Yes. It began about three years ago. Of this sum £15,000,000 will be found by the Exchequer and the balance will have come from the balance in the fund when the programme started in 1949, the proceeds of sweepstakes during the period of the programme and the limited income from investments from the commencement of the programme until now when all the investments are liquidated to meet commitments.
During the currency of the programme to date £11,000,000 has already been spent on hospital building works.
Before leaving this question of the Hospitals' Trust Fund I would like to pay a tribute to all associated with the collection and the spending of the moneys for the excellent work they have done. Thanks to the fund, we now have, in the cities and throughout the country, numerous new and reconstructed hospitals of a very high standard and, while there is much that still remains to be done in the way of improving facilities, we are immeasurably better off than if the sweepstakes had not come to our aid.
To come back to the progress which is being made with the short-term building programme, I must first report on the regional sanatoria, for which I am directly responsible under the Tuberculosis (Establishment of Sanatoria) Act, 1945. Dublin and Cork regional sanatoria are well under way, and should be finished next year. The remaining regional sanatorium, at Galway, is even closer to completion and a part of the institution, with accommodation for over 280 patients, is now functioning.
I think it is proper that I should pay an overdue public tribute here to the very valuable assistance which has been given by the building and engineeringindustries, and by some firms in particular, in carrying out arrangements for the advance purchase of materials needed for the Dublin and southern regional sanatoria. These arrangements were initiated by my predecessor, Deputy Dr. Browne, at a time when, owing to the critical international situation, it seemed possible that the work might be held up owing to difficulty in securing materials. The assistance of these industries and firms, which was given as a national service and without any profit whatever, has made it possible for the work to proceed with the greatest possible speed.
The House, I know, will not expect me to refer in detail to the position of the several hundred projects included in the programme, and I propose to mention only a few of special interest. In the case of the two major general hospitals to be provided in Dublin, that is, the new St. Vincent's and St. Laurence's Hospitals, planning to the budget has presented difficulties. Agreement has been reached with the St. Vincent's authorities which enables them to proceed with the completion of planning of the new hospital at Elm Park. I expect to see representatives of St. Laurence's Hospital in the near future, and to reach a final decision then about the building of the proposed new hospital at Cabra. I am glad to say that very satisfactory progress is being made with the reconstruction of St. Kevin's Hospital and that the standard of accommodation for patients there has been vastly improved, and will be further improved over the next few years. Rapid progress is being made with the building of the new cancer hospital at Oaklands, Rathgar, which will accommodate 150 patients. The treatment unit in this hospital has been opened and the whole hospital should be functioning later in the year.
The planning of the new Coombe Maternity Hospital is proceeding and construction work on the regional general hospitals at Galway and Limerick is making good progress.
Striking progress has been made with the provision of additional accommodation for mental defectives. A new institution has been opened at Lisnagry, near Limerick, for femalemental defectives, and the Brothers of St. John of God have acquired new premises at Celbridge containing accommodation and teaching facilities for 180 high-grade mental defectives. The erection of a 180-bed extension to the home conducted by the Brothers of Charity at Glanmire, Cork, is in progress and work has started on the building of a 120-bed extension to St. Joseph's, Clonsilla, which is conducted by the Sisters of Charity of St. Vincent de Paul. I have also approved a scheme of extensions and improvements at Stewart's Hospital, Palmerston. All told, the scheme relating to mental defectives included in the programme initiated in 1948 should make available 1,400 additional beds, which should greatly relieve this very pressing problem.
In the case of clinics and dispensaries, I am hoping for a very rapid improvement in the position. In the case of the county clinics, which will provide facilities for specialist consultations in each county, most of the works have started, or are near the point of starting, and this service is gradually coming into operation as the clinics are completed.
I was glad to note that in the recent debate on a Supplementary Estimate for my Department, Deputies showed a very keen interest in the improvement of dispensaries. I told the House on that occasion in some detail what was being done about them, and all I wish to say about them now is that Deputies, particularly those who are members of local authorities, can further this work materially, and if each will do all that he can in this respect in his own area it will be a great help.
