I move:—
That a sum not exceeding £6,994,160 be granted to complete the sum necessary to defray the Charge which will come in course of payment during the year ending on 31st day of March, 1956, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Ard Chláraitheora), and certain Services administered by that Office including Grants to Local Authorities, Miscellaneous Grants and Grants-in-Aid.
The Estimate now before the House is, in round figures, £1,100,000 less than what was voted for health for 1954-55. For fear that some Deputies, misunderstanding the position, might be tempted to make incorrect assumptions because of this saving to the taxpayer, let me say at the outset that if we have been able to cut the Estimate by over £1,000,000, this does not imply any lowering of standards in the health services in the coming year. As the House and the country is aware, the improvement and expansion of health services is one of the stated objects of Government policy. Provision is, in fact, included for an increase of £160,000 in grants to the health authorities towards the cost of the services which they will provide. The reduction for the coming year will be found in the Grants-in-Aid of the Hospitals' Trust Fund. Again, this does not mean that I have cut down on the hospital building programme in the slightest.
The amount needed by way of Exchequer subvention to that fund had been overestimated since 1953-54 when the Exchequer first came to the relief of the fund. In that year the overestimate on a provision of £4,500,000 was £1,600,000. In the year just passed, the Estimate provision was £3,500,000 and the amount required was £2,000,000 representing a saving of £1,500,000 approximately. The reasons why there was this consistent overestimation are threefold. One reason is that there has been, fortunately, a continuing improvement in income from the sweepstakes. The second reason is that there has been some delay in the completion of and payment for the building works in progress. Finally, some of the large new hospital building projects, despite the most strenuous efforts, have started later than was anticipated. These three factors have all operated to reduce the demand on the Exchequer for hospital building but the building programme has remained unaltered and it will go ahead without the deletion of any item and without any avoidable delay. For 1955-56, I have aimed at a more realistic Estimate of what the taxpayer must provide to augment the Hospitals Trust Fund—and this is why the Estimates volume shows a reduction of £1,250,000 on the appropriate sub-head; but even at the reduced figure, the provision is £250,000 higher than the amount which was actually required in 1954-55.
As is customary on these occasions, I propose to give to the House some of the main vital statistics for recent years. The figures which I will quote for 1954 are provisional, but those for earlier years are final.
The birth rate for 1954 was 21.1 per 1,000 of the population compared with 21.2 per 1,000 for 1953. The marriage rate was 5.4 per 1,000 of the population the same as for 1953. There was a slight increase in the death rate for 1954. It advanced to 12.1 per 1,000 of the population, from 11.8 for 1953, but the 1953 figure was the lowest death rate ever recorded for this country.
Infant mortality fell from 39 per 1,000 births in 1953 to 38 in 1954. The maternal mortality rate was 1.05 per 1,000 births, both these rates being the lowest ever recorded in this country.
The death rate for T.B. has again fallen. The figure for 1954 was 35 per 100,000 population. This compares with 40 for 1953 and is less than half the rate recorded as recently as 1951, when the figure was 73 per 100,000 of population.
The cancer death rate dropped slightly in 1954—to 145.6 per 100,000, compared with 147.1 in 1953. This reduction is not, of course, sufficient to lessen our concern about the cancer problem. While the full solution of this problem must await the result of research being carried on in countries better equipped than ours to organise it, I may say that we are fortunate in acquiring in recent years one of the best equipped cancer hospitals in Europe—St. Luke's Hospital, Rathgar, which is run by the Cancer Association of Ireland.
With the exception of diphtheria, deaths from which increased from three in 1953 to five in 1954, and gastroenteritis, which caused 172 deaths in 1954, practically the same number as in 1953, the figures for other infectious diseases showed an improvement on those recorded for 1953. There were 32 deaths from whooping cough compared with 61 for 1953; one from typhoid, compared with four in 1953; 15 from poliomyelitis as against 33 in 1953; and 179 from influenza, compared with 432 in 1953. Deaths from measles dropped from 36 to 30, and there were two deaths from scarlet fever—one fewer than in the previous year.
I think that the House will agree that the general picture shows some improvement in that we are securing a reduction in the avoidable causes of death. This has been accompanied with a decline in the incidence of infectious diseases and, while some of the credit for this must go to the advance in medical science and to improvements in living conditions, a good deal is due to improved health services and to increased willingness on the part of the public to avail of them.
The local authorities have maintained their health services at a reasonably high level during the past year, and in that period a number of improvements have been brought about in various important aspects of those services. Considerable progress has, for example, been made in hospital building, and we have seen, or we shall very shortly see, the opening of some of the major hospitals which have been in steady progress for a considerable time past. I will give some details of these projects later. As regards the general medical services, one development particularly useful to the public is the functioning of an appreciable number of the county clinics. These are now in being in Roscommon, North Cork, Offaly, Mayo, Tipperary (North Riding), Kerry, Meath, Donegal, Cavan and Longford. Building work on five other county clinics is almost completed and the construction of four other of these important buildings will start soon. Planning on about half-dozen more is still proceeding.
