Dáil Éireann debate -
Tuesday, 25 Jun 1957

Vol. 162 No. 9

Committee on Finance. - Vote 63—Health.

Minister for Health (Mr. MacEntee)

I move:—

That a sum not exceeding £6,064,600 be granted to complete the sum necessary to defray the Charge which will come in course of payment during the year ending on the 31st day of March, 1958, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Árd-Chláraitheora), and certain Services administered by that Office, including Grants to Local Authorities and miscellaneous Grants.

Perhaps I should remind the House that the amount asked for under this motion is based on the Estimate for the Health Services which was prepared by my predecessor. I am presenting it as drafted; the amount in respect of my Department which was included in the Vote on Account which the Dáil has granted was based upon it; it is the general administration of the Department in the last year of the Coalition which will be discussed upon it; and in these circumstances I have not thought it essential to amend the Estimate in any way.

The Health Estimate is one of the largest with which Dáil Éireann is faced this year. The £6,064,000-odd which is now being asked is in addition to the £2,050,000 which has already been granted under the Vote on Account of last March. Thus, within the current financial year the net draw on the Exchequer under the Estimate is expected to be £8,114,000-odd. The gross figure, before deduction of Appropriations-in-Aid, is, in fact, £8,448,360, to which it is proper to add the sum of £39,350 which is provided in the Estimates for other Government Departments to cover expenditure which is likely to be incurred by them for the Department of Health.

The Appropriations-in-Aid for which credit was taken when preparing the Estimate are expected to provide £333,760. The largest of them, amounting to £318,200, is from the Local Taxation Account, and represents, in fact, a direct contribution from the taxpayer, per specified item of tax revenue, to the costs of the service. Health authorities under various heads are expected to provide further Appropriations-in-Aid of the Vote, totalling £3,940. Other sources are expected to yield £11,620, towards which it is anticipated that fees for searches and certified copies of entries of births, deaths and marriages will produce £10,300. Summarising all this, we may say that this year the Department of Health and health services which it provides, or which are provided under its general supervision, will cost our citizens, qua taxpayers, in round figures and as a direct charge, £8,472,150. £8,500,000 is a broader and more readily remembered, but not grossly inaccurate statement of the amount.

The outstanding sub-head in the Estimate is sub-head H.—Grants to Health Authorities—for which no less than £8,150,000 will be required. That sub-head does not reveal the actual cost of the health services which the community provides for its citizens. It may be taken broadly to represent half the actual cost of our present health services during the current year. It is in fact rather less than half, since some expenditures do not rank for recoupment. I am sure, however, that we shall all agree that the figure of £8,150,000 for Exchequer contribution for health grant alone is quite enough in our present circumstances to be going on with. It can be taken, I think, as a very close estimate of the amount which ratepayers will be called upon to find for their health authorities this year.

The categories of ratepayer and taxpayer, as we all know, overlap very broadly. In the main they comprise industrial and commercial undertakings, farmers, businessmen, and their employees. However else all these interests may differ from each other, they have this in common: that as taxpayers they contribute out of one of their pockets towards the cost of health services, and as ratepayers they contribute out of the other. In both cases it is, of course, an exacted contribution, which all told will amount this year to over £16,600,000. A substantial sum, a very large sum indeed when regard is had to the slender resources, the modest producer income out of which it is taken.

A question must naturally arise in the minds of all who think seriously and objectively on these matters, as to whether as a community we are getting adequate value for this expenditure, whether in fact our health services justify their cost. I confess that, at this early stage of my responsibility for them, I am not in a position to give a decided answer to that question. I am sure that I should not be able in any case to give one with which everybody would agree. So much depends on the value which an individual places on the maintenance of health and the preservation of human life. But when we come, for instance, to relate this expenditure to our mortality rates for last year, as compared with earlier years, there is much evidence to show that the developments in our health services which have taken place in recent years are giving tangible and measurable returns.

Take, for instance, maternal mortality. Last year the number of births registered was 60,738, giving a birth rate of 21 per 1,000. The number of maternal deaths due to pregnancy and child birth was 50, that is, at the rate of approximately one death per 1,215 births. In 1955, the number of births was 61,622, the maternal mortality 70, which is equivalent approximately to one death per 880 births. In 1947, however, when there were 68,978 births, the corresponding mortality rate was one death per 530 births; while in 1937, with 56,488 births, the figure was one death per 277 births.

The mortality rate among infants under one year has shown the same trend. Per 1,000 live births it was 36 in 1956 and 37 in 1955, as compared with 41, 68 and 73 in 1952, 1947 and 1937 respectively. In all forms of tuberculosis the downward trend in mortality is even more marked. From 889 in 1955, the number of deaths from this cause fell to 689 in 1956. Undeniably, the rate of tuberculosis mortality is still higher than in some other countries; but at 24 per 100,000 population it showed a marked improvement over previous years, when as for instance in 1955, 1953, 1950, 1947 and 1937, respectively, it was 31, 40, 80, 124 and 123 per 100,000. Our overall death rate per 1,000 of population was 11.7 in 1956. It was 12.6 in 1955, 11.9 in 1952, 14.8 in 1947 and 15.3 in 1937.

All in all, taking the birth rate and the death rate in combination, it will be found that the rate of natural increase of population in this part of Ireland—and, indeed in the whole of Ireland—is higher than in England, Wales or Scotland.

