Yes. I shall begin by reviewing briefly the more significant vital statistics. In 1962 there were more births, more marriages and fewer deaths than in 1961. I am not claiming credit for all that, of course. The number of births registered was 61,782, an increase of 1,957 on the previous year. The rate, at 21.9 per 1,000 of the population, was again appreciably higher than in England and Wales where it was 18.0 per 1,000 and in Scotland where it was 20.1 per 1,000. The number of marriages in 1962 was 15,627, an increase of 298 on 1961. The number of deaths was 33,838, a decrease of 925.
Heart disease, accounting for 10,974 deaths as compared with 11,064 in 1961, was, as previously, by far the most fatal of morbid conditions. Next to heart disease, but a long way behind it, cancer was again the greatest "killer". It accounted for 4,897 deaths in 1962, as compared with 4,704 in the previous year. Of the deaths from cancer, 697 were from those forms of the disease which are grouped under the title of lung cancer. The corresponding figure for 1961 was 682. I shall revert to this matter and comment upon it later. When introducing the Estimate for 1962-63, I expressed the hope that a cobalt unit for cancer treatment would soon be available at St. Luke's Hospital, Rathgar. I am glad to be able to report that the installation of the necessary apparatus was completed during 1962 and that patients have been receiving treatment at the new unit since November of that year. Recently I sanctioned proposals for the provision of a second cobalt unit at St. Luke's and for a further unit at St. Agatha's at Cork. It will, however, be some time before these two new units are in operation. I may mention here that recently a research project into the manner in which cancer spreads in the human body from its site of origin has been embarked upon at St. Luke's Hospital. This study is not being financed from funds at my disposal, but important accommodation and facilities for it are being made available at the hospital.
Simultaneously with the erection and equipment of the cobalt unit at St. Luke's Hospital a new department for the provision of a radio-isotope service was also built and equipped. The capital and running costs are high and it is imperative that the services it offers should be availed of on a wide scale. This has been arranged for and the department at St. Luke's Hospital is providing services for other institutions and for large numbers of outpatients.
Before I pass on to the other matters which arise out of the Estimate, I feel that I should again recall how the recently-issued Report of the Advisory Committee to the Surgeon-General of the United States Public Health Service on smoking and health has highlighted the grave hazards which statistical studies indicate are associated with smoking and, more especially, cigarette smoking. I do not wish to labour the point but if I were addicted to cigarettes, which I am not, I should accept that report as a very grave warning and change my smoking habits accordingly.
The total number of deaths from all forms of tuberculosis was 426 in 1962 as against 420 in 1961. The figure for 1962 is the second lowest on record. The incidence of the disease continues to decline, the number of new and reactivated cases in 1962 being about 200 fewer than in the previous year; thus the number of beds needed for adult respiratory tuberculosis patients on the 31st March, 1963, was 1,648, as compared with 1,883 on the corresponding date in 1962, and approximately 6,000 nine years ago.
The position is satisfactory, so far as it does. Nevertheless, it continues to be most important that everybody should make full use of the facilities available for the prevention of tuberculosis. To encourage them to do so the National Mass-Radiography Association proposes to concentrate more and more on community surveys, in the course of which an intensive effort is made to secure that everybody in a selected area except young children will come forward for X-ray. While, in general, the response to these surveys has been gratifying, it is regrettable that in some areas it fell far short of what was expected.
The number of maternal deaths during 1962 was 27, giving a death rate of 0.44 per thousand live births as compared with 0.45 in 1961 and 1.32 in 1957. But the rate in 1962 for England and Wales was 0.36, for Scotland 0.40 and for Northern Ireland 0.30. It will be seen, therefore, that we have much ground to make up in this most important sector.
The infant mortality rate, that is, the deaths of infants under one year expressed as a proportion of every 1,000 live births, resumed its downward trend in 1962, being 29 as compared with 30 in 1961 and 35 in 1958. The corresponding rate for England and Wales was 22 in 1962, while that for Scotland was 27 and for Northern Ireland 27. It is worth noting that the Maternity and Infant Care Scheme was availed of, fully or partly, in respect of 68 per cent of the 59,825 births registered during 1961.
At the instance of my predecessor in office, the Medical Research Council of Ireland have engaged on a survey into the causes of perinatal mortality, that is, of foetal deaths, occurring after the 28th week of gestation, and of deaths occurring within seven days after birth. The field work on this survey has been completed, and arrangements are in train for processing the data under expert professional guidance.
