As the House knows, I am somewhat limited in the time I may take. Therefore, if my replies to matters which have been raised here appear brief or scrappy, or in some other way unsatisfactory, I would ask the indulgence of the House because I am anxious to conform to the order the House has made.
Deputy Esmonde referred to the incidence of heart disease and asked for a breakdown into age groups of the figures for deaths from that disease for the years 1962 and 1963. I am having this information complied and I shall arrange to have it sent to the Deputy. He may not perhaps be aware that a considerable amount of research on the subject of heart disease is at present being conducted here.
Some Deputies suggested that the Departments of Health and Social Welfare might be merged. I should like to point out that the functions of the Minister for Health are primarily concerned with the treatment and prevention of ill health and those of the Minister for Social Welfare with the provision of an income maintenance service. It should be understood that the health services are only incidentally concerned with economic considerations but social welfare services are directly designed to relieve economic hardship. To combine, as a couple of Deputies suggested, in one Department functions so essentially different in character and operation would be improvident, and unwise and frustrating in its consequences; for one of the essential functions would inevitably be subordinated to the other, social welfare requirements being sacrificed to health requirements or vice versa, to the detriment of the public as a whole.
Deputy T. F. O'Higgins deplored the fact that I had accepted a grant-in-aid to enable me to continue with my hospital programme. I should much prefer to do this without Exchequer assistance but I certainly would not go so far as the Deputy in contemning it. He seems to make virtue of the fact that it had been incontinently withdrawn from him in 1956-57 and withheld from him in 1957-58. I am disposed to believe that neither the withdrawal of it, nor the withholding of it, in those years was done at his instance. For if they were, then Deputy T. F. O'Higgins would have been responsible for all the loss, inconvenience, unemployment and suffering that the virtual suspension of all hospital treatment entailed at that time. This I do not think he would willingly be.
The Deputy refers to a building programme which he had drawn up before he left in 1957. It was a magnificent manifestation of optimism. On the basis of prices ruling even in those days, it would have cost £5½ million. I am sorry to say my predecessor had not one red cent to give effect to it. On the contrary, he had already received the proceeds of the 1957 Grand National Sweepstake in advance of the normal date, in order to meet pressing obligations in respect of work already done.
There were 38 projects in my predecessor's programme. For various reasons, nine of these dropped out of the programme and, of the remaining 29, 22 have been completed or are practically so, six others are in progress, and planning on the remaining scheme is well advanced. In addition to these 29 schemes, other works, requiring about £3¾ million, have been completed, are in progress, or are being planned; so that by the end of the year almost £8 million worth of work will be in hand or in train.
In his references to the Elm Park, Coombe and Erinville projects, Deputy O'Higgins was sadly served by his memory. I must, therefore, remind him that so far as Elm Park and the Coombe were concerned, he had not made up his mind as to whether these two particular projects or the new St. Laurence's Hospital or the Regional Hospital at Wilton Road were to be allowed to proceed. In these circumstances, it is quite fanciful of him to suggest that under him work on Elm Park or the Coombe would have commenced in 1957 and been completed in 1960. Even the mere planning of these major works would have occupied 2½ or 3 years; so that, taking into consideration the time to be allowed for tendering, it would have been 1961 or later before the necessary contracts were signed and the works begun. All this, of course, on the basis that Deputy O'Higgins would have been in a position to finance the contracts from the Hospitals Trust Fund—a position in which, I must emphasise, he would not have been.
As for Erinville, my predecessor agreed in February 1957 that plans for it should be examined and finalised, but that it should not be allowed to go to tender until 1958 or 1959. In the case of this particular hospital, there have been grievous delays on the building and were it not for these the new maternity block would have been functioning over a year ago. However, it was put into commission recently.
Deputy O'Higgins expressed disappointment that I did not say that there would never be again a fear of a thalidomide type of tragedy in this country. No responsible Minister could possibly give such an undertaking. No matter how arrangements for the testing of drugs by manufacturers are improved, it will never be possible to give an absolute assurance such as the Deputy asks.
In fact at the recent World Health Assembly the Director of Health Services of a European country said that while his country carried out strict clinical and pharmaceutical evaluation of drugs, the possibility was being considered of excepting possible mutagenic and teratogenic effects from certification of safety and efficacy. This is a matter which affects all countries and arrangements have been inaugurated by the World Health Organisation which it is hoped will ensure that adverse drug reactions will be notified to it, so that this information may be disseminated to member states. The steps to be taken by us in this connection are at present receiving consideration.
Deputy Dr. Browne referred to the Select Committee on Health Services whose work he appears to regard as a "parliamentary game". Deputy Treacy also referred to this Committee in a manner which suggested that its findings could have been expedited and its report made available long ago. A similar view was also expressed by Deputy Kyne. One would think from all this, that the Government asked the Dáil to set up the Committee just to "rubberstamp" the proposals of the Labour Party in regard to health services. If this had been the intention, no doubt the Committee could have reported long ago. But that would have been, I suggest, to make a laughing-stock of the Dáil.