The intention, as the House is aware, is that a wide range of specialist services will be provided in these clinics. Already a good start has been made and, in general, specialist medical, surgical, ophthalmic, T.B., orthopaedic, obstetric and psychiatric clinical sessions are held in them at regular intervals and arrangements are in train for making available at the clinics other specialist services.
A further important step in the development of adequate specialist services at provincial level was the conversion to permanent status of temporary posts of regional orthopaedic surgeon and regional radiologist. Experience has shown that some revision of the regions, as previously constituted experimentally, was necessary and such revision has been made. In addition, the appointments made are sufficiently flexible to further adjust the regions if that should be necessary at a later date. Local pathological services are also in course of development. A full-time pathologist has been recently appointed at St. Kevin's Hospital and an appointment of a pathologist to take charge of the pathological department in St. Finbarr's Hospital in Cork will shortly be made. It is intended that when these pathologists will have reorganised and brought to a high level of efficiency the services in the hospitals to which they have been appointed, they will set about developing pathological services for local authorities in the surrounding regions in the same way as such services are being developed in the western region based on the Galway Central Hospital laboratory specialist staffs. It is hoped to make a start soon in other areas. One of the obstacles in our way is the scarcity of trained laboratory technicians. During the year four students who completed their training in the laboratory at Galway Central Hospital have taken up duty as laboratory technicians—two in Galway, one in Sligo County Hospital, and the fourth in St. Patrick's Chest Hospital, Castlerea.
I regard this development of specialist services at local levels as of the greatest importance in the provision of adequate health services. There are, of course, certain specialities which can, and should, be developed only at the main centres of medical training; but there is a range of services which it would be economic and sound medical practice to develop in every county on a regional basis so as to provide for ready access to them on the part of every citizen, and it will be my endeavour, consistent with the maintenance of the highest scientific level of services, to make arrangements accordingly.
The arrangements for administering anaesthetics in connection with local authority health services have been examined carefully over a period and local authorities have now been urged to have fully qualified and experienced anaesthetists available wherever a fully satisfactory anaesthetic service is not already in existence. I have suggested to those authorities that where the existing arrangements are not up to the desired standard, posts of anaesthetist should be created on conditions and terms which I have outlined to them. It is not generally appreciated how much the science of anaesthetics has developed in recent years and how much this development has contributed to the treatment of conditions hitherto regarded as untreatable. It is no longer good practice to rely on the services of the young house surgeon in training. By the appointment of specialist anaesthetists as proposed, the quality of the services provided in the county hospitals, already good, should be further improved.
I have also agreed to revised and improved conditions of appointment for county surgeons. All existing incumbents were allowed the right to opt for the new conditions and a number of them have already done so. The surgeons may, in future, engage in private practice outside the county hospitals, as consultants, provided that such consultant practice will not interfere with the efficient performance of their duties as county surgeon. I am also considering proposals which, if adopted, should achieve uniform conditions of service for county physicians.
In the Dublin area, the improvement of the services at St. Kevin's Hospital continues. A permanent whole-time pathologist, as I have already mentioned, took up duty in that hospital recently. A maternity unit containing approximately 80 beds and 80 cots was opened in St. Kevin's last summer. This unit is in charge of a highly qualified obstetrician-gynaecologist, assisted by a consultant paediatrician and other necessary medical staff. The former fever hospital premises in Cork Street have been renovated and are now being used to house chronic ambulent male patients from St. Kevin's. The development of a permanent home for ambulent aged or otherwise incapacitated patients at Ballymun is still under discussion with the authorities of St. Kevin's and substantial agreement should soon be reached.
All this is in conformity with the plan to transform St. Kevin's into a first-class general hospital. Much still remains to be done by way of demolition of unsuitable and redundant buildings but the end of the job is already in sight. A whole section of the hospital is now completely renovated and the next year should show a dramatic change in appearance. What is more important, however, is that the level of service to the sick poor of Dublin afforded in this hospital has kept pace with the structural changes; and with the further improvements contemplated, the Dublin Board of Assistance should have every reason to congratulate itself. The emphasis which has been given to this hospital has been the subject of criticism in the past. There is a good reason for this emphasis in that while the Dublin voluntary hospitals can be selective as to the type of patient they will accept and retain—and I am not saying this by way of criticism of the excellent services which these hospitals provide —St. Kevin's must accept, treat and retain every poor patient referred to it and thus fills a most important role in our health services in Dublin and district.
I would like at this point to mention that the excellent maternity unit consisting of 28 beds in St. Colmcille's Hospital, Loughlinstown, was not fully used during the past year. This is a first-class unit, competently staffed and fully equipped to deal with any emergency. I am surprised, in view of the pressure of beds in the Dublin maternity hospitals, that the facilities which it offers are not being used to the extent to which they should be and I would urge doctors in practice in the area to visit the hospital and see for themselves the facilities available to them for their patients. If they do so, I have no doubt that the unit will be fully used in future.