These facts carry a great measure of assurance that the nation is receiving an appreciable return for our expenditure on the health services, heavy and burdensome though some may feel that expenditure may be. There is, I think, no need to stress that the marked decline in mortality which I have described is in itself an incontrovertible proof of a considerable and comprehensive improvement in the health of our people.

I have mentioned that the rate of natural increase of our population is higher than it is with our neighbours. This is due mainly to the fact that the birth-rate here is higher than with them. Thus, both in 1955 and 1956 it was 21 per 1,000 of population, whereas in England and Wales in 1956 it was 16 per 1,000 and in Scotland 18. But the marriage rate of our people, on the other hand, still remains markedly lower than it is in Great Britain. The annual rate for the past two years has been only 5.7 per 1,000 population; while in 1956 in Scotland it was 8.5 and in England and Wales 7.9. In the light of these figures, it is clearly of the utmost importance, if we are to survive as a nation, that everything must be done that can within reason be done to maintain the general health of our people, using to this end all the means which scientific, medical and surgical research continues to make available to us in an ever more astonishing degree.

In view of the low marriage rate, we must particularly concern ourselves to ensure that those diseases will be conquered which are especially deadly to children. Diphtheria, measles, whooping cough, diarrhoea and enteritis are still prevalent and liable to infect others. This year, we have initiated a new service of vaccination against poliomyelitis. Now, in regard to this new service, we have been at pains to make it known that protection against infection cannot be guaranteed. On the other hand, polio-vaccination is now accepted generally as a valuable protective measure against this dangerous disease. For a number of reasons, the service this year must be confined to children in the earlier age groups; but the limits will be enlarged as soon as this becomes practicable.

Vaccination against poliomyelitis has been added to mass-radiography, B.C.G. vaccination, small-pox vaccination and diphtheria immunisation, all of which are available, free of charge, to everyone who desires to avail of them to help him in safeguarding his health and that of his children. The statistics which I have already given show how effective those measures have been in combating disease and repelling death. They should be much more generally availed of; and the cooperation of all who may be able to influence public opinion to that end will be welcomed very warmly indeed by the officers of my Department.

A few minutes ago I gave figures for the striking decline in maternal mortality in childbirth or during pregnancy which had manifested itself particularly in recent years. The proof which those figures afford, not only of the effectiveness, but of the need for our ante-natal services, is irrefutable. Under Section 16 of the Health Act of 1953, these services are available free of all charge to expectant mothers in the lower and middle income groups. If only they had been availed of early in pregnancy, some of the mothers who died last year and their babies might be alive to-day. The important thing is for the expectant mother to go early to her doctor. He will, I have no doubt, welcome her visit, and she herself will be easier in her mind and more secure as to the out-come.

The changing pattern of the incidence of sickness and disease which I have outlined is producing its own peculiar problems. The more notorious killers of past generations are being mastered, even rapidly mastered; but the fever hospitals and sanatoria which were designed specially to combat them still remain. In some cases, it has been possible, at reasonable expense, to adapt such buildings to more general purposes and in this way they have eased the immediate pressure on existing hospital accommodation. In a few cases, such adaptation has not been possible. In every case, also, some redundancy in permanent staff has had to be left to solve itself by the effluxion of time—an expedient which does not always make for satisfactory and economical administration. And economical and efficient administration of our health institutions and of our health services generally has become an imperative need.

This is the tenth year since the Government in 1947 published a White Paper outlining proposals for the improvement of the health services. It may be a salutary exercise to quote the following passages from pages 37 and 38 thereof:—

"With the gradual improvement and expansion of the health services, it is estimated that the gross annual expenditure on the scheme will amount to about £9,150,000 at the end of the first ten-year period. The estimated net expenditure on the scheme would then be about £9,000,000 when credit is taken for receipts from sources other than rates and State grants in respect of expenditure on health services. The estimated expenditure on the scheme includes provision for the expanded services authorised under the Tuberculosis (Establishment of Sanatoria) Act, 1945, and the services provided for under the Health Act, 1947.

The net cost of the services at the end of the first ten-year period, including free general practitioner, specialist, hospital (local and regional), mental treatment, infectious disease, tuberculosis, and domiciliary nursing services would be provided as follows:—

Local Authorities	£4,500,000
State Grants	£4,500,000
Total	£9,000,000.”

This year, as the Estimate shows, the State grants to health authorities are expected to amount to £8,150,000 which is approximately nine times what they were in 1947-48. The local authority share of the cost of those services will also be £8,150,000, or 1.72 times what it was ten years ago. And the total amount to be expended under these two heads will be £16,300,000.

It may be useful too, at this stage, to recall the amount which ten years ago it was thought would be required for hospital construction and reconstruction, if effect were to be given to the proposals then outlined for the expansion of our health services. The matter is dealt with in the 1947 White Paper in the following terms:—

"The full development of the scheme which has been outlined will involved the provision and equipment of a number of hospitals and health institutions under the control of voluntary agencies and health authorities. For the most part, the institutions which will be comprised in the building programme are already in course of planning. It may be assumed that the institutional programme will entail a capital expenditure of about £30,000,000. Furthermore, existing institutional accommodation for the aged and infirm, and persons suffering from chronic ailments, is far from being satisfactory. Improved provision will have to be made in due course for this purpose. Replacement would, however, mean an eventual additional capital outlay in the neighbourhood of £13,000,000. The work cannot, therefore, be undertaken until the more pressing needs of the acutely ill have been met."