On the general question of the disbursement of grants from the Hospitals' Trust Fund there have been suggestions that having regard to the fact that the sweepstakes were initiated on behalf of the voluntary hospitals an undue proportion of the funds has been used for the benefit of local authority hospitals. I should make it clear once and for all that under the Public Hospitals Act, 1933, the Minister forHealth was given authority to disburse these funds after consideration of the reports which he receives from the Hospitals Commission on applications for grants which have been made to him. Nothing in that Act requires the Minister to allocate any set proportion either to voluntary or local authority hospitals and the intention was that the funds should be disbursed to the best advantage of the hospital and allied services of the country as a whole. Consequently as the moneys are disbursed strictly in accordance with the powers conferred by an Act of this House there is, in spite of suggestions to the contrary, nothing improper in the manner of their spending.
Voluntary hospitals provide only about one-third of the hospital bed accommodation in the country but by the time the short-term programme has been completed the authorities of such hospitals will have received more than two-thirds of the funds which have been or will be provided from the sweepstakes. I have had discussions with deputations from the Associated Hospitals' Sweepstakes Committee which represents the voluntary hospitals on this general question and they have told me that they were satisfied that there were no grounds for complaint on this score.
The committee I have mentioned was perturbed in regard to the deficits position of the participating hospitals. The aggregate of the deficits in 1939 was £157,500. For 1948 it had risen to £399,500 and in the following year it had reached £473,700. At that stage it was apparent that the figure could not be allowed to increase indefinitely and in June, 1950, my predecessor decided to "peg" them for a period of three years at the average for the years 1947 to 1949, at the same time authorising local authorities to pay increased capitation rates for patients sent by them for treatment. The increase was 10/6 per week i.e. from three and a half to four guineas. At the same time the rate for national health insurance patients was similarly increased, and it was decided that payments on foot of the deficits would be made, as to nearly half, about 15 months earlierthan usual and, as to nearly the remaining half, about nine months earlier than usual.
In the event, when the amount of the deficits for 1950 became finally known, it was apparent that it would be necessary to make some further adjustment. I was in full agreement with the principle of a limitation and I regarded my predecessor's basis as a suitable one to adopt but I made certain adjustments which I considered were justified by changed circumstances. As a result most hospitals had their deficits paid in full in respect of 1950, the first year of the three year period. The amount paid reached the very large sum of £508,774.
When it seemed that the 1952 deficits would far exceed even the figures so adjusted, I authorised local authorities to increase their capitation rate to five guineas a week (four and a half guineas for sanatoria) from the 1st January, 1952. This compares with a pre-war rate of two guineas, an increase of 150 per cent. It has now become clear that, with the deficit payments on the existing basis, even this increase will not cover the expenditure of some of the hospitals and I have, therefore, authorised a further increase of seven shillings weekly in the capitation rate for hospitals and sanatoria with effect from 1st January, 1953. It is obvious that some alteration in the basis of paying deficits in respect of 1953 and subsequent years will be necessary and I am reviewing the whole position. When the proposals in the new Health Bill are made effective, local health authorities will be responsible for paying voluntary hospitals for a larger proportion of their patients.
Other things being equal, this increased income from local authorities should have the effect of reducing the deficits, or at least of containing them within reasonable limits. The voluntary hospitals do excellent work and, of course, are an integral part of any health service which we may provide; but having regard to the position of the Hospitals' Trust Fund and to the fact that the deficit payments have increased in runaway fashion bynearly 250 per cent. from 1939 to 1951 as compared with a general cost of living increase of only about 125 per cent. in the same period, some steps must be taken to encourage economies and to bring down the amount of the deficits. I have that matter, also, under consideration.
Under the Public Assistance Act, 1939, it is estimated that one-third of the population is entitled to a full range of medical assistance, the work of the dispensary medical officer in his dispensary or in the patient's home when he attends to give domiciliary service being backed by the district and county hospital and by the voluntary hospitals which care for patients sent to them by local authorities at a charge of £5 12s. a week. There has been little development of this service in the year at the general practitioner level. An experiment in the holding of evening dispensaries has been commenced in Dublin City and in Sligo town, but otherwise there has been little significant change.
There has, however, been some improvement in the specialist backing of the dispensary medical officer. Orthopaedic surgeons on a regional basis have been appointed in four regions, one covering the Counties of Cork and Kerry and Cork City, another the Counties of Kilkenny, Waterford, Tipperary, Leix, Offaly and Carlow and Waterford City, another the Connaught counties and Donegal and a fourth the Counties of Louth, Meath, Westmeath, Monaghan, Cavan and Longford. Another will, it is hoped, be appointed soon for Limerick City and County and Clare. The service which these surgeons can give is limited by the extent to which they can secure hospital beds for their patients but improved facilities in that respect are being provided.