I have mentioned the satisfactory progress which is being maintained in the reduction of the death rate from T.B. An extra 110 beds were provided for T.B. patients during the past 12 months, bringing the total number in the country to approximately 6,900. We shall soon have an appreciable number of first-class beds added to these. The Dublin Regional Sanatorium at Blanchardstown will take its first patients in the near future, and the Southern Regional Sanatorium, near Cork, will follow suit shortly afterwards. Since the Department of Health was established one of the main concerns in the field of T.B. was to see that adequate bed accommodation was provided and we are now in the happy position that there is virtually no waiting list in any county, with the result that a person unfortunate enough to contract T.B. can get into hospital without delay if he or she needs hospital treatment. With the opening of the regional sanatoria it will be possible to discard certain hospital accommodation not up to first-class standard and to allow the reversion for other necessary purposes of certain other accommodation. The Department and the health authorities can now, therefore, turn their attention in greater degree to the improvement in the field services for dealing with this disease. A great deal has already been done in these directions; but I hope that we shall be able to intensify our efforts in the near future.
It is good to be able to record that we have reached this position in dealing with the scourge of T.B.; but it is my duty to stress that we have no grounds at all for complacency. Our death rate here is still much too high—it is half as high again as in Northern Ireland and in Scotland and the number of new cases coming to the notice of health authorities in recent years shows little or no reduction. We cannot afford to relax our vigilance, nor to eschew the excellent facilities which are widely available throughout the country for the prevention and diagnosis, as well as the treatment of T.B. I would appeal, therefore, to the public in general to utilise these facilities which are available to everybody without cost. I would ask, especially, those who have charge of children, adolescents and young men and women to see to it that these very important members of our community look after their general health and make the fullest use of the chest X-ray service and the B.C.G. vaccination service. These are the two most important weapons in our defence against this disease. There is no excuse for those who do not make use of these weapons.
Not so many years ago a chest X-ray involved a journey to the county town and the cost of the X-ray plate was relatively considerable. Now, thanks to a highly developed mass-radiography service, the X-ray apparatus is brought into factories and schools, into halls and market squares in the smaller towns and even to the country cross roads, and all that is involved in availing of the service is to walk into a room or a coach, and stand, without undressing or other discomfort, for a moment in front of the apparatus and the operation is over. The miniature film costs little to take or to processand, incidentally, nothing to the person X-rayed—but it shows up the presence of T.B. in the lungs even at the early stages when the disorder is most easily cured. The B.C.G. procedure is almost as readily available and involves no more discomfort than would be involved in a few mild pin scratches and for this the person vaccinated gets a high degree of immunity against T.B. infection.
Every new case of T.B. is the result of infection by a person already suffering from the disease, and I feel that the stage has now been reached when it should be the duty of the medical staffs of health authorities to make as determined an effort, whenever a new case comes to light, to trace the infector as they do to trace the source of a case, for example, of typhoid. We now have the knowledge and the weapons to enable us to combat this disease, which in the past has taken such dreadful toll of the lives and the happiness of our people, and I hope, in the current year, to present to health authorities a proved method of dealing with the problem on a systematic basis; but in the last analysis the success of any public health operation depends on the degree of co-operation forthcoming from the community. I would, therefore, appeal to every Deputy in the House to do his utmost to develop an informed public opinion so that we may achieve maximum benefit from our efforts. Such an informed public opinion should encourage the use by young and old of the mass-radiography service and the use of B.C.G. vaccination for children and young adults.
During the year a good deal was done to improve facilities for those suffering from mental ill-health. The present building programme, which will run for the next four years, includes the provision of eight new admission units, 12 nurses' homes, and a staff home at district hospitals. At Portrane Mental Hospital 248 beds are being provided in two new units, the first of which will be available very soon, and work has started on supplying separate accommodation for 20 child patients. Work is going ahead at Grangegorman on the provision of accommodation for 80 patients. The programme also includes the provision of infirmaries at Ardee and Cork Mental Hospitals and a number of extensive schemes of reconstruction. Sanitary, mechanical and heating services are also included in the programme.
The number of out-patients' clinics established under the Mental Treatment Act, 1945, continues to increase. Seventy-seven such clinics were in operation during the past year. At these clinics some 900 sessions were held and the attendances of patients numbered approximately 4,750.
The improvements scheduled in the building programme over the next few years should bring about substantial betterment in the overcrowded conditions in a number of mental hospitals, which have been a matter of serious concern to me. I should explain in this connection that the coming into force of the Mental Treatment Act, 1945, with its facilities for the reception of voluntary and temporary patients and for the development of active psychiatric treatment, has given a great impetus to the treatment of mental disease in the early stages, when the prospects of recovery are most favourable. These welcome developments have added substantially to the accommodation problem in our mental hospitals. The rate of receptions of patients since the Act came into force has increased enormously.