That was the position as forecast in 1947. It is well, I think, that we should look at the position as it is to-day. As a first step in the execution of the scheme outlined in 1947, in 1948 a priority programme of hospital works was drawn up on the direction of the then Minister for Health, Deputy Dr. Browne. It was to be completed within seven years and envisaged a gross provision of about 12,300 beds and 375 cots to give a net addition to existing accommodation of about 9,000 beds and 300 cots. The present position in regard to this 1949 programme is that schemes have been completed which provide for about 9,100 beds and about 170 cots; while works are in progress to provide a further 550 beds and 30 cots.

In addition, since 1949, nine nurses' homes and four staff homes have been erected, providing accommodation for about 830 persons. Two other nurses' homes are in course of erection. The balance of the programme still remaining for execution covers about 2,650 beds and about 175 cots, but due to changed circumstances, it may not now be necessary to provide some of the accommodation contemplated in 1948-1949.

At the time the programme was drawn up, it was estimated that it could be completed for £17.5 million. To-day its cost is estimated at £41.75 million, after allowing for the fact that included in it originally were some projects which it is now virtually certain will not be proceeded with.

Some minor changes were made from time to time in the 1949 programme prior to 1954, but early in that year a number of new projects were added to it. These were to provide some 819 new beds, giving a net addition of 673, of which only some 114 remain to be provided. The latest estimate for the total cost of this programme is £950,000.

Since 1954, it would be true to say that the provision of hospital accommodation additional to the 1949 programme, as supplemented in 1954, has been under continuous review; but it was considered that with the resources available to the Department it would not be prudent or justifiable to undertake a further extensive programme until it became clear that already existing commitments could be fulfilled. It will be appreciated that the initiation of the 1949 programme was enormously facilitated in the first place by the enforced accumulation during the war of considerable balances in the Hospitals Trust Fund. From this source, which, let me emphasise, is now exhausted, and from the proceeds of current sweeps and Grants-in-Aid from the Exchequer, there was spent £22.25 millions within the eight financial years ended on the 31st March last. It is estimated that over the same period hospital authorities spent about £3.2 millions on capital works.

Included in this amount was about £500,000, which was in the possession of voluntary hospital authorities, and which had been derived mainly from funds which they held from the proceeds of the first six sweepstakes. Local authorities on their part expended about £2.7 millions, which was raised by way of loans from the Local Loans Fund. Subventions from the Exchequer in aid of the Hospitals Trust Fund amounted to £6.78 millions, and these were utilised both for capital purposes and other purposes as the need arose. The total amount from all sources expended on hospitals and associated institutions within the eight-year period was £25.45 millions, of which no less than £21.9 millions was spent in the six years which ended on the 31st March, 1957.

As I have indicated, all the assets accumulated during the war in the Hospitals Trust Fund have now been exhausted. It was decided last year that the Minister for Finance would no longer provide Grants-in-Aid of the construction programme. He finds it difficult indeed to provide moneys for the Local Loans Fund. Moreover a large part of the income of the Hospitals Trust Fund has now perforce to be devoted, not to building new hospitals, but to keeping existing voluntary hospitals open. The sum total of all this is that so far as future hospital construction is concerned, we are now faced with an acute financial problem. In these circumstances a searching review of the remaining hospital programme, in its relation to actual needs and probable resources, is being undertaken. It is not a task which we approach with any confidence that an impeccable programme will result. On the contrary, it is quite clearly indicated by the experience of the past seven or eight years, that it is very difficult to make an assessment of hospital requirements, in their several categories, which will be approximately applicable to conditions prevailing even a few years later.

The rapid development of new drugs and new treatments may modify the persistence and prevalence of certain diseases so substantially, that the need for specialised institutions for particular types of cases is correspondingly diminished. A striking example of this is furnished by the rapid decline in the incidence of tuberculosis over the past few years. In 1949 the number of reported cases of tuberculosis was 7,552. In 1955, the latest year for which final figures are available, the number of cases had fallen to 5,613—a reduction of over a quarter in the six year period.

It will be appreciated that in consequence of this very desirable and gratifying change, some institutions which were in use as sanatoria are no longer required and have had to be closed or adapted to other uses. This will be the case also with some others in the relatively near future. Among these will be Ardkeen Sanatorium, which was opened as recently as July, 1952, and which cost about £1,050,000 to build. The demand, I should emphasise also, for fever hospitals has been similarly reduced.

It is easy to be wise after the event and hindsight is a much too common faculty; a layman, however, like myself, may be forgiven if he wonders whether it would not have been more rewarding to have spent more on other needs such as the provision of more accommodation for mental defectives and on the improvement and extension of mental hospitals. I say this, conscious of the fact that three of the four regional sanatoria which have been built since 1947 were projected under my own aegis as Minister for Local Government and Public Health.

Not only has future hospital building to be related to our future needs, as we may be able to foresee them, but it has now to be strictly related to our probable resources. And, in my opinion, these will be meagre indeed by comparison with the standards which have prevailed in recent years. I have already mentioned that all the accumulated assets of the Hospitals Trust Fund have been exhausted and that the Minister for Finance is no longer in a position to supplement expenditure from the fund. The actual position, I may say, is even worse than these facts indicate, inasmuch as the sweepstake income for the current financial year has already been heavily drawn upon to meet payments due prior to the 31st March in respect of voluntary hospital deficits. Consequently so much less is available for current expenditure on building.