Infant mortality in the city here is somewhat higher than in the rest of the country; and it has been suggested that the prevalence of congenital malformations may be associated with this fact. Accordingly, I made a special grant to the Medical Research Council, from the Hospitals Trust Fund, and side by side with the perinatal mortality survey an investigation into the incidence of such abnormalities in infants born in Dublin city is now in progress. In this inquiry, which is necessarily a long-term one, an attempt is being made to isolate the factors that interfere with normal intra-uterine development. The survey is proceeding, but I do not expect that anything will emerge from it for some time yet.
Over the years the incidence of and deaths from gastro-enteritis in children under two years have continued to be exceptionally high in Dublin city and have been the cause of much concern. The Medical Research Council have interested themselves in the phenomenon and I have made a grant from the Hospitals Trust Fund to finance an investigation which has been proposed.
Before leaving the subject of maternal and infant care, I should mention that, at my urgent request, the Medical Research Council undertook a special investigation to establish, so far as might be possible, the number of babies born in each health authority area with deformities which could reasonably be attributed to the use by expectant mothers of the drug thalidomide. The Council have completed the survey and their report is now being studied in my Department. In the meantime I have requested the National Organisation for Rehabilitation to consider what facilities are required to assist the children involved. Many of them will require artificial limbs and the Organisation has arrangements in train for the provision of this service at the National Limb Fitting Centre at Dún Laoghaire.
There has been an overall decline in the incidence of poliomyelitis: in 1962 59 cases occurred with four deaths. An examination of the cases reported shows that young people are the most susceptible to the disease.
When introducing last year's Estimate, I referred to the developments in oral vaccination against poliomyelitis in other countries. I sought the advice of the Medical Research Council on this matter, and it recommended that a prophylactic service using oral vaccine should be organised on a national basis. However, I thought it prudent, because of reports received in September, 1962, of cases of poliomyelitis in Canada and the United States following the administration of oral vaccine, to defer the introduction of the service here. The Medical Research Council have again considered the question in the light of investigations which were carried out in the countries immediately concerned, and have endorsed their earlier recommendation. I propose to proceed in accordance with this renewed recommendation and hope to introduce a general scheme of anti-polio vaccination during the coming financial year.
Last year I made special reference to the problem which had been presented by the outbreaks of smallpox which had occurred during 1962 in Great Britain and in the Federal Republic of Germany. Fortunately, no case of the disease was imported into this country but that the public were alive to the danger was demonstrated by the fact that during the first six months of 1962, over 300,000 people were vaccinated against the disease. Though this fact in itself was gratifying, it would be much better and more effective if vaccinations were accepted as a routine measure rather than as a safeguard to be sought en masse when an emergency has developed.
As some public anxiety was manifested when it became known that a case of typhoid had been imported into Dublin from Zermatt, I should make it clear that our public health service is organised and fully equipped to deal with occurrences like this, and that, when circumstances warrant them, all necessary steps to prevent the spread of infection are taken.
I turn now to a second group of diseases, those which disable rather than kill. Foremost among these is mental illness. Despite the fact that the number of mentally ill under institutional care was further reduced during 1962, the condition continues to be one of the most pressing problems in the field of health. The numbers under care increased steadily in the post-war years up to the year 1958, since when there has been a gradual decline. Notwithstanding that over the past five years there has been a reduction of 1,800 in the number of hospitalised mental patients, overcrowding continues to be one of the worst features of our mental health services.
Some of the reduction was secured by transferring to redundant sanatoria elderly patients, who no longer needed psychiatric care, but for the most part, it was achieved by more intensified treatment, leading to earlier discharge, for those admitted to hospital, coupled with the continued rapid development of out-patient services. On the other hand, the number of admissions to mental hospitals has also tended to rise, partly because of an increase in the rate of re-admissions, but mainly because the improvement in the services has created a greater demand for them. Patients are coming forward more readily for treatment and seeking it at an early stage in their illness, at which time the prospects of its success are greatest. The rising re-admission rate is by no means peculiar to this country, and is mainly attributable to the fact that it is now the accepted thing to give a patient his discharge when he has recovered sufficiently to permit this to be done. Formerly such a patient might be retained in hospital indefinitely.
More and more, it is becoming obvious that a high level of community services is an essential element in mental therapy; and I hope as trained personnel becomes available to provide these more generally than heretofore. On the other hand, while in-patient care remains a vital part of the psychiatric services, it is no longer generally regarded as the first line of defence; it is now viewed as a service of last resort, to be availed of only when the possibility of keeping the patient within the community and out of hospital has been exhausted.