To give an example, 5,500 patients, in round figures, were received during the year 1953 as against a total of 3,000 in the year 1947—an increase of over 80 per cent. Another factor which has added to accommodation difficulties is the great increase in the number of old people in the mental hospitals. The proportion of people over 65 years in the mental hospitals in 1953 was more than double the proportion amongst the population as a whole. The increase in the number of old people in mental hospitals may be attributed to a substantial extent to the tendency on the part of young people to shirk their responsibilities towards aged relatives. Discharges of patients have increased to a satisfactory degree—but admissions have gained over the number of patients leaving, and the net effect has been to increase, only temporarily, I hope, the populations in the hospitals.
The facilities and accommodation available in district mental hospitals have been the subject of unfavourable comment recently. As I have indicated, I myself have been fully conscious of this for some time past and I have established a small expert committee (not a commission as has been erroneously stated) consisting of representatives of the county managers, county medical officers of health, resident medical superintendents of mental hospitals and my Department, to consider the problem of overcrowding and to make recommendations to me as to the practical steps which can be taken to relieve such overcrowding, having due regard, of course, to our financial resources.
There has been a considerable amount of criticism of the increase in the amount which the Dublin Corporation now contributes to the Dublin voluntary hospitals towards the cost of providing hospital treatment for poor persons resident in Dublin, and some of the critics have suggested that I am responsible for this increase.
The position is that until the Health Act, 1953, came into force, Dublin Corporation, as such, did not have any responsibility for the provision of such treatment for those in the lower income group except in regard to T.B. and fevers. The responsibility rested on the Dublin Board of Assistance. This board did, of course, provide free treatment for the poor in its own hospital—St. Kevin's—but did not pay anything towards the cost of treating poor persons in Dublin who went to the voluntary hospitals unless they had been admitted at the board's request. The voluntary hospitals, in catering for Dublin's sick poor, were really supplying a service for Dublin which in other counties was provided by the appropriate local authority. This position continued until 1946, when the corporation were persuaded to make a regular contribution to the Dublin voluntary hospitals towards the cost of treating the poor resident in Dublin. The corporation's contribution was the produce of 1/- in the £ on the rates, and in current times this would give the voluntary hospital a little less than half what would be yielded by the approved capitation rate which local authorities in general were paying to extern institutions for the treatment of patients for whom they were responsible.
When the Health Act, 1953, came into force the Dublin Corporation, as a health authority, became directly responsible for providing institutional and specialist services under Section 15 of that Act. From the 1st August, 1954, the corporation has paid the voluntary hospitals at the approved rate of 16/- per bed day for patients treated by those hospitals free of charge or paying a nominal amount. I want to emphasise that this change is a direct result of the Health Act, 1953, and would not have taken place if that Act or similar legislation had not been enacted.
In addition, the Dublin Corporation and all other local authorities are now being called upon to provide for the hospital care and treatment of insured persons—a charge that was previously borne entirely by the Exchequer. This has meant that in respect of the hospitalisation of such persons in the voluntary hospitals each local authority must now pay a sum of £5 12s. per person per week—the exact payment which prior to 1st April last was borne by the Exchequer in complete indemnity of the Dublin Corporation and all other local authorities. Again, this charge takes place because of the provisions of the Health Act, 1953, and would not have taken place if that Act or similar legislation had not been enacted.
There are certain other aspects of the operation of the Health Acts which call for comment here. In lieu of the red ticket and the white ticket under the public Assistance Act, 1939, issued by a home assistance officer or warden entitling a poor person to the services of the district medical officer, there is now, since 1st August last, provision for the issue of a medical card, evidencing the right of the holder and his dependents to medical services from the dispensary doctor on all occasions during the currency of the card. In notifying health authorities of the revised arrangements, I suggested that application forms should be made freely available in places where people entitled to have such cards issued to them would be likely to have access to them and that other arrangements should be made to publicise the new system.
The response from the eligible classes has been extremely slow. In the whole of the former public assistance district of Balrothery only 34 persons had, on a recent date, had cards issued in respect of them. In certain dispensary districts only a handful of persons have got cards. I do not know what the explanation is. I am assured that in most areas practically all applications were dealt with promptly and that nobody who would formerly have got a "ticket" is refused a "card". Despite the advantages which have been urged in favour of the new system less than 10 per cent. of the population is covered by cards already issued although it has been accepted for years that a third of the population is entitled to free medical assistance. It is only recently that this position came to my notice and I am seeking from each health authority fuller information.
From 1st October last, the scheme of allowances for disabled persons has been in operation. The determination of the eligibility of applicants has been unduly slow. I can appreciate that in certain cases the chief medical officer, who is the certifying officer as to medical disability, would be reluctant to take a decision which might have the effect of awarding a pension for life without adequate medical evidence and the arrangement for obtaining such evidence varied from place to place, depending on local circumstances. I suggested to health authorities some time back that if there was likely to be delay in medical assessment, the means investigation should be proceeded with in advance. In certain areas there has been delay in dealing with applications but I am satisfied that the delay arose out of difficulties inherent in any new scheme and that in a short time the scheme will be operating smoothly.