But even if this were not the case the financial position would still remain stringent. So that if the extra accommodation which is essential is to be provided within any reasonable period, a drastic scaling-down in unnecessarily expensive standards must take place. This is imperative, not merely to make our capital resources go further but to avoid unduly heavy expense in running and maintaining the institutions. In regard to this, and all the other services under the Department of Health, I shall endeavour to ensure that the public will derive the maximum benefit from such moneys as are expended upon them. It is in the light of this intention that I ask the Dáil to pass this Vote.

Mr. T.F. O'Higgins

The Minister, in moving the Estimate for his Department, has stated it to be an Estimate prepared for submission to the Dáil by me as his predecessor. He has given a very comprehensive and general account of some of the difficulties which any Minister for Health is faced with in present circumstances.

This Estimate shows a significant reduction in the amount sought for this Department last year. The reduction in the Estimate is largely concerned with the elimination of the Grant-in-Aid to the Hospitals Trust Fund from the Central Fund. This year, for the first time since, I think, 1952, the Vote which the Minister seeks from this House contains, in relation to hospital building, no subvention from Central Funds: That is a significant departure and it represents a decision taken by me and my colleagues in the former Government. It was a decision reached as a result of a careful review of the capital position of the State, balanced against present and future hospital requirements.

I think it is realised that since the initiation of the Hospitals Trust Fund in 1931 or so, a great deal of money has been expended on the construction and provision of hospitals. Now, some 30 years later, it is possible to consider whether all that expenditure was wisely decided or not. As the Minister said in his statement, hindsight is not often indicative of good judgment, and I think if one were to review the expenditure by the State on hospitals here over the past 20 or 30 years, one could only come to the clear judgment that it has been made less fruitful by reason of the local government system which we operate here and which we inherited from those who previously ruled our destinies.

When there was a fund available in the early 1930's for hospital construction and provision, unfortunately it became the story that different counties competed for the provision of county hospitals and the result has been over the past 20 or 30 years that a great number of small and often badly equipped—due to no defect in the hospital—hospitals were built just because a county hospital was provided in the neighbouring county. At the same time, it is now apparent that the provision of county hospitals was decided upon considerations which were regrettable and which have led to the exclusion of new hospitals in certain pivotal points throughout the country where in fact they should have been provided.

Anyone looking at the Midlands will find, in part of my constituency, an excellent new hospital in Tullamore, another new hospital in Roscommon and still another in Mullingar, but the town of Athlone, which is an important centre of population in that area, had no new hospital provided for it. That is only an example of the haphazard manner in which, over the years, we have embarked on the building up of our county hospitals. The pattern was haphazard because of the system of local government which we have here and under which completely artificial local boundaries put a limit on the obligations and duties of different authorities responsible for health services.

Again, without desiring to indulge in hindsight, it certainly seems regrettable now that in those early years the actual requirements of the country in relation to hospital services were not fully investigated on the grounds of density of population, irrespective of whether an area of dense population spilled over a county boundary or not, and that instead of building a great number of small county hospitals, some imaginative mind did not see the need for five or six regional, local hospitals throughout the country which could have served as medical centres and which could have been served by a number of small, cottage type district hospitals built on logical lines.

That is what might have been. The fact is that this vast expenditure over the years has been devoted to the provision of a great number of small country hospitals and I fear that that process must continue. I fear that the Minister is faced with the necessity that it must continue, until the county hospital scheme is eventually satisfied. For instance, the Minister is faced, I know, with an impelling need for a new county hospital in Cavan. I know certain suggestions in that regard were made last year to the Cavan health authorities, but if they are not found feasible on examination, there is a county where the existing facilities are very much sub-standard and that can only be remedied by an addition to the long list of some county hospitals, because unfortunately the Minister has no other way of meeting the difficulty if the suggestions that have been indicated are found on examination not to be feasible.

In County Longford, there is urgent need for new county hospital facilities. I believe that need can be met only by the provision of a new county hospital and that in a county which has, in Mullingar, not far distant, a new hospital already provided and equipped and which has in Manorhamilton, not very far removed either, a new hospital, but one which can serve only a very limited portion of County Leitrim. The dilemma with which the present Minister or any Minister for Health will find himself faced is that the needs of these isolated places not already provided for under the programmes over the years can be met only by the provision of more hospital beds.

In Waterford, there is, too, very grave need for better general hospital facilities. Indeed, it was in relation to the situation in Waterford that the suggestion was made to the bodies concerned that the new sanatorium at Ardkeen might be used, with certain necessary adaptations, for general hospital purposes, and I am very glad to read into what the Minister has said that that suggestion looks like bearing fruit. If it is possible to use Ardkeen for general hospital purposes, that will provide an example to the country of what can be done with a bit of common sense towards utilising worthwhile buildings for purposes other than those for which they were designed, while, at the same time, meeting a very grave public need. I hope that, by the adaptation of Ardkeen, the people of Waterford will find themselves very quickly provided with the new general hospital they require so urgently.