Though we have still, I regret to say, substantial deficiencies to make good, conditions in our mental hospitals have improved considerably. It is, of course, mainly a matter of the large sums of money which are required to repair generations of neglect. Yet, I believe, I can claim that with the little we have had at our disposal much has been done. I have continued to stress to mental hospital authorities the need to upgrade their institutions. They have been on the whole most receptive to my suggestions, and I am glad to be able to say that as result, considerable improvement works have been completed or are in progress.
With my approval, a Training School for Occupational Therapists has been set up at the National Rehabilitation Centre in Dún Laoghaire. This centre now has 25 students. Next year the number will be increased by a further 30 and in the following year, there will be yet a further increase. Occupational therapists are not, of course, employed exclusively in mental hospitals, but the availability of personnel, adequately trained in occupational therapy, will considerably enhance the outlook for the mentally ill.
There is not anything so depressing as the spectacle of large numbers of patients sitting around in day-rooms and corridors of a mental hospital, doing nothing. As our capability to occupy the patients in more congenial tasks increases, the change for the better in the morale of patients will be accelerated; for nothing produces a more favourable therapeutic response in the mentally ill than to be made to feel that, however handicapped, one is of some use in the world. The pride and delight which mental patients exhibit in their occupational accomplishments is convincing evidence of the important part which useful and worthwhile employment can play in the cure and rehabilitation of the mentally ill. Therefore we shall do our utmost to develop and diversify our facilities for occupational therapy.
Deputies who participated in the discussions on the Health Authorities Act, 1960, will recall that one of the more teasing problems to be dealt with originated in the fact that for the purpose of the mental hospital service the county of Wicklow was conjoined with the city and county of Dublin in the Grangegorman Mental Hospital Board. Apart from the fact that some reconsideration of the organisation of the mental health services under the Dublin Health Authority would be opportune, I have taken the view that it would not only be advantageous to Wicklow to have its own mental hospital, but that if it had, the problem of overcrowding in St. Brendan's and St. Ita's hospitals might be a little eased.
Thanks to the public spirit of the authorities of the Royal National Hospital for Consumption for Ireland, Newcastle, County Wicklow, to whom I, with the people of County Wicklow and of Dublin city and county, am indebted, it became possible to suggest to the Wicklow County Council that they should establish their own mental hospital. The county council are considering the suggestion and matters are now, I hope, in train for establishing a new mental hospital in the premises of this former sanatorium.
Other very desirable projects in regard to the services for the treatment of mental illness made some progress during 1963 but it would be more appropriate to deal with these in connection with the Estimates for 1964/65.
The Commission of inquiry on Mental Illness which I asked to examine our existing mental health services, are still pursuing their task with care and diligence. At the beginning they were hampered by the inadequacy of the statistical information available. However, a new system of returns which was introduced on 1st April last will facilitate their researches and will assist us in planning hospital accommodation and psychiatric services for the future.
How true it is that mental illness is one of our most pressing health problems is borne out by the fact that we still have 19,250 of our people in mental hospitals. Among European countries we have an unenviable record in this regard. Why this should be so is not at all clear; but, whatever the reasons, the present position makes a considerable drain on our social and economic resources. But, as I have just set out, every effort is being made, on the basis of our present knowledge, to remedy the position by continuing to improve and expand our treatment services.
The House will recall that some years ago my officers made a preliminary special study of the problem of mental handicap on the basis of which I subsequently issued a White Paper entitled "The Problem of the Mentally Handicapped". That document indicated that among the major difficulties to be overcome—apart altogether from the provision of additional accommodation and the recruitment and training of staff-were the ascertainment of the number of mentally handicapped persons, the precise nature of the services and the accommodation required for them and the form of training best suited to our circumstances. With our limited resources, it is of paramount importance to obtain sound and well-considered answers to these problems.
With this in view, I set up a Commission of Inquiry to look into the whole position. The personnel of the Commission is expert and representative, and its terms of reference are very wide. It is, however, faced with a truly formidable task, for there has never before been a planned approach to the problem of mental handicap in this country. The Commission has been meeting regularly and I am hoping it will be able to submit its report within the next year, perhaps even within this year.
In the meantime we have been pressing forward with the provision of extra accommodation for mentally handicapped persons. Thus the number of beds available, which on 1st April, 1962 was 2,703, had risen by 31st March, 1963 to 2,741. In the nine months ending on 31st December last, it rose by a further 156 to 2,897.
Included in the figure for the increase in the last nine months mentioned are 40 places provided by the authorities of Peamount Sanatorium for adult mentally handicapped persons who had received training in one or other of the institutions provided for the training of boys. By accepting these patients, the Peamount authorities made possible the admission of 40 new children to intensive training institutions. This development is a very desirable one indeed. It will not detract in any way from the credit which is due to the organisations which have been longer in the field, if I publicly thank the Peamount authorities for their co-operation.
