First of all, I should like to join with other Deputies in expressing appreciation of the work of the Department of Health, particularly over the past ten years, since the passing of the 1947 Act, which has resulted in such a satisfactory improvement in the general health position in the country. If the position is not as satisfactory as we should all like it to be, we must have regard to the ability of the community to bear a completely comprehensive national health scheme. The question of cost is important and it would be foolish to disregard it in expressing wishes that everything we would hope to be able to provide for all our citizens, irrespective of whether they are rich or poor, could be provided in our present circumstances.
In introducing his Estimate, the Minister asked a very pertinent question, when he asked if value was being received for the expenditure involved. He went on to say:—
"It is difficult to give a completely satisfactory answer to the question as to whether value is being received for the money spent. It is difficult because, in the nature of things, it is impossible to measure the amelioration of sickness and ill-health, the value of human lives prolonged, and the consequent relief and happiness experienced by individuals and their families in terms of pounds, shillings and pence."
Every Deputy will support this statement. Nevertheless, we must remember that ours is a small community of fewer than 3,000,000, largely agricultural, whose national income is in the region of £160 per year per head—certainly one of the lowest in Europe and possibly one of the lowest in the world. In speaking about what we are spending on health services, we must have regard to the necessity to spend in other lines also, to expand the national income so as to provide our people with better social services, of which health is one of the most important.
I know the Minister for Lands has been criticised because, in several recent speeches, he has advocated a transfer of moneys from what we might call "non-productive outlays" to productive outlays, his argument being that, if a greater share of the national income had been spent on productive outlays during the past 25 to 30 years, this country to-day would have a far greater national income, that taxation would therefore be less per head of the population and that we would be able to afford the type of social welfare amenities which every Deputy would like to see made available to each and every citizen, particularly to those who, through no fault of their own, are unable to provide for themselves.
I gather from the Minister's speech that he is following the precedents set by his predecessors in trying to arrange that priority will be given to certain sections. Priority should be given—I do not mean that the priorities should be necessarily in this order, but I just take it as a group—to expectant mothers. I agree with Deputy Dr. Browne that much still remains to be done in that respect. We have done a lot to ensure that expectant mothers will have the necessary pre-natal treatment that they need and proper treatment during the confinement, with post-natal treatment and then treatment of the infant who is one of our future citizens, someone on whom those of us who have families may rely to provide for us and look after us in the future.
Then we have care of the old and the infirm. Those categories have first charge on any Estimate which seeks to cater for the health of the community. Thereafter, I agree with the present concentration on infectious diseases, where not alone may persons injure themselves but may injure their neighbours or other members of the community. For that reason, we have over the years expended very substantial sums of money in the treatment, in the first instance, naturally, of tuberculosis and other infectious diseases, fevers and so on. I agree with Deputy Dr. Browne that in that category the care of persons suffering from poliomyelitis should be included. I do not know what the cost would be —the Minister is in a better position to say than I am—but, accepting that principle, I think polio should be included in that category.
Again, we have to concentrate on certain specific diseases or ailments which are among the higher killers in the community. Cancer has been mentioned and I propose to say something on that later on. Cancer, heart ailments, rheumatism and mental diseases are the sort of things which should be concentrated on as specific diseases or ailments which take a heavy toll of human life, particularly in our small community.
I think I am correct in saying that the Minister mentioned also that we had come to the end of an era, the end of a decade, in the provision of health services for the community and that we had arrived at a time of pause, when we were more or less consolidating what we had done and awaiting for the national income to expand before another step forward could be taken. Any reasonable person would accept that as a reasonable thing to do.
I should have liked the Minister to have given us some idea of what we as a community had spent over that decade and, if possible, what we had spent fighting against various diseases such as tuberculosis. If my rough and ready estimate is correct, the war against tuberculosis has, over the past ten years, cost this community something between £35,000,000 and £40,000,000. When I say that, I naturally include the amount of money spent from the Hospital Sweep funds on the provision of sanatoria and which, strictly speaking, is not a charge on the community. It is the money of thousands of people who subscribe to those funds and it has been a god-send to successive Ministers for the provision of sanatoria and so on.