It was considerations along the line I have mentioned, added to the grave shortage of capital in recent years, which brought about a very careful consideration of the question as to how in future we should develop our hospital programme. I had to consider that very fully indeed. I was aware, on the one hand, that, by reason of the pattern over the years, certain hospital projects were needed and must proceed. I was aware also that the capital required for their construction would not be as readily available in the future as it had been in the past. Added to these difficulties was the fact—a fact to which the Minister has not referred in any detail—that in the past two or three years, the burden of maintaining the voluntary hospitals as going concerns became more and more acute.

As Deputies are probably aware, it has been the practice of the Minister for Health, acting in the capacity of a trustee dispensing Hospital Trust Funds, to pay a large proportion of the deficits of the voluntary hospitals, those deficits being, of course, the shortfall between revenue and expenditure. The hospitals which benefit under the deficit scheme are for obvious reasons very largely the teaching hospitals in Dublin City and Cork, though there are some other voluntary hospitals throughout the country. If my recollection is correct, in the financial year ending in 1954, the deficits of the voluntary hospitals ran roughly around the £500,000 mark. I am not now speaking of the actual deficits. I am referring rather to the sum which was regarded as being sufficient to meet in some reasonable way the claims of the hospital authorities. At the end of that year, the claims of the voluntary hospital authorities for that portion of their deficits not met had become so serious that special sanction was required to increase the various payments in respect of such deficits by roughly another £250,000. By 1955 and early 1956, payments of that order were being made out of trust funds to meet the deficits of these voluntary hospitals.

In the autumn of last year, coincidental with the review of our hospital requirements, it was found that the deficit requirements of the voluntary hospitals had risen by another £200,000 and that they then approached the £1,000,000 mark. Deputies should remember that the income of the Hospitals Trust Fund last year—it has risen slightly since, I am glad to say—upon which decisions can be made was an income of roughly £2,000,000. From this income, the voluntary hospitals had to be kept in operation and, in addition, some form of rational programme had to be devised whereby future urgent hospital projects could be met.

To devise a building programme circumscribed by these difficulties meant that a certain number of decisions had to be taken, decisions involving considerable elements of chance. It was my duty to draw up a form of working programme in respect of which some possibility of its being financed over the years could be entertained. I felt that the correct approach to that problem was, first of all, to meet, not in full but in large measure, out of the yearly income of the Trust Fund, the deficits of the voluntary hospitals and then to decide what new hospital building could be financed with the balance of the yearly income of the Trust Fund.

I do not know whether it will appeal to the Minister or not but, certainly, I left for his examination and consideration a limited programme which I feel he could and will be able to finance. It will involve, and has involved this year, a certain amount of borrowing, if you like, from the income of the Trust Fund next year but that was a position which could not be avoided. It is a programme which, if it is adhered to, will, I think, mean that over the next few years the urgent hospital projects can in fact be provided.

It will mean that a number of people will be disappointed. For instance, there are, as Deputies are aware, four major hospital projects which have been talked about for a number of years and in respect of which I suppose there have been very clear commitments by the State. There is to be a new Coombe Hospital, a new St. Vincent's Hospital, a new St. Laurence's Hospital in the city. There is also to be a new regional hospital for Cork. I think it is clear—certainly it was clear to me—that all those four projects could not be financed simultaneously and, accordingly, in any building programme of any rational size, based on due regard for the financial capacity of the Trust Fund, it will be necessary to select out of those projects such of them as should have priority.

It was my view, but the Minister may take a different view, that of those four projects priority should be given to the Coombe Hospital because, as Deputies are aware, there is an urgent need in this city, despite all the hospitalisation we have had over the years, for additional and better maternity accommodation. The building of a new Coombe Hospital would be of considerable importance, particularly in Dublin, in view of the very fine record our maternity hospitals have obtained over the years.

I felt that of these four projects priority should be given to the new Coombe Hospital and to St. Vincent's Hospital in view of its relation to the new university project and to the problem of medical teaching. I do not know what view the Minister may have with regard to these matters but that is the manner in which my mind was running.

Apart from the two major units which I felt could be financed over the years, I also made provision in the tentative programme which I drew up for other urgent needs throughout the country. I was aware that in County Monaghan, for instance, there is an overcrowding problem in the local authority hospital and that provision had to be made to meet the very urgent claims in that regard of the people of Monaghan.

In addition, in various parts of the country there were, and are, similar urgent needs in relation to general hospitals. Apart from the requirements of the various health authorities for increased accommodation in their general hospitals and the need for further maternity accommodation throughout the country, there is also the very grave need that exists in many parts of the country in relation to the improvement and possible extension of mental hospital accommodation. That cannot be overlooked. I am glad that the Minister referred to that in his statement and I hope that, within the funds available to him, everything possible will be done to meet, either by adjustment or otherwise, the needs of mental hospital authorities.

It was because of considerations such as I have mentioned that a new hospital programme was in process of being defined. In fact, so far as I was concerned, the process had ended and definition was complete. It is a matter entirely for the Minister now as to whether he will proceed along that line or, as he appears to have indicated, deal with the problem on some other lines, but I want to assure the House, so far as I and my colleagues are concerned, that we recognise very fully the problem which faces the Minister in relation to the hospital requirements of the country. We recognise very fully that in that regard the Minister has a very serious financial problem on his hands.