Further additions to the accommodation available for mentally handicapped patients are in course of planning but, as in the case of development in the mental hospitals, I think it more appropriate to deal with them when presenting next year's Estimate.
In recent years voluntary organisations in the cities and larger towns have established services in day-centres, schools and crèches for the mentally handicapped; and these are being availed of by a constantly increasing number of children. Naturally, I have followed with great interest these developments in community care. Apart from the immediate benefit accruing to the children attending them, the experience derived from them may be of assistance to the Commission of Inquiry in formulating its recommmendations. I am sure that every Deputy will join with me in expressing appreciation of the zeal and devotion of those who have been associated with them.
The Dáil is aware of the good work of voluntary organisations in the development of vocational rehabilitation services. Regulations which I made under section 50 of the Health Act, 1953, enable financial assistance to be given to these bodies. Other regulations also made by me empower health authorities to pay allowances, where necessary, in respect of trainees to cover maintenance during training. Facilities for training and services for the placement of disabled persons in employment are available through the Rehabilitation Institution Ltd., and the other voluntary organisations working in this field; but existing facilities in vocational schools are also to be availed of in suitable cases. It should be borne in mind that the regulations concerned with vocational training and placement in employment differ from those concerned with medical rehabilitation. Medical rehabilitation is a separate service and has been developed, under other provisions of the Health Acts, as a part of the hospital and specialist services.
In recent years great emphasis has been laid on the need for greater productivity and efficiency in industry. It has not been so generally realised that it is equally desirable to secure the maximum of efficiency in the health services. An unnecessary duplication in this field of accommodation, equipment, or personnel is an unjustifiable dissipation of resources. If resources become superfluous to a particular service, or if a service may be made more economical by efficient reorganisation and pruning, the superfluities can be readily used in the improvement and expansion of services — and there are several—not yet at their optimum. All those concerned with the services, whether individuals, health authorities or other bodies, must have constant regard to considerations of efficiency and economy. My obligation as Minister for Health is to ensure that in the allocation of public funds for capital purposes new accommodation or equipment is not provided except where the need cannot be met by existing institutions or by special arrangements for co-operation and the sharing of resources between them.
Considerations of economy and efficiency are particularly pertinent in the case of sanatoria which, because of the decline in tubercular disease, are under-utilised or are redundant. Some health authorities are reluctant to permit such places to be put to proper use and will only do so under extreme pressure and after protracted argument. This frame of mind is most unfair, not only to ratepayers and taxpayers, but to those sufferers from conditions, often psychiatric, who are deprived of much needed accommodation by this dog-in-the-manger attitude.
Sometimes even a similar disposition may be encountered in the authorities of a voluntary general hospital, who frown at any suggestion of sharing facilities or equipment with other hospitals and are almost obsessed with the aim of making their institutions entirely self-contained. The end result is unnecessary duplication of equipment and wasteful deployment of personnel. When one has met this attitude, it is very gratifying to publicise a development in which economy and efficiency through co-ordination are being sought for.
The provision of a reliable and efficient sterilising service for any hospital is a matter of prime importance, but with every hospital doing all its own sterilising work, it is a costly item. For some time, my Department, though it was hesitant in raising the matter with the hospitals, had hoped for the development of a central service of this kind. The idea became a practical proposition when a number of Dublin surgeons, who had seen the work of a Central Sterile Supply Service in Glasgow, suggested that a similar service might be set up here, an approach which was warmly welcomed. A meeting of representatives of all the Dublin hospitals, including the health authority hospitals, was arranged and it was agreed that the matter should be further examined by a working party, which was to consist of a number of persons selected at the meeting together with some members from the staff of my Department. The working party, which met on many occasions, mostly at night, in the Custom House, has presented me with an excellent report confirming the feasibility and desirablility of setting up a central service. Copies of the report have been circulated to all the hospitals concerned and a meeting of their representatives will be held next week at which they can state their views. If the project is proceeded with, it should provide a service which from the outset will have a guarantee of absolute reliability and security and, in the long run, be more economical than the present fragmented service. Moreover, such a service could in due course be extended to all hospitals in the State.
Over three years ago, I authorised resumption of planning on two major hospital building projects in Dublin, to wit, the new Coombe Hospital on which work commenced in August last and the new St. Vincent's Hospital at Elm Park on which work commenced recently. When I was introducing the Estimate for 1962/63, I commented on the slow progress made in the re-planning of the St. Vincent's project; nothing which has occurred in the meantime has induced me to change my view in that regard. However, it is a good thing we have been able to get to the stage that work has been actually resumed on the project.