The Minister, in his Estimate, has dealt at some length with the question of cancer. I am in agreement with most of his remarks, but I should like to take this opportunity of expanding on this subject with which I have had some connection over the past seven or eight years. It is quite true, as the Minister pointed out, that there is a substantial apparent increase in the number of deaths from cancer over the past ten years, from just over 4,000 in 1947 to 4,817 last year, or, in other words, the percentage of deaths is now one-seventh compared with one-eleventh ten years ago. The Minister rightly pointed out that in assessing the significance of these figures, certain qualifications must be borne in mind. Facilities for the diagnosis of cancer have been expanded enormously and the treatment of cancer is now at a much higher and more efficient stage than ten years ago. There are considerably more beds available, more expert personnel available and generally speaking, the services are now considerably better, more efficient and more expanded than they were when the 1947 figures were taken.
There is the further fact referred to by the Minister that there is now more accurate certification of deaths, and that has also affected the figures. Further, the average age of the population has been going up and will continue to go up and, as it does, the incidence of cancer is bound to rise with it. It has been estimated by experts in the field of cancer research and treatment that about 2,000 per 1,000,000 people of the population get cancer, and if we accept this figure as applicable to our own small State, it would appear that somewhere between 5,500 or 6,000 people per year will become infected with cancer.
I should like to give some figures of what has been accomplished during the past ten years. As most members of the House are aware, the diagnosis and treatment of cancer up to a few years ago was carried on by two old-established cancer hospitals and I should like to take this opportunity to pay tribute to the magnificent work which these two voluntary institutions carried out for many years, despite a shortage of funds, personnel and equipment. Some seven or eight years ago, an organisation was set up by the then Minister, Deputy Dr. Browne—the Cancer Association of Ireland—and its first task was to make good the shortage of personnel, equipment and beds which existed at that time.
It may not be generally known that in as short a period as seven years ago about 2,000 people a year died of cancer because they could not get treatment, as it was not available. That position has been changed completely and we have now reached the position where we have, in Dublin, a main cancer centre and the two voluntary hospitals to which I referred. There are diagnostic centres throughout the country, in Limerick, Galway, Sligo, Tralee, Waterford and Cork, and they can cater for any number of patients coming forward and presenting themselves for treatment, so that we are now in the position that anyone requiring treatment for cancer can get it without any delay.
As Deputy Dr. Browne pointed out, it is now largely a question of getting the people to utilise the facilities which are there. Deputy Dr. Browne appealed to the Minister to inaugurate a propaganda campaign and I would suggest to the Minister that that campaign might be better-and certainly it would cost less-carried out by the institutions which have shown themselves competent to deal with the diagnosis and treatment of cancer. With the co-operation and support of his Department, I am quite certain the institutions concerned would carry out an effective propaganda campaign.
Possibly one of the reasons why our statistics in regard to cancer make such gloomy and discouraging reading is the fact that we have spent so little on cancer services over the years. If we spent, as the Minister has pointed out, £17,500,000 per year on the health services, it would be interesting to know what percentage of that went on the anti-cancer campaign. Possibly it may not be practicable to get all these details because I know that cancer is not treated only in the specialist hospitals. A good deal of it is treated by surgery in the general hospitals. Last year, about 4,500 new patients were treated in the three cancer hospitals as against about 1,600 in 1950, just seven years previously, so that the amount of State aid and aid through the Hospitals Sweep funds that is given to the specialist cancer hospital, is a fair indication of the amount of money provided by the State for the fight against cancer.
I think the public would be very surprised by the small cost to them of the present cancer services. If, as the Minister points out in his report, one-seventh of all the deaths in the State last year were due to cancer, it would be interesting to know what the percentage of money spent on cancer services amounts to. I think it would be found to be a very tiny fraction and far below the one-seventh alluded to by the Minister.