Neither the Minister for Social Welfare nor I was satisfied, however, with the attitude of certain local authorities who regarded the new scheme of allowances as a means of saving money on the home assistance account and we informed health authorities, which, in general, are also home assistance authorities, accordingly. The Minister for Social Welfare has, in addition, made an Order which makes it clear that the first 10/-, at least, of a maintenance allowance will be ignored in considering the grant of home assistance. I hope that, as a result, we will not have, in the future, a repetition of the parsimonious attitude which we have seen in some cases up to the present. It was not the intention of this House, or the Oireachtas in general, that payment of these allowances should result in automatic disqualification for home assistance and I am sure that Deputies who are members of local authorities will use every opportunity to ensure that effect is given to the object of the scheme.
There has been a tendency in certain areas to lay down a rigid means scale in regard to eligibility for services for the lower income group and to say that anybody outside that standard by as much as 1/- a week would be ineligible. I have no objection to a scale for determining that a person is eligible, but I am not prepared to agree that any applicant should be turned down on the basis of such a scale, and I have informed the responsible officers of local authorities that before any application is refused all the surrounding circumstances of the family must be taken into account. I hope that as a result there will be less grounds for complaint in the future.
As from 1st August last, there was provision for a free choice of doctor for maternity care for women in the lower income group. It was hoped to secure that every such woman could go to the doctor of her choice and get from him, under the scheme, complete ante-natal and post-natal care and attendance at her confinement if necessary. In an effort to overcome differences which had arisen concerning this scheme, I met the representatives of the medical profession prior to the 1st August last and reached agreement as to the nature of the services to be provided and as to the fees to be paid to participating doctors. The schemes is working satisfactorily enough in most areas although in places some doctors—even dispensary doctors—are not coming forward. I fear that this reluctance to participate on the part of these doctors is to some extent occasioned by the attitude of certain members of some health authorities whose publicly expressed hostility towards their medical staffs has done little to inspire confidence in the minds of the doctors on whose co-operation the success of the scheme depends.
This scheme is not compulsory on anyone—either on the doctor who is expected to work it or the patient who is expected to benefit by it. It is a voluntary scheme and as such depends for its success on support, goodwill and co-operation from all. I only hope, therefore, that there will be an end to the wrangling and disputing which has taken place about this matter and that this worthwhile service will operate henceforth in an atmosphere of goodwill. To my mind, nothing is less calculated to secure the co-operation of local authority medical staff than the placing of pistols to their heads. I have no doubt that, given a reasonable attitude on the part of local authorities, the maternity scheme will in a short time be operating satisfactorily. The attitude of mistrust on the part of the medical profession which in recent years has been a characteristic of relations with local authorities is changing, and I deprecate strongly action on the part of any section of the community which would tend to revive the old bad feelings of hostility and suspicion.
The present year will be an important milestone in the progress towards the achievement of an adequate standard of hospitalisation facilities in the country. It will witness the coming into functional operation of some of the more important projects provided for under the hospital building programme, namely, the regional sanatoria of 516 and 404 beds in Dublin and Cork respectively, to which I have already referred, the general regional hospitals at Limerick and Galway and the Children's Hospital, Crumlin. By the end of the year we will have reached the stage that about two-thirds of the hospital building programme undertaken from 1949 on onwards will have been completed and works involving some further 400 beds will be in progress. In addition, some of the remaining important building projects on the programme, namely, the new St. Vincent's and St. Laurence's Hospitals and Cork Regional Hospital, have reached an advanced stage of planning and I am hopeful that building operations will be under way before long.
The Dublin and Cork Regional Sanatoria and the Limerick Regional Hospital of 278 beds have recently been opened and I expect that the Galway Regional Hospital will be functioning before the end of the present year. It is also expected that the 304-bed Children's Hospital at Crumlin will be ready in the current year. An 80-bed genito-urinary unit at the Meath Hospital, Dublin, should be available shortly. In the field of orthopaedics I expect that the new 133-bed hospital at Gurranebraher, Cork, will be opened shortly. A nurses' home catering for 239 nurses serving the Mater Hospital, Dublin, was opened during the year.
A new 34-bed district hospital at Cahirciveen is nearing completion. Work is in progress on county hospitals at Letterkenny (90 beds) and Dundalk (100 beds) and on a 30-bed district hospital at Dungloe. It is expected that building operations will commence within the next few months at Bantry (37 extra beds and improvements of the facilities available at the hospital), at Carndonagh (31 beds) and later in the year on a new 70-bed county hospital at Longford.
Since the building programme was undertaken about 300 maternity beds have been provided—representing about 40 per cent. of the programme envisaged. I have mentioned the 80-bed maternity unit provided at St. Kevin's Hospital. An extension providing for 30 beds at the Rotunda Hospital, Dublin, is almost completed. Work has commenced on a 60-bed Regional Maternity Hospital at Limerick and on projects involving about 30 more beds in local authority hospitals at Letterkenny, Dungloe, and Baltinglass. Satisfactory progress is being made with the planning of the new 144 maternity bed Coombe Hospital.