Excluding works on county homes, to which I shall refer later, the total value of the hospital building works, the planning of which I authorised, as circumstances following the financial crisis of 1956 permitted, amounts to approximately £10 millions, about £7½ millions of which will be met by grants from the Hospitals Trust Fund. The estimated cost of works completed or in progress within the £10 millions programme is about £6 millions. Apart from the two major Dublin projects I have mentioned, this figure covers a wide variety of works throughout the State. Instances are the extension of Erinville Maternity Hospital, Cork, the installation of the cobalt unit at St. Luke's Hospital, Dublin, a new paediatric unit at the Rotunda Hospital, Dublin, major schemes for accommodation of mentally handicapped children at Delvin, County Westmeath and at Cregg, Sligo, various works at Galway Regional Hospital, admission units at Cork and Castlebar Mental Hospitals and other works at the mental hospitals at Grangegorman, Letterkenny, Portlaoise, Enniscorthy, Killarney and Waterford.
Tenders have been approved for a major extension at the National Medical Rehabilitation Centre at Dún Laoghaire, for a new maternity block at the County Hospital, Castlebar, and a new nurses' home at the County Hospital, Kilkenny. Tenders in connection with a scheme of extension at St. Vincent's Home for mentally handicapped children at Lisnagry, County Limerick, have just been received and are at present under examination. The actual construction work on all these schemes, the cost of which is estimated at almost £½ million, should, therefore, commence within the next month or so.
Projects at the stage at which tenders have been invited but not yet received, or at which it should be possible to invite tenders inside the next six months are estimated to cost over £1.3 millions. The largest single item in this is the major scheme of extension at Sligo County Hospital which for certain specialties will then become a sub-regional centre. Other major items are an extension of the National Maternity Hospital at Holles Street, a new nurses' home at Portrane Mental Hospital, major works at the South Charitable Infirmary, Cork, and Jervis Street Hospital, Dublin, a new admission unit at Clonmel Mental Hospital, and a scheme of adaptations at St. Joseph's Home for Mentally Handicapped at Kilcornan, County Galway. Of the grants from the Hospitals Trust Fund amounting to £7½ millions involved in this programme, over £5 millions or 66? per cent will be payable in respect of projects in voluntary hospitals.
Much has been done, by raising the standards of nursing care, of dietary, of decoration, of furnishing, and of sanitary accommodation in county homes to improve the lot of patients. I cannot say the same in regard to the progress which has been made with the programme of radical improvements which was designed to bring accommodation up to what could be regarded as an acceptable standard. Originally it had been thought that little more than the reconstruction of the existing structures would be required. On detailed examination of the existing buildings, it was found that many of them had inherent defects which either could not be eradicated at all or eradicated only at very great cost. In such cases there was no reasonable alternative to new building. The progress of planning has had to be altered accordingly and this has made delays inevitable. In many cases this re-planning is nearing completion or has been completed, wholly, as in the case of the Home at Mountmellick where construction work is in progress on a comprehensive scheme costing about £250,000; or in part, as in the case of the Home at Stranorlar where new, single-storey, accommodation for 98 chronic sick patients is in course of being built as part I of the major scheme.
Experience has led me to accept with some reserve forecasts of the time needed before any project can be brought to tender stage; but I can see no reason at present why it should not be possible to invite tenders for the following works in the periods indicated:
Before 31st March next: Castleblayney—Comprehensive scheme.
In the April/June quarter: Clonakilty—Chronic sick (100 beds), central services, staff unit and full central heating. Ennis—Chronic sick (200 beds), convent, and central heating.
In the July/September quarter: Athy—Comprehensive scheme. Longford—Chronic sick (94 beds), central services, central heating. Trim—Completion of comprehensive scheme.
In the October/December quarter: Castlebar—Chronic sick (230 beds), convent, staff home, central services and central heating. Roscommon— Chronic sick (200 beds) and central heating.
The cost of the county homes schemes is met, as most Deputies know, by borrowing from the Local Loans Fund and health authorities have recouped to them from the Vote, half the loan charges involved, subject to an overriding maximum cost per bed. The aggregate cost of the schemes, which are already in progress or which should go to tender within the next year or so, is of the order of £3 million. In addition to the schemes I have enumerated, planning is at various stages in relation to other schemes and I expect that after the end of the next year there will be a steady flow of further works going to tender, until all our county homes will have been brought up to an appropriate standard.
