in respect of nearly half the amount and approximately six months in respect of the major portion of the second half. This will save hospital authorities a good deal of their embarrassment in respect of borrowing and will save, in cash, the overdraft interest.
The payment which, as from 1st July, will be made to most hospitals by local authorities in respect of their patients, will be increased from £3 13s. 6d. to £4 4s. 0d. a week. This increase will fall in full on this Vote this year and, in the case of most local authorities, it will be several years, owing to the operation of the Health Services (Financial Provisions) Act, 1947, before any portion of the increased charge will fall on the local rates. The Minister for Social Welfare also has taken steps to increase payments made from National Health Insurance funds in respect of the maintenance of national health insurance patients.
The basis on which the payment of deficits will be made to each hospital in respect of each of the three years 1950, 1951 and 1952 will be either (1) the average amount of the deficit in the three years 1947, 1948 and 1949, or (2) the hospital's estimate of the amount of its deficit in 1950, whichever is the lower.
I do not think any Deputy will consider that an unreasonable basis. I may say that over one-third of the hospitals will be entitled to get up to the full amount of their estimated deficit so that no hardship or semblance of hardship can arise in their cases. In other cases the earlier payment and the increased income resulting from the increase in the capitation charge will either bridge the gap completely or go a good way towards it.
I feel that it is important that I should repeat what I already said in my reply to Deputy Briscoe about two matters. The first is that certain members of hospital boards have for some time been urging the Hospitals Commission to do something on the lines of what has been done. I will quote again the appropriate extract from the circular issued by the Hospitals Commission dealing with the matter:—
"The commission is aware that hospital authorities have been keenly alive to the extreme seriousness of the deficit position and, from time to time, representations have been made by members of hospital boards that more effective measures of internal control of expenditure might be achieved if hospitals were informed in advance of the amount of the grants they might expect to have paid to them in respect of the following year's deficits. It was contended that the current system of paying the deficits tended to sap the initiative of boards of management, since under it there did not appear to be the required incentive to economise."
The second point is that I wish to emphasise that at no time did the total annual investment income of all the Hospitals Trust Fund exceed £330,500, and as the amount paid in deficits in respect of 1948 was nearly £400,000, as the amount to be paid in respect of 1949 will reach that figure, and as £400,000 is the annual figure now fixed in respect of the years 1950, 1951 and 1952, it is futile to talk about the reservation of the investments of the fund to provide an endowment to pay the deficits. Even if every penny in the fund at its peak had been earmarked as an endowment for the deficits, the income would be insufficient for the purpose. I am not aware, however, that it was ever the intention to earmark all the money in the fund as an endowment. The sum provisionally set aside for that purpose some years ago was, as I mentioned £5,720,000, and that could do no more than meet half the deficit. I hope, therefore, that in future there will be less uninformed criticism on this matter.