I have already referred to what is being done in regard to mental hospitals. About one-third of the 830 new beds budgeted for in the current programme have been provided. While with the completion of that programme coupled with the schemes of renovations and improvements undertaken by a number of mental hospital authorities much will have been achieved, a considerable amount remains to be done and I am giving special consideration to the problem of mental hospital accommodation in the formulation of the next building programme.
Considerable progress has been made with the programme to provide proper institutional facilities for mental defectives. During the present year a 280-bed extension at St. Mary's, Drumcar; a 180-bed institution at St. Raphael's, Celbridge, and 180-bed extension at Our Lady of Good Counsel, Cork, will become available to receive patients. The conversion of Glenmaroon House, Dublin, into an institution for 200 mentally defective girls is almost completed. In addition, I anticipate that a further 80 beds will shortly be available at Stewart's Hospital, Palmerstown, while portion of a 240-bed extension at St. Joseph's, Clonsilla, should be ready by the autumn. When all these projects have been completed almost 1,400 additional beds will have been made available for mental defectives—which represents an increase of about 100 per cent. on the accommodation available before the programme was undertaken. The provision of two further institutions at Delvin and Sligo is being undertaken and planning is in progress. It is proposed that these institutions will provide 500 additional beds.
I have already mentioned the progress made with the provision of county clinics. In so far as dispensaries are concerned 72 new buildings have been completed in the course of the last three years. It is anticipated that a further 80 new premises will be completed this year which means that satisfactory progress is being made towards the goal of replacing unsatisfactory dispensary premises throughout the country.
I now come to the question of the future of the health services. My first concern will be to improve existing services to the maximum extent practicable. Over the years the quality of the services provided has improved enormously. The general practitioner services provided by our health authorities have been, in general, excellent. The general practitioner service is the backbone of any health service, State, local authority, or private, but the general practitioner in our local authority service must be given the necessary tools. Already there has been considerable improvement in dispensary premises and dispensary equipment and the present programme provides for still greater improvement. The dispensary doctor is now provided to a much greater extent than heretofore, and in more accessible form, with the specialist backing he needs and that backing is being further improved, as I have already mentioned when dealing with local specialist services. I include, of course, under that head, the services provided in the county hospitals. There is also available the specialist backing provided at the teaching centres which I hope will be even more readily available in the future.
I regard as a higher priority the development of the preventive services. Immunisation and vaccination services, as I pointed out to all health authorities when I visited them last September, are of the utmost importance in keeping our population healthy. Luckily we have escaped the outbreaks of smallpox which have occurred practically on our doorstep in recent years, but we must be in a state of preparedness to deal with an outbreak should it occur here and the need for vaccination against smallpox has not abated one iota because it is no longer compulsory. The success of the campaign for diphtheria immunisation by reducing the incidence and the created a misplaced feeling of complacency in the population as a whole. I am advised that the relative immunity from this disease which we now enjoy will continue only so long as we can keep a high proportion of our children immunised and I propose to continue our efforts to induce parents to see that their children are afforded the protection which immunity gives.
My third great objective in the matter of immunisation is to secure that every child and young adult is given the protection of B.C.G. vaccination. If Deputies will glance at the cost of T.B. hospital services in the details of sub-head H in Part III of the Estimate, they will see that this service alone is costing us nearly £2,000,000 this year. To this must be added a further sum of £596,000 for infectious diseases maintenance allowances— mainly in respect of T.B. This bill of over £2,500,000 a year for the treatment of T.B. is staggering and could be reduced considerably in future years by the use of B.C.G. Surely on narrow grounds of public expense alone, to say nothing of the wider implications of broken lives, shattered homes, untold personal and family misery and the loss to the national economy, it behoves us to leave no stone unturned in our development of the preventive service.
My next objective is the protection of the health of children, and for this purpose to ensure that facilities are available to correct defects and to ensure that all reasonable steps are taken to make sure that he or she grows up to healthy manhood or womanhood. In the child welfare clinics which now, by law, must be established in every town of over 3,000 population, the opportunity is provided to have periodic, regular checks-up on health. If proper use is made of the clinics, much illness in childhood and later can be prevented. While there is a statutory obligation to provide child welfare clinics in every town with a population of 3,000, there is no barrier to the establishment of similar clinics in smaller centres of population and I would strongly urge on health authorities that they should not confine themselves to their statutory obligations in this respect. I cannot emphasise too strongly that a good clinic service will pay an immediate dividend to the rate-payers and the taxpayers of this country. I have recently issued a comprehensive circular to health authorities as to the nature of these clinics and I hope that these authorities will give every encouragement to their medical staffs in the development of this service.
In rural districts, the provision of child welfare clinics will not be feasible but there is another means by which the health of children in these areas can be safeguarded. I refer to the suggestion which I made to health authorities when I visited them in the autumn that they should, as opportunity offers in each area, appoint a qualified general trained nurse who would, in addition to providing appropriate care for sick children, act as guide and friend to mothers of young families. Seeing the children regularly in their home environment, she would be in a particularly favoured position to note the signs of incipient disorders and could advise the mothers on the means available to them to have such disorders remedied before they develop. There is a host of other ways in which she could help.