At the same time, I would express the hope that the size of the problem would not—and I am sure will not— drive the Minister into a decision which in fact will mean that any one of the urgent projects, not major projects but smaller projects, will be postponed. I think the urgent ones can be done. It is a question of opinion as to which are urgent and which are not, but I think there are quite a number of very urgent requirements which it is possible to fill over the next few years.

May I express the hope—and I think that in this connection I am supporting the view the Minister seems to have expressed in his speech—that, in relation to the adaptation and use for other purposes of existing hospitals, there will be a more generous understanding of the financial problem facing both the Minister and the health authorities, and also of the duty owing by all to make sure that hospitals are used as hospitals?

Deputies will remember some time ago that there was a sanatorium in this country which was created out of a hospital designed and intended for other purposes. In fact, this sanatorium was intended to be used as a mental hospital. By reason of the very grave need at the time for the provision of beds for tuberculosis sufferers, with the agreement of the local health authorities, it was decided to turn that hospital into a sanatorium. When that decision was reached, the people in the town affected were enormously concerned. They did not mind having a mental hospital in their town but they strongly objected to the plague being brought to it. They organised to some effect against the decision. Fortunately, the local agitation did not lead to the alteration of the decision and the mental hospital became a sanatorium.

About 12 or 18 months ago, happily it was possible to reach the stage whereby it could be decided that this building was no longer required for tuberculosis and accordingly it was decided that it should be handed back to the mental hospital authority. But, lo and behold, there was another agitation. The people of the town again got together. They wanted to retain the sanatorium because, in the interval, apparently, the awful effects of the plague had not affected them, but the monetary return that came from patients' visitors going to the sanatorium did affect them. The suggestion was solemnly made by public representatives that it should become the duty of the Minister for Health and the health authority concerned to retain this hospital as a sanatorium, although, in fact, happily, it was no longer required for that purpose because the incidence of tuberculosis had disappeared. That is an example of the kind of unhelpful approach which can make more and more difficult the rational development of hospital services in this country.

The switching of many other sanatoria throughout the country should now be possible. There are quite a number of other buildings at present used for tuberculosis purposes which can now be used for other purposes, provided all sides of the House, others whom we can influence and health authorities realise the need for it. Our mental hospitals, with some exceptions, are overcrowded. We need more and more accommodation for mental defectives, as the Minister has mentioned. In some parts of the country, there is still a scarcity of accommodation for maternity cases. In many parts of the country, due to the pattern of hospitalisation, the number of general hospital beds is not adequate. In those circumstances, it appears wrong that we should not try to draw into the three regional sanatoria as many cases as possible in order to make free the smaller temporary tuberculosis sanatoria for other purposes.

I see Deputy Mooney behind the Minister. May I hope that he bears that in mind? There is that problem— at least it was—in County Monaghan. In any event, I am glad to learn from the Minister's statement that the process of using existing hospital accommodation for other and more urgent needs is engaging his attention, and I hope that everybody who can help in that regard will help, both here and elsewhere throughout the country.

May I pass from consideration of the hospital position and the building programme to other matters which are allied to some extent? The Minister very properly referred to the size of the expenditure required for maintenance of our hospitals and for the provision of health services. I feel, with the Minister, that the expenditure which has been incurred and which he seeks to-day from the House is fully justified. Every penny spent wisely on the provision of amenities in relation to health services and on the services themselves is money well spent. That of course does not mean that due regard should not always be paid to the elimination of expenditure which, through experience, has been found not to be fruitful.

I should like to pay tribute to the health authorities with whom I had experience, particularly in the last 12 months when I had occasion to ask them to examine their health expenditure with a view to seeing whether they could, without curtailing in any way the quality of health services, effect any economies. I have not got the details with me but my general recollection is that the response of the health authorities to that appeal was extremely satisfactory and that the health authorities found, on a fresh examination of methods which perhaps had been in use for a long time, that quite a substantial saving could be achieved. In particular an effort was made last year to have a full examination of the internal working and administration of certain large hospitals, particularly sanatoria, with a view to seeing if savings could be effected. I think one working party, if not two, embarked on such a mission and again met full co-operation from the local authorities affected and were able to achieve considerable savings.

Without suggesting that the Vote which the Minister seeks is in any way excessive I do hope that the effort at examining, where possible, the details of expenditure will continue and that it will continue to receive full co-operation from local bodies and from those who can influence them. I notice that the Minister did not give us any of his views as to whether certain health authorities should be unified or not. Perhaps it may not have been in order for the Minister to give any indications of policy on his Estimate but I just express the hope that the suggestions of a unified health authority in Waterford, Cork, Limerick and Dublin will be examined by him, I always regard that scheme as being one way of getting rid of the absurd local government divisions which unjustly make the administration of our health services so expensive. I hope that the Minister will examine these schemes as sympathetically as possible. Last year I availed of the opportunity of discussing these proposals with the health authorities concerned and I hope my advocacy in that regard has won some support.

May I make another suggestion to the Minister with reference to a matter completely removed from much of what I have been discussing? It is a matter of administration. It concerns the administration of an important service in the country, that is the provision of free medical service for those unable to provide such service for themselves, in other words, the present dispensary service. I should like to remind Deputies that what we know as the dispensary medical service is quite an old service. It was founded under the charitable legislation passed in Victorian England and it represented a provision made in accordance with British notions for urgent medical care for the poor of Ireland.