I have dealt so far only with schemes that are included in the approved building programme, that is, schemes for which funds have been promised. The problem, however, does not end there. Further schemes, most of them highly desirable, have been put before me, on which the total outlay would be in the region of £15 million. Moreover, we must budget in the long term for other inevitable expenditures as well. Without anticipating in any way the recommendations of the Commissions on Mental Illness and on Mental Handicap, it is probable that they will suggest that greatly improved facilities are required in the fields which they are at present exploring. Further, if the moneys were available, the position of the teaching hospitals and the accommodation problem in the case of nursing staffs would also merit very special attention. Thus, to achieve a final solution of our hospital problems in the matter of physical accommodation will entail a staggering financial outlay, beyond our immediate resources. Consequently, I have no option but to apportion the funds at my disposal in an ordered manner; and this compels me to issue certain warnings to the promoters of hospital projects.
The first of these I have given frequently already. It is that it is a waste of time and effort to try the technique of the fait accompli. I will not in any circumstances pay any portion of the cost of any project undertaken without my prior approval. To do so would be grossly unfair to hospital authorities—and there are many— which abide by the rules.
The second is that once approval has been given for any project, the hospital authority concerned must ensure that the planning is carried out with dispatch. In selecting its consultants, the hospital authority should ensure that they will be in a position to proceed expeditiously with the work. Otherwise, I may not have any option but to relegate the project to the end of the queue or even to cancel a grant already authorised.
The third warning is that hospital authorities must be practical and eschew any grandiose notions. In the difficult financial situation obtaining we cannot hope to provide every amenity and every facility that would constitute the ideal hospital. On the contrary, economy must be the keynote in our approach to hospital building; and, accordingly, we must content ourselves with modest and reasonable standards. The drop in income from the most recent Sweepstakes as compared with the previous year, when coupled with the heavy revenue deficits of the voluntary hospitals, is a forcible reminder that building on a pre-war scale is out.
With regard to the details of the Estimate for 1963-64, Deputies will observe that, including the two Supplementary Estimates, the first of which is now before the House, and the second of which will be taken immediately this token Estimate is disposed of, there is an increase of £1,133,660 over the Estimate for 1962-63. This increase, to all intents and purposes, is attributable to Subhead G which, with the amount in the Second Supplementary, provides for a total of £11,330,000 in grants to local health authorities in aid of their expenditure on health services. The total revenue expenditure by health authorities in the current year, after allowances for receipts such as charges for services, is now estimated at over £22½ millions.
Over the past year or so, representations have been made to me from a number of quarters regarding the proportion of the cost of the health services falling to be met from local rates. As Deputies will be aware, the statutory provisions governing the apportionment of these costs between the Exchequer and the local rates are contained in the Health Services (Financial Provisions) Act, 1947. This revolutionary piece of legislation was a milestone in the history of the health services; I say "revolutionary" because in fact it revolutionised the system whereby the health services had been financed up to that time. Prior to the 1947 Act, local finances had borne by far the greater part of the cost, being supplemented only by modest State grants—grants which, apart from their modest size, had the further disadvantage that they could not be disposed of as the local authorities themselves might think fit but had to be applied to limited specific health purposes. In terms of money, the Exchequer grants represented at £900,000, a mere 16 per cent of the total cost of the services being provided. Thus the local authorities were paying 84 per cent of the cost of the health services before the present system of financing was introduced. By virtue of the 1947 Act which I have mentioned, this 84 per cent has been reduced to 50 per cent and, though it is the fact that, partly because of rising costs, including staff wages, and partly because of greatly expanded services, the actual costs have risen substantially since 1947, the fact remains that the Gross National Product has risen enormously and that proportionately, the allocation of costs has been adjusted heavily in favour of the local rates.
In the year ended 31st March, 1957, the average rate for health services, including mental health, in county health districts was 12/4d.; this had increased to 15/11d. for the year ended 31st March, 1963. The comparable figure for county boroughs shows an increase from 16/11d. to 19/9d. Thus, in the six-year period since 1956-57, the health rate increased in the county council areas by 3/7d., on average, and in the county borough areas by somewhat less. When due allowance is made for the increase in costs, particularly salaries and wages, and the striking improvements, over that period, in the facilities available for the treatment of the sick in our modern hospitals it can hardly be said that this increase is unduly large.