Clinics are held in each county at regular intervals and the district medical officer has, therefore, in his own area a specialist colleague to whom he can refer cases for further investigation and any necessary treatment. I need hardly stress to Deputies the advantage which this represents both to the patients and to the dispensary medical officer. Deputies havetold me that the service is very much appreciated both by the doctors and the patients.
A similar development has taken place in three regions in regard to radiologists and appointments will shortly be made in two other regions. This should save pressure on hospital beds in addition to providing a better and more rapid service than at present.
Other major developments in this direction must await the provision of more county clinics. When the clinics are provided and staffed, patients will have within their own counties many of the specialist services which they could obtain otherwise only by long and unwelcome journeys to hospital centres like Dublin and Cork— journeys which the patient is inclined to defer until it is too late. The general practitioner service under the public assistance code has had, of course, for many years the backing of the county surgeon and the county physician. The new specialist services will not supplant but will supplement and improve that support.
In the recent debate on a Supplementary Estimate for my Department, some Deputies referred to what they called the inadequacy of the salaries of dispensary midwives. These midwives are paid on a salary scale of £120 to £150 a year. They are part-time officers, and I cannot accept the contention that for the amount of work done they are underpaid. Over the country as a whole, the average number of maternity cases dealt with on behalf of their local authorities by each of these dispensary midwives has worked out at just under 17 per annum in recent years, which means that each midwife gets an average, over the whole country, of £7 14s. per case.
Looking at the matter from another angle, the amount of time spent on dispensary midwifery by these officers, averaging 17 cases yearly, must be small; and for this small expenditure of their time, they are paid a salary of £120 to £150. Unlike private midwives, the dispensary midwives have an assured income for those cases whichthey attend on behalf of the local authorities, and moreover, they also have the right to private practice as well.
I cannot tell the House what fee the private midwife in general gets; but I do know what happened in 1951-52 in three specimen counties for which I recently got figures. In one of these the average number of cases dealt with by 46 private midwives was 17, at an average fee of three guineas; in the second one, 17 midwives had an average of seven apiece at £3 to £3 15s. per case, and in the third, 12 midwives attended an average of 21 cases each at a fee ranging from three to five guineas. These private midwives certainly did not do as well as their colleagues in the local authority service, who drew their secure and higher income for attending an average of 17 local authority cases each in the same year, and who, in addition, were able to take on private cases. On these facts, I think no reasonable individual can argue that for the work she does, the dispensary midwife, on average, is not paid enough.
County homes come under the heading of public assistance. Deputies will remember the White Paper on the reconstruction and improvement of these homes issued in October, 1951. The proposals in the White Paper included the development of these institutions or other premises as hospitals for chronic sick, and as homes, in fact as well as in name, for old people; and the provision of special and separate institutions for the care of other classes which are at present accommodated in the county homes. The cost of carrying out the works necessary to implement the reforms will be met by loans raised by public assistance authorities. Repayment of the loans will be spread over a period of 40 years and the State will contribute one-half of the annual loan charges, up to a maximum of the loan charges on a sum equivalent to £500 per bed in each reorganised institution.
The total capital cost of the work is estimated at £5,000,000. The authorities concerned have been invited to submit their comprehensive schemes to give effect to the White Paper proposalsand a number have already done so. Once the schemes have been approved in principle there should be little delay in getting ahead with the necessary works. The Estimate now before the House contains the modest sum of £1,000 as the estimated sum which will be necessary in 1953-54 to meet the State subsidy on the loan charges, but it is adequate for the making of a very substantial start during the year.
I now come to the Mental Treatment Act, 1945. That Act was comprehensive and introduced many new features. The passage of time has revealed certain respects in which it could be improved and I hope to introduce legislation within the next year to bring about those improvements. In the past year, improvements in the mental treatment service followed the same pattern as in the preceding years. Premises and facilities for treatment are being improved as far as available funds permit and the extern psychiatric clinic service was expanded somewhat.
I would like to emphasise again what has been said so often before—that we have great need for a more enlightened public opinion on the subject of mental illness and that there is no more disgrace attaching to it than there is to physical illness. If people would avail to a greater extent of the clinics in the early stages of mental illness, much suffering to patients and to relatives would be avoided.