The provision of such care here has developed and remained along lines quite different from the development in Britain. We all know that it was a very common practice for the British Parliament, when it had the right to legislate for Ireland, to try experiments here but to develop along different lines in England itself. As the provision of medical service for the poor has developed we have had the dispensary system made into something immutable, something which apparently many people regard as being incapable of change. I think it should be changed. I think the dispensary service in the country has outlived its use.

Recognising as we all do the need for providing medical service for those who are unable to provide it for themselves, the only question then is how can such a service be provided. One must recognise that there are parts of the country where, by reason of the poverty of the people and the scarcity of population, there may not be a practice for a medical practitioner. In those areas, and because of those considerations, it may be necessary, and obviously it is necessary, for the State, or the health authority, to subsidise a doctor, to pay him a sufficient sum to enable him to remain in that locality and to provide there, as part of his duty, the needed medical care for poor people. That, of course, is the justification for our present dispensary system and the only defence that can be adduced for its continued operation.

When we leave such areas and have regard to our large centres of population, the City of Dublin, Cork and other cities where there is no shortage of doctors whatsoever, where there are available to the people the services of any number of doctors and where there is a living to be made by medical practitioners, as proven by the fact that doctors' door plates jostle one another in different parts of the city, in those circumstances the need for subsidising medical services in such centres of population is not apparent. The only case for paying a doctor is to keep him in a certain district. In our large centres of population, there is no shortage of medical practitioners. That is one side of the case.

There is the other and more important aspect, which is that if the State recognises a duty—and it is a very clear duty—to provide medical care for persons who cannot afford to provide such care for themselves, there is no reason why such a person should not be entitled to go to the doctor of his or her choice. I think that a free choice of doctor for those entitled to free medical services is a provision which should be made. I am sure Deputies appreciate that at the moment any person entitled to, or holding a medical card, who requires medical attention is entitled to go only to the dispensary doctor in his particular district. If the dispensary doctor is not available he will have to go to whatever locum tenens is in his place, but he is not entitled to go to anyone else. If, in fact, he does fail to get the dispensary doctor and no substitute arrangements have been made, then, and only then, may he go to somebody else, but he will have to pay whatever fee is asked. It becomes a matter for machinery later on as to whether such a fee may be recovered from the doctor who should have attended him.

There is no choice, and it does not matter in the slightest whether the patient has confidence in the doctor to whom he has to go. That does not enter into it. Only the particular dispensary medical officer for the district can provide the service which is required. If the person to whom I have referred happens to have a wife and she is expecting a baby, as an expectant mother she is entitled to go to any doctor she selects herself—any doctor who has made an agreement with the health authority concerned or any health authorities. She has a free choice of doctor in relation to her condition of pregnancy. Not only has she a free choice of doctor but, as appears from the Minister's statement, and as has been said on many occasions, she is encouraged to go as quickly as possible and seek the advice and counsel of her doctor, and it is not her health authority's doctor; it is not the State doctor; it is the doctor she selects herself, the man in whom she has confidence.

That maternity service is working well with the full support of the medical profession and with the full support of persons who can advise and influence mothers to avail of it. It is working well because it is based on the idea of a free choice and encouragement from the State to women to avail of it, but the operation of a free choice of doctor in maternity cases, placed side by side with our present dispensary conditions, leads to absurd anomalies. Mrs. White may be attending Dr. Black because she is expecting a baby. She may have the greatest confidence in Dr. Black but if, on her way out from Dr. Black's house, she slips and sprains her ankle she cannot go back to Dr. Black. She must go to Dr. Green, the dispensary doctor, though he may be a man with whom she has had words because she originally went to Dr. Black instead of going to Dr. Green. That is an absurd situation.

I felt very strongly as Minister that the justification for the present dispensary system, unmodified, ceased once the operation of the maternity services became possible. Once it became possible, in April of 1956, to provide in a practical way the general practitioner care for mothers, I felt that the present dispensary system no longer should be continued in the country. Indeed, I made a statement some time before the last general election that my views were along that line and that I felt modification was necessary. I know too, in that regard, like all things that are desirable, that there is the financial element. I am well aware that if the Minister made an administrative decision to provide through health authorities free medical services, with a free choice of doctor, he would be faced with the need of superannuating a number of existing dispensary doctors. I proposed an examination of what that cost might be. I have not the figures before me now but I am certain they would be available to the Minister.

I do not believe the sum involved would be so enormous as to dispose of further consideration of this matter. It will be remembered—indeed, I think it was a decision of mine which certainly kept this aspect in mind—that for some years back no permanent dispensary appointments have in fact been made in Dublin City or, I think, in Cork. The reason usually advanced is that, by reason of new building in the city, the limits of existing dispensaries cannot be regarded as permanent. One object was to facilitate the alteration of the present system, where possible. I believe the financial element involved, if it were applied gradually over a number of years, could be considered if a start were made in Dublin in respect of a free choice of doctor to those entitled to medical services, even to start with a pilot scheme—if, for instance, the Crumlin and Kimmage and Drimnagh areas were taken. So far as I can recollect, the appointments in that area are all temporary appointments.

In one of the Crumlin dispensaries, two or three additional doctors are brought in to do relief work. If a pilot scheme were embarked on there, I am quite certain many of the complaints about the operation of the services under Section 14 would begin to disappear and that those whom it should be our concern to provide with the best possible service, the poor, would realise that something worth while is being done for them. In any event, I feel it is a worthwhile departure and I hope the Minister will not have a closed mind on it.