There is another factor in connection with cancer to which the Minister did not refer and to which I should like to make a brief reference. That is the question of research. Research, as everybody knows, is a very expensive undertaking, an impossible undertaking for a country of this size; but apart from the fact that it is a small country, it is a homogeneous community and we can carry out here some very useful research on questions of statistics, and I think this would be well worth the Minister's support and financial assistance.
I should mention, incidentally, that the system which the cancer hospitals employ in the utilisation of the external diagnostic clinics throughout the country saves the ratepayers and taxpayers a considerable amount of money. Under this system, as probably most Deputies know, the experts from some of the cancer hospitals travel down the country and see the patients there rather than that each patient should have to be sent up from the local authority health centre and have to travel at the local authority's or his own expense. In assessing even the present small cost of cancer services to the State, there should be, in fairness, a setting-off in respect of the amount of money local authorities and individuals are saved. Not only do we run our cancer services at a very small cost but also to the financial advantage of local authorities and the individuals concerned.
In regard to incurable cancer cases, up to recent years, such cases had two options: the patient either went home again and died there, usually in considerable distress and naturally causing considerable distress to his family, or went into one of the homes run, possibly, by a community, and known as a hospice for the dying or a home for incurables. I think that is a feature of the cancer campaign to which the Minister would do very well to direct his attention. Some sort of institution, not a hospital for the dying, but some form of institution where a certain amount of treatment could be made available, should be built. A few of these throughout the country would be sufficient and, if they could be provided, they would be a tremendous asset and addition to our whole cancer campaign. Naturally, every hospital likes to think its function is to cure and not to look after chronic cases, but I think every hospital would admit that the problem of chronic cases needs special and urgent attention. That is certainly true in the case of cancer treatment.
The Minister would be well advised to examine closely the possibility of greater co-ordination of the existing cancer services. I say this, knowing there are difficulties in the way of closer co-ordination or integration, but I feel, of necessity, in our case as a small country, with a small population and limited income, any integration which we can achieve in our cancer services will lead to greater economy and efficiency and give better service in the long run to our patients.
In 1949, a body known as the Consultative Cancer Council reported to the Minister's predecessor, Deputy Dr. Browne, and that report has been largely the basis on which much of to-day's cancer treatment services are founded. The time is now opportune to make that report available to the public. It was compiled by 17 medical and lay experts and is a very fine report on the general cancer position in the country at that date. Its recommendations would also be of considerable value to health authorities and others interested in health and particularly the treatment of cancer.
I do not wish to say anything more about cancer. As the Minister is aware, I could say a lot more: I am, perhaps, more closely identified with the question than any other Deputy. A good deal has been achieved through voluntary organisation at little cost to the State, and I personally think the Minister would do well to continue the anti-cancer campaign through these agencies. In saying that, I have regard to the fact that the question of overall policy is one for his Department, but looking back over what has been achieved, particularly in the past five or six years, I think the record of these voluntary agencies will bear the closest examination by any impartial or expert investigation. Certainly, speaking for myself, I would welcome such an investigation from any authority or commission set up by the Minister.
Several Deputies have spoken about the treatment of mental defectives and I should just like to add to one point made in regard to the care of child mental defectives. Deputies have paid tribute to the communities in their own areas undertaking the care of these mentally defective children and I should like to appeal to the Minister in regard to the community of the Sisters of Charity of St. Vincent de Paul who manage a home for mentally defective children near Limerick City. I think the Minister is aware of the tragic necessity to increase the accommodation in this institution, which was originally a large private house and was acquired by the community some years ago. Its maximum accommodation is 36 children and at present they have 170 children on their waiting list.