Despite the fact that interest in this matter of increases in the rates has concentrated largely on the health services, what must not be left out of account is the fact that the local rates in respect of other major services have increased in much the same proportion. A similar upward trend is, for instance, observable in the case of housing; in the year 1956-57 the housing rate in County Carlow was 1/4d. in the £; by 1962-63, it had increased to 5/5d. In County Donegal, the housing rate was 3/- in the £ in 1956-57; by 1962-63, it had risen to 4/10d. In Cork County Borough, the housing rate rose from 3/1d. in 1956-57 to 6/5d. in 1962-63; in Dublin County Borough, it rose from 4/3d. to 5/8d.; in Limerick from 5/11d. to 6/5d. and in Waterford from 2/3d. to 6/3d. Under the heading of General Purposes, the same upward trend is visible; in Longford the rate under this heading for 1956-57 was 6/5d.; by 1962-63 it had increased to 9/7d. The figures for General Purposes in Louth in the same years showed an increase from 4/5d. to 6/5d.; in Mayo, from 6/3d. to 8/8d.; in Tipperary (NR) from 7/4d. to 10/8d.; and in Wexford, from 5/7d. to 8/10d.
Part of the reason for these increases has, of course, been that, in general, the tendency is to expand and improve services—a movement which, I am happy to report so far as the health services are concerned, the health authorities themselves wholeheartedly support.
The hospital services are by far the largest element in the cost of the health services. As will be seen from the details in Part III for Subhead G of the Vote in the Book of Estimates, it was originally estimated that they would cost £15,060,000 in the current year. To this figure must be added a further expenditure by health authorities of £790,000 in respect of which an additional Health Services Grant is provided for in the second Supplementary Estimate, to be taken in conjunction with this Estimate. The total anticipated expenditure by health authorities on hospital services in the current year is, therefore, the formidable sum of £15,850,000.
This, however, does not represent the total cost to public funds, even ignoring capital expenditure, of the hospital services. To that figure must be added the amount which it will be necessary to add from the Hospitals Trust Fund to make up the revenue deficits of the voluntary hospitals. It is estimated that that figure in respect of 1963 will be £2,200,000.
It was never contemplated that sums of such magnitude would be diverted from the Hospitals Trust Fund for the purposes of keeping the revenue accounts of the voluntary hospitals in balance. The progression in the size of the deficits, year by year from 1956 onwards, is interesting. The figure for 1956 was £920,000—I quote the figures to the nearest £10,000—in 1957, it was £960,000; in 1958, it was £1,100,000; in 1959, £1,190,000; in 1960, £1,440,000; in 1961, £2,040,000; in 1962, £2,160,000; and in 1963, it is estimated as I have said, at £2,200,000. The cost of maintaining patients in the voluntary hospitals, as in the case of the local authorities' own hospitals, has been increasing steadily, in part due to increased staff costs and in part to advances in medical science which now make it possible to treat and to cure patients for whom previously little could have been done. The revenues of the voluntary hospitals, however, have not been keeping pace with the expenditures, largely because health authorities, who are liable for the cost of treatment of the vast majority of the patients, pay for them at rates which are completely unreal, and in most cases far below what it would cost them to maintain the patients in their own hospitals, even if they had the facilities to do so.
While the deficits were increasing at this spectacular rate, the capitation rate, excluding the supplement payable in respect of services of visiting medical staff, paid by health authorities to all the major hospitals in respect of in-patient services rendered by these hospitals, remained at 18/- a day from 1956 until April, 1962, when the rate was increased by 6/- for the teaching hospitals and 3/6d. for the non-teaching major hospitals. These increases were barely sufficient to cover the eighth round of increases in salary granted by the hospitals to their staffs, in line with the increases granted by local authorities to their local staffs, and a further increase in the capitation rates was long overdue when they were again increased, with effect from 1st October last. These last mentioned increases account for £170,000 of the increase in the Health Services Grant being provided for in the second Supplementary Estimate.
As Deputies will be aware, the capitation rates are being further increased with effect from 1st April next but as no provision for any expenditure arising out of that increase is included in the Estimate now before the House, I presume I would be precluded from dealing with that matter until next year's Estimates are under discussion. It is not only for the increased cost to health authorities of services given on their behalf in voluntary hospitals, however, that provision has to be made in the second Supplementary Estimate. According to the most recent information supplied by the health authorities, the cost of services in their own hospitals in 1963/64 will be greater by £430,000 than had been originally estimated. The largest single item in that figure is £170,000 for salaries and wages. Drugs and medicines account for a further £50,000 approximately. The balance is spread over miscellaneous heads.