The activities of my Department in the past year under the Health Act. 1947, have been considerable. To describe them in detail would take up an undue amount of the time of the House and consequently I will confine myself to some of the more important.
Probably the greatest and most expensive single problem covered was tuberculosis—local authorities are now spending on the service very little less than £3,000,000, half of which, of course, is recouped from the Vote— and I propose to deal with it briefly under three main heads—prevention, diagnosis and treatment.
Under the heading of prevention, I presume that I may confine myself tothe narrower aspects and that I need not refer to such matters as better housing and living conditions generally. Apart from propaganda advocating care of general health and avoidance of the more normal risks of contracting tuberculosis, the main activity has been an expansion of B.C.G. vaccination. The national B.C.G. Committee set up in 1949 as an interim measure to get a service going in counties which were not ready at that time to provide a service of their own, had carried through about 108,000 vaccinations up to 31st December last, spread over a large part of the country.
The areas which operate their own service as part of the normal public health service—the Cities of Dublin and Waterford and the Counties of Kilkenny and North Tipperary—carried through a further 25,000 vaccinations up to that date. Figures for the current year should be even better, as the schemes are now operating more efficiently and the public, having become aware of the benefits of the procedure, are coming forward in greater numbers. The immunity conferred by these vaccinations should in the future have a considerable effect on the cost of the tuberculosis service.
The quality of the diagnostic service has been constantly improved by better organisation of the public health field service, improved local facilities for full-plate X-rays and, particularly, by the availability of the mass miniature X-ray service provided by the National Mass-Radiography Association. This last-mentioned service, although it is only now getting fully into its stride, has already done a vast amount of very useful work, and has X-rayed about 150,000 persons.
In regard to treatment, the cry is for more and still more beds. I have not attempted to evaluate the various factors which contribute to that demand—greater willingness to avail of treatment provided, improved case-finding and improved therapy in sanatoria which saves the lives of patients but incidentally increases the average length of stay in the institutions. I am reasonably satisfied, however, that there is no increase in the incidence of the disease. The number of bedsoccupied by pulmonary tuberculosis patients under the tuberculosis scheme in tuberculosis institutions and tuberculosis sections of general hospitals was 5,695 on 31st January last. This represents a very great increase in the number of occupied beds over the number a few years ago.
While the provision of beds for cases of pulmonary tuberculosis has got the lion's share of the publicity on the pressing problem of increased bed accommodation, there has been no neglect of the need to provide beds for cases of non-pulmonary tuberculosis. Co-operation between health authorities and the orthopaedic surgeons I have referred to has resulted in the making available of beds for such cases in self-contained sections of county and district hospitals as a temporary measure pending the provision of more suitable accommodation in special regional institutions.
The first of these institutions to become available is the former Woodlands Sanatorium at Galway, which, with the transfer of its pulmonary cases to the new Merlin Park Sanatorium, has become the long-stay centre for orthopaedic tuberculosis patients for Connaught. Into it have been transferred patients who were on waiting lists at home or were occupying beds needed for more urgent cases in acute hospitals. Other new institutions are in course of construction at Gurranebraher, Cork, and at an advanced stage of planning at Kilcreene, Kilkenny.
In regard to the institutions I have been talking about for the treatment of tuberculosis patients, I feel that it cannot be too often repeated that the level of treatment is as good as is given anywhere. Medical, surgical and nursing services are of a very high standard and conditions generally, which are of so much importance to long-stay patients, have improved considerably in recent years.
Before I leave the subject of sanatoria I feel I may be expected to say something of the new drug which some time ago appeared to give promise of providing a solution to the tuberculosis problem. The drug in its various formsis under test in a number of our sanatoria—local authority and voluntary —and until the tests are completed I think Deputies will agree that it would be inappropriate that I should express a final opinion. I regret, however, that I must say that the earlier very bright hopes will not be realised.
I mentioned earlier that the incidence of certain other infectious diseases had declined. I do not propose to deal with them in detail but I think it well to remind the House that for the scheduled diseases, which, of course, include tuberculosis, a free diagnostic and treatment service is provided, so that no person need defer treatment on grounds of its cost. It is hardly necessary to remind Deputies of the provision for payment of maintenance allowances, in addition, to persons suffering from certain of these diseases. The amount of these allowances has recently been increased appreciably. It has to be remembered that the allowances are intended to do no more than provide a reasonable minimum family income when a breadwinner becomes unable because of the disease to continue to provide for the family, and so to encourage him to accept treatment at the earliest possible stage while he still had excellent prospects of recovery. The bill for these allowances in the current year is estimated at £580,000 which, the House will agree, is quite a considerable sum.