Very expansive, and I have no doubt expensive, plans were put before the Minister's Department two or three years ago. I appreciate in present circumstances there is little likelihood that the Minister can give his sanction to go on with these plans, but I should like to add this appeal to a personal appeal I made to him quite recently to sanction at least an increase in the accommodation by 50 or 60. I think every Deputy could tell a truthful and harrowing story of some mentally defective child in its home and the pain and grief it causes parents, and how unhappy such a child is among other children who are fit and well. I would ask the Minister to make a special effort—I know my demand is only one of several—to allocate the necessary funds to increase the bed accommodation in this institution. These good ladies are doing a wonderful work and I think we could afford the necessary funds to give them another 50 or 60 beds.
The question of adult mental defectives was also mentioned. In some of our mental homes, there are persons who would be better described as senile, and I think it should be possible now, through accommodation becoming available, due to the closing down of other institutions, to transfer some of these senile patients to the vacant institutions. Long ago, it was regarded as the duty of children to look after their parents in their advanced years but having regard to the modern complex life we lead, I do not think it is possible now for younger couples, with perhaps four or five children of their own and possibly living in very difficult circumstances, to undertake the care of a parent who may be senile. For that reason, I think that we, as a community, must accept the responsibility of looking after them.
I should also like to appeal to the Minister—this has become an almost annual affair—to increase the very modest grant which he pays to the Medical Research Council. That would be money very well spent. The Medical Research Council is a body which has done a tremendous amount of work in the past. I think I am correct in saying that the present sum is not more than £25,000 or £30,000 which, even in our straitened circumstances, is a very small sum indeed.
Deputy Dr. Browne made reference to the future of the health services here, in particular, making a comparison with the national health service in England and in the Six Counties. I do not think that at the present time we, as a community, however desirable it may be, could accept the financial obligation of a completely free national health scheme. It is inevitable that a free, or almost free, scheme will come some day, but how soon I cannot say. It will come because the people will demand it. The number of people who are just over the border-line are continuing to grow in numbers so that eventually there will be such a demand that whatever Government happens to be in power will be unable to refuse. Eventually, we will have some form of comprehensive State health scheme in this country. If and when that day comes, I hope we will learn from the experience of the British national health scheme.
There is one unit in that scheme which I should like to see preserved free of State and departmental control, that is, the family doctor. Whatever scheme we may evolve, I hope the family doctor will be kept outside it and that the freedom of choice of doctors about which other Deputies spoke will be maintained.
Reference was made to the voluntary health scheme. I must admit that I am very much in favour of that scheme. Even though it is a restricted scheme and does not give some of the benefits it should give, it does provide for a gap in our health services. Unless I am mistaken, I do not think the cost of that scheme compares badly with the cost of the health services as a whole. I think the Minister gave the figure of £5 10s. per head of the population as being the cost of health services. If I understand the terms of the voluntary health scheme correctly, the first scheme costs £12 per year for a husband, wife and four children, which works out at £2 per head, less the income-tax allowance on the premium.
Even though the voluntary health scheme does not provide maternity services—that is its greatest defect—it is a cheap scheme, unless there is some hidden cost in it which I cannot see. It is true that there are other categories where the cost is greater, but even taking the highest scheme, £23 for a husband, wife and children, the average cost is less than £4 per head. There is an allowance for income-tax, which reduces that sum by approximately a further one-third. I do not think it is correct to say that it is far more expensive and far less satisfactory than the per capita cost of the health services as a whole.
Let me end as I began by paying a tribute to all the Ministers who have undertaken this onerous and difficult job of Minister for Health. It is not an easy one. As the Minister quite rightly said, one is caught between the upper and nether millstones of the public demanding more services at less or no cost and, at the same time, crying out against high taxation and rates. I am afraid we cannot have it both ways. Like every other community in the world, we want to have it both ways. The best any Minister can hope to do is to give the best and most efficient and, in the circumstances, the cheapest service the community can afford.
The Minister stated that the very closest scrutiny will be made of our health costs. I hope that same scrutiny will apply to his own Department. I feel that there is no use going down the list to find where to effect economies. The place to economise is at the top. I believe there is room for economy and efficiency in this Department as, indeed, there is in every Department of State.