When one comes to consider the hospital service strictly in the financial context, one must accept that while this is "big business", one cannot apply to it the yardsticks which are appropriate to industry and commerce. The businessman can readily assess the degree of success achieved in his year's work by reference to the financial return which it has yielded. For hospital management there are no such clear guide-lines, and the spur to greater efficiency is, in most cases, the rather crude and negative one of financial stringency. Yet in spite of the difference in objectives between business concerns and hospitals, they share a need for good and effective administration. Some branches of hospital activity such as catering and laundry work would, of course, pose problems similar in many respects to those met with in commercial undertakings operating in these fields. Not only in regard to services like laundry and catering, but in all branches of the hospital organisation, there can be no argument about the value of a frank look at each job that is being done to establish the need for it, or of engaging in a painstaking search for the best and most economical way of doing whatever it is clearly necessary to do.
Since the war there has been growing recognition in business and industrial management of the need for constant analysis and improvement of working methods. The application of work study methods in the hospital setting has lagged behind but in the past few years both in Great Britain and in Northern Ireland these procedures have been successfully applied in hospitals and many improvements in methods have been secured. Through the initiative of the Institute of Public Administration an opportunity has been offered to a number of those concerned with hospital management in this country to learn from those engaged in hospital work study elsewhere something of the methods employed and the improvements to be secured through the application of these methods. I am satisfied that in the long term the consistent application of modern management techniques coupled with the dedicated work of the medical and nursing staffs will ensure that our hospital services will provide the highest standards of treatment and care for the patients under conditions of maximum efficiency and convenience of operation.
The expansion and improvement of the health services in recent years is reflected in the increase in the number of medical and other personnel employed. For example, the overall number of wholetime medical staff employed by health authorities has increased by more than 30 per cent since 1958, the greatest proportionate increase occurring in the mental health service. With increased staffing requirements, it is essential that an adequate supply of suitably qualified candidates will be available for local authority posts. Difficulty is experienced from time to time in the recruitment of doctors in the house officer grade in our local hospitals. This may be due partly to a bias which, inexplicably, appears to exist among medical graduates against accepting employment in these hospitals and partly to the inducement offered to our young doctors to accept lucrative posts abroad. With our limited resources, we cannot compete on equal terms with wealthier countries in the matter of remuneration and conditions of employment. But to those who wish to live and work in their own country, however, we can say that there are openings in our expanding services which offer reasonable standards of remuneration and working conditions.
In the last two years, with a view to showing young people studying for the medical profession the scope and standard of the work being carried on in local hospitals, a scheme was introduced under which medical students in their fourth and final years were offered employment in the local authority hospitals during the college vacation periods. Forty-six students in 1962 and 84 students in 1963, mostly in their final year, were engaged and the reports on the results of the scheme were so encouraging that it is being repeated this year. I would stress that the aim is not to replace or dilute the resident medical staff, but rather, as I mentioned, to provide students with an opportunity of acquiring at first-hand, knowledge of conditions so that they will be encouraged to take up posts in local authority hospitals after graduation.
Because of the limited amount of funds available for dental services and the insufficient number of dental surgeons available to health authorities, it has not been possible, much to my regret, to provide a comprehensive dental service for eligible persons under the Health Acts. The position in regard to recruitment has, I am glad to say, improved somewhat. As an essential step in the further development of the service I have approved of the appointment of chief dental officers in Dublin and Cork, and senior officers in Limerick, Kerry, Donegal, Mayo, Waterford and Galway, and hope to persuade the remaining health authorities to make similar appointments, where appropriate.
During the debate on the Estimate for 1962/63, I mentioned that the National Organisation for Rehabilitation had agreed to operate a national hearing-aid service for persons eligible for aural services under the Health Acts. The service is now obtainable at the organisation's premises in Ballsbridge, Dublin, but I regret to say, despite urgings by my Department, health authorities have been rather slow to avail themselves of it. It is to be hoped that in the coming year there will be a considerable improvement under this head. In association with the hearing-aid service, the organisation will provide an educational advisory service for the benefit of children and this will be backed by the arrangements now made by health authorities for ascertaining, early in life, what children have defective hearing.
I wish that I was able to do much more to ameliorate the condition of those, particularly children, whose hearing is defective. But two things are needed for the expansion of the service: money and trained personnel. So far as the latter essential is concerned, we have had to start from almost absolute zero; and it has been slow, sometimes almost frustrating, and expensive to acquire a sufficiency for the launching of the present service. And as for money! Well, the attitude of the main Opposition, not only toward the last Budget, but even toward the recent Vote on Account, indicates that they will do their utmost to persuade the taxpayer not to provide it; and this is tantamount to denying to those who suffer from deafness, the benefits which we could otherwise make available to them.