Before I leave this question of infectious diseases, I want to emphasise that no patient can be regarded as cured until he is back at his old job or trained for some other job most suited to his post-treatment condition. Two voluntary committees, in Dublin and at Toghermore, County Galway, are doing excellent work in training ex-tuberculosis patients but they would be the first to admit that, excellent though their work is, only the fringe of the problem has been touched. I am at present considering the whole problem of rehabilitation; and I have included in the Health Bill some provisions which should help in dealing with it.
The registration provisions of the Food Hygiene Regulations made underthe Health Act, 1947, were brought into operation on 1st October, 1951, for hotels, holiday camps, restaurants, fish-mongers and poulterers and on 1st April, 1952, for butchers and pork butchers, and premises where ice-cream is made or where a manufacturing or wholesale food business is carried on. While premises will not be registered unless they comply with the regulations, I think that traders have found the health authorities reasonable in their requirements for the improvement of premises. The number of premises requiring extensive alterations is relatively small and large-scale improvements or the purchase of elaborate equipment will not be insisted on unless they are absolutely essential.
A standard for ice-cream was brought into operation on 1st August last, after consultations with the trade interests concerned. Ice-cream must now contain at least 5 per cent. by weight of milk fat, 9 per cent. by weight of milk solids other than milk fat and 10 per cent. by weight of sugar.
In view of the impending improvement, in accordance with the Health Bill proposals of the maternity and child welfare services, I do not propose to deal here in detail with the various steps taken or to be taken to improve these services. The only reference I propose to make in that regard is to the paediatric service now provided by the three Dublin maternity hospitals in regard to children, during the first six weeks of life, born in these hospitals or on the hospital districts. The funds for the service are provided partly by Dublin Corporation and partly from the Vote now before the House. The service is working reasonably well considering the initial difficulties and, provided these difficulties are resolved, will prove a considerable asset to the public in Dublin. As I have said, it is limited to children born in the hospitals or on their districts and this is an undesirable limiting factor which will have to be overcome.
I dealt in some detail with the Health Services (Financial Provisions) Act, 1947, on the Second Stage of the Health Bill and consequently I do not propose to go into the matter in any detail now. There are, however, a fewfigures to which I would like to draw the attention of the House. Expenditure by local authorities on health services to which the Act applies rose from £5,650,000 in 1947-48 to over £10,630,000 in 1952-53. The Exchequer bore only 16 per cent. of the expenditure in 1947-48 but in 1952-53 it bore 50 per cent. Stated another way, local authority expenditure rose in the period by £573,000 or about 12 per cent. Exchequer contribution increased in the same period by £4,405,000 or about 480 per cent. These figures speak for themselves and provide, I think, the complete answer to any criticisms that the Exchequer has not been generous in its support of the health services.
In a recent debate on a Supplementary Estimate for the Health Vote it was stated by Deputy Sweetman that the Kildare County Council had experienced difficulty due to delay in the final determination of its position in relation to the grant. I have since looked into the matter. Kildare is one of the small number of authorities for which standard expenditure has not yet been finally certified, owing to a delay in the completion of a final audit of accounts but the grants paid to Kildare have been based on figures supplied by the county council and verified as far as possible by my Department. The margin of possible variation from these figures is, I am satisfied, extremely small, and the estimated balance of grant at present due to the county council in respect of the four financial years 1948-49 to 1951-52 is only £658. The advances of grant paid for the year 1952-53 amount to £103,300 or 95 per cent. of the total estimated grant, in line with the payments made to every other health authority and were made on the due dates. I cannot accept therefore that the county council has suffered materially as the Deputy suggested.
The industrial and economic loss resulting from ill-health each year is of course immense and the amount of suffering caused to mind and body is incalculable in terms of money. The Government are satisfied that expenditure on health services is fully justified both on economic and humanitariangrounds and are determined to continue to expand and improve the health services in this country until we have reached a position where medical services of as high a standard as any obtainable in any other country will be readily available to all our people who need them.