I am not suggesting that the nurse should take the place of the doctor in the medical care of children but there are many points about which a mother might be in doubt which she would not regard as of sufficient importance to justify a visit to the doctor but which she would be willing to put before the nurse. Most of us are familiar with the work of the Jubilee nurse. These nurses have been doing excellent work in the areas in which they operate and the suggestion which I have made to local authorities is that they should put into districts where there is no Jubilee or Lady Dudley nurse the equivalent of such nurse, with this difference that the new nurse would concern herself as much with the maintenance of health as with the care of those who are sick. Already in the districts where the local authorities have appointed district nurses, reports on the value of their work in the preventive field are most encouraging.
In the making of such nursing appointments, I am making a break with tradition. Up to the present the public health nurse has been appointed to the county but the practice has grown up of attaching her to the chief medical officer's office at a central point in the county, from which she goes out daily to do her duties, returning each night to her base. The practice has been to appoint the midwife to a particular district to which she remains attached for the remainder of her service unless she competes for, and is successful at a competition for appointment to another district. I do not regard either of these procedures as satisfactory. The present public health nurse is too far removed from contact with the people and, as regards the midwife, it is, I feel, undesirable that the officer who is becoming less active should have to remain in a large scattered district where long travelling taxes her energies.
Consequently, I propose that the new district nurse should be appointed to the county but assigned initially to the particular district in which the new vacancy has occurred. When vacancies occur in other districts in the county, the existing nurses would have the right to transfer, in order of seniority, if they so wished, so that in the course of time a nurse would automatically find herself in the district most suited to her age and which she regarded as most desirable. This procedure should not result in too frequent changes and it should make for a happier and, consequently, a better service.
I now come to the school child. The school health examination service has now been in operation for many years, but it has not been wholly satisfactory. Visits of the schools medical officers have been made only at long intervals, and while in most counties a child is now seen about three times in the course of school life, many conditions of ill-health can develop in between the visits of the schools medical officer and not be detected or dealt with at a sufficiently early stage. I have now recommended strongly to every health authority that it should overhaul its system so as to ensure that every school is visited at least once a year. At each annual visit, the schools medical officer would see all children who had commenced school that year, a group of children midway through their school course and those expected to leave at the end of the then current school year. In addition, and this is most important, he would see children who missed the school medical examination because of absence the previous year and also all children to whom his attention was drawn by parents or by teachers as well as children whom he had noted for re-examination on the occasion of his previous visit.
The implementation of these arrangements would mean, in many counties, the appointment of an additional assistant county medical officer; but the money involved would be money well spent, saving lives perhaps but certainly obviating later ill-health to the advantage of the child, the family, the community in general, and the ratepayers in particular. Here again I want to emphasise, as I have done to councillors in every area I visited, that every penny spent, within reason, on the care of children's health pays rich dividends. I hope that next year when the Health Estimate comes before the House I shall be able to announce that this important health service is functioning in a satisfactory manner.
I have never made any secret of the fact that I do not regard the Health Act, 1953, as the last word in regard to the health services of this country but I have already announced publicly that, so as to remove, once and for all, the question of health from Party political controversy, I intended to implement that Act. That is still my policy. Accordingly, I made a special review of facilities existing and prospective, in the latter part of last year and I came to the conclusion that by the latter part of the present calendar year the necessary facilities would be available and the necessary arrangements could be made to extend the benefits of Sections 15, 16 and 17 of the Act to all, or virtually all, those covered by these sections which relate to hospital and specialist services, to maternity care and to the care of neonatal infants. I informed local authorities accordingly so that they could make appropriate provision in their estimates and I have made the necessary provision on that basis in sub-head H of the Estimate before the House. I must confess to a certain amount of misgiving in regard to the matter. I know that in some areas there will be a certain amount of difficulty but I hope that with goodwill all round it will be possible to reduce such difficulty to a minimum and to ensure that there will be no lowering of the quality of the services available to the present eligible classes who must have first claim on our sympathies and on our resources.
I have already mentioned the maintenance allowances introduced under Section 50 for disabled persons. That section also provides for a service for the training of disabled persons for suitable employment and for making arrangements with employers for placing them in employment. I am anxious that this service should be brought into operation as soon as possible but the problem is complex and our experience in relation to it has been limited up to the present. A number of voluntary bodies are at present doing admirable work in some of the specific problems which have to be faced in the rehabilitation of disabled persons but I think that before any large-scale scheme is organised under this section of the Act a complete review of what facilities we have at present and of what are required should be made by a new, broadly-based body.