The Minister referred to certain public health services in operation in the city—the tubercular services and the various vaccination and immunisation services in relation to different diseases. He made a passing reference to the new anti-polio vaccination scheme. When he is replying, I hope the Minister will tell us how many children have come under that scheme —in other words, of the estimated figure upon which a scheme was based, what has been the response? In addition, I should like to know whether steps were taken by health authorities adequately to acquaint parents of the desirability of availing of this scheme. I was myself at some disadvantage in knowing exactly the details in relation to what particular period it is necessary to apply to have children included in the scheme. I did not observe any effort by health authorities to advertise in any large way. I should like the Minister to deal with that.

I was through the wards of St. Finbarr's Hospital, Cork, last year in the middle of the epidemic. It would be a tragedy if the general public did not avail fully of the present vaccination services made available by health authorities. As the Minister said, it is not possible to say whether or not the vaccine will give an immunity or what immunity it will give, but the indications are that probably it will be a defence against this appalling disease. Nobody who was present in Cork City last summer and who had any experience of the ravages of such a disease amongst young children could have any hesitation in supporting in every possible way parents in availing of the scheme.

While the Minister might not like to say it, perhaps I, having no responsibility, may say it. It is well that people should realise that the incidence of polio in Dublin City at the end of last summer and right throughout the autumn gave very grave grounds for anxiety. In the ordinary course of events, this year is the year when we could expect a polio epidemic—not last year but this year. Were such an epidemic to come, with this vaccination service available, it would indeed be tragic if the public did not respond adequately. I was glad to see that scientific advice on the subject in England indicates it is possible, even in the event of an epidemic, to continue vaccination. Nevertheless, I hope the public will respond to the availability of these services.

There is only one other matter which I should like to raise. If the Minister tells me he has no responsibility for it I must accept that, but I think it is a matter that should be discussed even in a slight respect. I refer to the problem of medical education in this country. I do not desire to discuss the education aspect of it because that is the responsibility of the Minister for Education. At the same time, Deputies should be aware there is a very grave danger that recognition by outside countries, particularly Great Britain, of our medical degrees may be withdrawn unless our medical schools conform to certain standards suggested outside.

I know that there are difficulties in dealing with this problem but I do hope that the Minister, in any efforts he may make to deal with the problem of medical education, will get support because it would be a very serious problem for the country if the position of our medical schools were in any way endangered. We have at the moment in Cork and Galway, outside Dublin, two important medical schools which in all probability would not be there if recognition of our medical schools were withdrawn in 12, 18 months or two years' time. I hope that aspect of this danger will be recognised by all concerned.

May I say to the House in conclusion that I think the statement which the Minister made to-night and the statistics which he gave us, afford evidence of the continued improvement in our health services in the country? The developments in the past 18 months or two years in individual health services were welcomed, particularly the improvement in the mother and child service. As the Minister has said, that is an important development because it deals with one of the black spots so far as the health of this country is concerned and that is the alarmingly high incidence of infant mortality over the years. I am glad that service is now in operation for those in respect of whom it is felt that a financial need existed.

I am glad that the improvement in the falling incidence of tuberculosis has continued and I hope that such a good story can always be told. While I have no doubt that in the work of the Minister's Department matters of difference will arise from time to time, certainly such differences that may arise between us in this House will not be without regard to the problems which face the Minister or any Minister for Health. I should like to say, if the Minister will permit me, that he has available an excellent Department. Certainly, I found, as Minister, that I was extremely well served. I know the Minister will be too.

Dr. Browne

The statement which the Minister read to the House is a very heartening one indeed. It is clear that the bill must be met now for the advances which have been made in the health services over the years. Even though the bill appears to be a substantial one, very few either inside or outside the House have the slightest regrets that this very considerable sum of money must now be found and continue to be found in the years ahead so that we will see an end to preventable disease and a position created in regard to unavoidable disease wherein the medical profession and the nursing profession will be provided with the best possible facilities to treat people when they become ill, which is, of course, the prime responsibility of the Minister and his Department.

Deputy O'Higgins raised a number of very interesting points. Probably the most interesting is that dealt with to some extent by the Minister. That is the attitude to hospital building. The point at issue is whether over the past 20 or 30 years we have spent the moneys at our disposal as effectively or, as Deputy O'Higgins said, as fruitfully as possible.

In relation to that, we should bear in mind that the State and the community have been spared the expenditure over the years of millions of pounds from the Central Fund and from taxation as a result of the magnificent Hospitals Sweeps enterprise. All that money would have had to come either from taxation or the rates. We have got into the habit of forgetting the fact that a normal society accepts this problem of providing hospitals for the sick as a normal demand on the communal funds in the form of rates or taxation.

We recognise that same fact ourselves. We must find money for the provision of schools, houses and the building of roads. There are a number of social necessities for which we must provide the money from the Central Fund and for which we can expect no return in material wealth. In trying to get the sizeable burden which the Minister must now face in the years ahead into proportion, it would be worth bearing in mind that this burden has been greatly eased in the past 20 or 30 years by virtue of the fact that we could draw on the Hospitals Sweep fund during all that time.

Progress reported; Committee to sit again.

The Dáil adjourned at 10.30 p.m. until 10.30 a.m. Wednesday, 26th June, 1957.