The Committee was not set up to accept, endorse, or recommend in accordance with the preconceived notions of any person, or Party or body in relation to the health services. The resolution of this House requires it to make a thorough and independent appraisal of the whole of the existing system of such services; and this is precisely what the Committee is engaged in doing. I suspect, however, that the attempts which are being made to jostle and hustle the Committee in its task derive from the fact that the more closely the investigations are pressed the more clearly it becomes established that there is no serious or general dissatisfaction with the health services as they exist.
Deputy Dr. Browne suggested that, even though this matter is at present under consideration by the Select Committee, I should make known, at this stage, what my intentions are in relation to the question of a choice of doctor for persons in the lower income group. My intentions can be simply stated: They are to consider carefully any recommendations on this or any other matter that may be contained in the report of the Select Committee.
It will be appreciated that the availability of doctors of choice is restricted by a number of factors. In isolated areas, for instance, there might be no more than one doctor available. There is also the point that any system designed to provide for a choice of doctor would, presumably, be operated on a panel basis. If the service were to be extended to groups other than the lower income group, it is inevitable that the panels of the more popular doctors would be filled rapidly; so that some persons who would prefer to have the services of such doctors would have to be content with their second or third choice. Apart from all that, any scheme which would provide for a choice of doctor would be a very expensive one.
Deputy Byrne accused me of smugness when I said that "we can justifiably claim that the quality of the health services available for our people is, on the whole, excellent and keeps pace with modern developments."
He on the other hand expressed the opinion that it fell behind the standard of advanced countries. Only an ignoramus could honestly hold that view and I do not propose to discuss it any further.
Deputy Dr. Browne has observed that "it should be very exceptional that a mother should die in childbirth." Such deaths are, in fact very exceptional among us. I am not saying that they are few or that they are not regretted but in 1963, there were 22 maternal deaths in 60,000 births, that is, roughly one in three thousand. Twelve years ago the rate was almost five times as high.
The Deputy has asked that the social and financial status of mothers who die in childbirth should be investigated. I think that such an investigation is inherent in the projected survey to be undertaken by the Irish Medical Association. I shall, however, examine his further question as to whether it would be possible to secure similar data in relation to infant deaths; but my feeling at the moment is that the studies in progress are likely to produce quicker results. In connection with this whole matter, however, it would be well to bear in mind that anaemia in pregnancy is a complicating factor in relation to the health of both mother and infant and that anaemia occurs without reference to the income group of the family.
A number of Deputies, among them Deputies Kyne, Treacy and Dr. Browne, advocated a comprehensive health scheme. Two of them, Deputies Kyne and Treacy, suggested that the cost of such a scheme might be met from insurance contributions. This question is being specifically examined by the Select Committee of this House, and I do not propose to deal with it now, beyond saying that estimates of the cost of such a scheme compiled in December, 1962, showed that, on the basis of the figures then available, it would cost in the region of some £30 million. On the assumption that the taxpayer would, through general taxation, bear one-third of the cost of the scheme, this would involve a special insurance contribution in respect of gainfully occupied persons of 10/- each per week. On the basis of current figures, however, the cost would be more likely to be £38 million a year and the special additional insurance contribution 12/6d. per person. If the taxpayer were not called upon to bear one-third of the cost, this latter figure would need to be increased by 50 per cent, that is, to 18/9d. per person.
Deputy Treacy seemed to think that individuals who were insured under the social welfare code contributed to the cost of the services available to them under the Health Acts. This, I may say emphatically, is not the case. No part of the contribution of a person who is insured under the Social Welfare Acts goes to defray the cost of the hospital and specialist service available to him under section 15 of the Health Act, 1953. The benefits which he receives under that section are entirely uncovenanted, conferred on him gratuitously by the Act in question, and I am surprised to find that Deputy Treacy seemed to be unaware of this.
Deputy Carroll urged that a doctor should accompany ambulances in accident cases. This would be a completely uneconomic use of the services of experienced hospital doctors. In the generality of accident cases no work can usefully be done for accident victims at the roadside or on the way to hospital other than to carry out first aid and resuscitation procedures. Anything more than that can best be done in the hospital. Fire brigade ambulance crews which deal with accident cases in the city are trained in these procedures. In the country areas, where such crews are not available, it is the practice for a nurse to accompany the ambulance on accident calls.
Deputy P. Hogan (South Tipperary) had a very useful comment to make on the idea of special accident hospitals. The comment was of particular interest because of his experience in this field. He certainly deprecated the idea that it would be of much use and, in support of this, the European Regional Committee of the World Health Organization, which discussed the organisation of resuscitation and casualty services last September, came to the conclusion that the establishment of special casualty hospitals was not to be recommended; and I am prepared to accept the views of the experts of the World Health Organization rather than those of some of the Deputies who spoke here in support of the opposite viewpoint.