I have accordingly decided recently to set up a semi-State organisation whose first task will be to find out how many disabled persons there are in the various categories, what facilities there are for their rehabilitation at present and what should be done to extend and improve these facilities. I have in mind that this body will be a limited liability company and that, when this first task has been accomplished, the body itself can be used as a continuing advisory organ for local authorities in operating their rehabilitation service. The association may also be able to supplement these services by operating some of their own but, naturally, the details of this side of their work cannot be decided upon until they have first reported on the questions to which I have referred.
I intend that the membership of this body should include representatives of employers, trades unions, the local staff who will be responsible for the health authorities' rehabilitation services, suitably experienced doctors, persons with experience in vocational education, representatives of my Department and others. The association will be given a grant from the Hospitals' Trust Fund which will be sufficient to get them going and I hope to arrange that their expenses thereafter will be met by contributions from health authorities in the same way as are the expenses of the mass radiography association.
The problems which will face those organising a rehabilitation service are many. There will be the medical problems connected with the training of crippled persons to regain the use of their limbs and to maintain a reasonable condition of general health and a proper mental attitude to their physical limitations. Some employers will be reluctant to take on these rehabilitated persons, and trades unions may see objections in some cases to agreeing to their employment. Finally, there will be the economic problem of trying to ensure that the work which disabled persons are trained to do will not merely be a way to keep them occupied but will help, to some extent at least, to support them. These problems must, however, be faced up to as the rehabilitation of disabled persons is likely to become more important as time goes by. New medical techniques are saving the lives of many people who would have died from such crippling diseases as poliomyelitis in years gone by. I look forward with confidence to the co-operation of all concerned in assisting the activities of this new rehabilitation association.
The matter of dental services has been engaging my attention since shortly after I took up office, and I have come to the conclusion that I should do nothing in regard to Section 21 of the Health Act until reasonable dental services are provided, in fact as well as in theory, for the classes at present eligible, viz., children and persons in the lower income group. These services are at present grossly inadequate, a fact which was admitted freely by every health authority I visited. In some areas, the staff employed is insufficient to do little more than attend to emergency extractions. In no area is it sufficient to give anything like an adequate conservative service. Purely radical treatment, of course, has its uses and might even be justified in certain circumstances in the case of elderly people, but nobody could contend that it is sufficient for children.
A dental consultative council established some years ago pronounced on the question of how many children, in our circumstances, could be dealt with by a whole-time dentist and at the beginning of January, I caused a letter to be addressed to each health authority setting out the numbers who are already the responsibility of the authority for dental care and the standard which had been recommended by the dental consultative council and asking them to make provision, if not immediately for the number of dentists required according to those standards, at least for a considerably improved service. That has been followed by a further comprehensive memorandum setting out in some detail how best a service could be provided. Our services are at present so poor that I cannot visualise a fully adequate service in most areas within a reasonable period and consequently I cannot at this stage even hazard a guess as to when we will be able to take on commitments in respect of classes additional to those already eligible for treatment. Meanwhile the existing dental services for insured persons will be continued by the Department of Social Welfare.
So far I have referred to services which are or will be organised by local health authorities for the classes defined in the Health Act of 1953. While the greater part of the population will be eligible for some or other of the services under this Act there will be a substantial group who are outside its scope but who may still be worried at the prospect of serious illness or accidents and the expensive treatment and care which follow in their train. Furthermore, I am sure there are many people, technically within the classes covered by the Health Act, who would prefer to make their own arrangements for medical or surgical treatment.
To meet the needs of these groups in particular, the idea of a national scheme of voluntary health insurance has been mooted many times in recent years. A detailed examination of the problems involved in establishing such a scheme was never undertaken, however, until recently, when I set up a body to advise me on the question. The main task of this body will be to advise me on the feasibility of a scheme of voluntary insurance which would enable citizens to insure themselves and their dependents against the cost of hospital, surgical, specialist and maternity services, medicines and dental services and the provision of medical and surgical appliances. If the committee consider such a scheme feasible, they will advise me on the type of organisation best suited for it, the contributions which would be needed, the manner of their collection, and the effect which it would have on the finances of voluntary hospitals. The advisory body have already held a number of meetings. They have not yet reported to me but if, following their findings, it appears possible to establish a national scheme of voluntary health insurance, I will do all I can to have it established. I make this promise because I think that a scheme of voluntary health insurance is the best way of easing the cares of those who, after all, contribute in great part to the cost of the services of health authorities to which they themselves are not entitled.
The recent introduction of an income-tax concession in respect of premiums paid for health insurance indicated that the Government is serious in its desire to encourage this form of insurance. I join with my colleague, the Minister for Finance, who in his Budget statement expressed the wish that the numbers claiming this tax concession would increase from year to year.
If it is found possible to introduce an adequate voluntary insurance scheme and if the services under the Health Act are developed on the lines which I have mentioned above, I think that the health services in this country will be of a scope and standard comparable to that of most others. May I express the wish that, with the development of the services on these lines, the misunderstandings, disagreements and rancour which have characterised the discussion of health problems in this country will be forgotten and that in future the organisation of health services will be regarded purely as a technical problem and not in any way as a political one?