Deputies Esmonde and Leneghan raised the question of the provision of local institutions to take care of mentally handicapped children in each locality. This is not practicable in a great many areas. Apart from the need to provide suitable and separate segregation facilities for each sex, special facilities for maintenance, education and training are required for the different age groups and for persons suffering different degrees and different types of handicap.
There is, too, the question of securing suitable and adequate staff. This is not always easy although the position has improved somewhat with the establishment of An Bord Altranais of a separate part of the Register of Nurses for persons specially trained in the nursing of the mentally handicapped. In short, I may say that, without regionalisation, it would not be possible to have sufficient numbers of the different age and other groupings to make provision of proper care and training a practicable proposition. With special relation to Deputy Leneghan's criticism, there are at present two residential institutions for mentally handicapped children in Connacht—Cregg House, Sligo, for girls, and Kilcornan House, near Galway for boys. In addition, it is hoped that very shortly Woodlands in Galway will be available. Children from Connacht are also admitted to residential institutions in other provinces.
Nursing is a noble and dedicated profession and it is only fitting that the remuneration and conditions of service of those engaged in it should be as attractive as the community can provide. I must deprecate statements made here suggesting that our nurses are overworked, underpaid and exploited. I have approved of the employment of additional staff to enable the hours of duty of nursing staffs in public authority hospitals to be reduced to 90 hours per fortnight. I understand that this is also in operation in our voluntary hospitals. Nurses in local authority service now have access to a scheme of conciliation and arbitration. I understand the general salary revision claim submitted by their organisation, the Irish Nurses Organisation, is, in fact, being examined at present under the scheme. Any resulting salary revisions will naturally be applied to comparable classes of nurses in the employment of voluntary hospitals participating in the deficit recoupment arrangements.
Deputy Kyne was unduly perturbed by the fact that some of our nurses emigrate. Many of our nurses do take employment in Britain and America, as do members of other professions, but, so far as nurses are concerned, it is a two-way trend; movement is not solely outward. It is inward as well to the extent that each year about 40 per cent of the registrations in the General Division of the Register kept by An Bord Altranais represents Irish girls who have trained in Britain or Northern Ireland and are returning to work here. Before I leave this matter, I might say we are not in general experiencing any difficulty in getting our requirements of nurses for our hospitals.
Deputy Hogan (South Tipperary) asked what was the position with regard to arrangements for the setting up of the proposed central sterile supply service. It is very far advanced.
Deputy Byrne raised the question of the standards of hygiene in Dublin licensed premises. The Food Hygiene Regulations are administered, I would remind the House, by the health authorities through their medical and health inspector staffs. I have no reason whatsoever to believe that these authorities are not enforcing the regulations in Dublin. If the Deputy has grounds for believing otherwise I should be grateful if he would furnish them to me. The Food Hygiene Regulations, apart from the registration provisions apply to licensed premises. Some time ago the Dublin Health Authority intensified action to ensure that the provisions of the regulations were being complied with in such premises. Unfitness of premises, including unsuitable sanitary conditions, may now be regarded as a ground of objection in connection with the grant or renewal of a licence and I have drawn the attention of health authorities to this fact. I promise also to draw the attention of the Dublin Health Authority to Deputy Byrne's remarks.
In October last, the Queen's Institute of District Nursing informed me that they were forced for financial reasons to contemplate dissolution. My immediate reaction was to express keen regret at this situation and to tell the Institute that I was very ready to consider ways and means of resolving their problems. It emerged that one of the main worries confronting the officers of the Institute was that their pension fund might prove unequal to the demands made upon it. I gave a formal assurance that should the Institute find itself unable to meet in full, its liabilities in respect of the superannuation of its staff, I would be prepared to make grants available to meet such a deficiency.
The second major worry of the Institute was the problem of securing additional funds to meet a contemplated increase in the salaries of the district nurses. For many years local health authorities have had my sanction to pay subventions to district nursing associations up to a maximum of 75 per cent of each association's annual expenditure. Notwithstanding this already substantial endowment from public funds, I told the Institute also in March last, that I was prepared to ask health authorities to increase their subventions, where necessary, to a maximum of 85 per cent of the annual expenditure of district nursing associations. This offer on my part, taken in conjunction with the pensions guarantee, cannot be regarded, I think, as ungenerous treatment.
I would suggest that those Deputies who were so eloquent in their pleas for more support for the Institute should emulate my action in a practical way by organising and engaging in a campaign to enable the Institute to raise the balance of 15 per cent which it requires in order to continue its splendid work among our people.
Deputy Tully stated that some dispensary doctors discourage patients seeking attention after certain hours at their residence. Dispensary doctors, I may say, and everybody knows it, I think, are required, of course, to afford medical attention at any time, on request to eligible persons in their own homes where such persons are unable, through illness, to attend at the dispensary. I have no evidence that dispensary doctors in general discourage calls to the homes of their patients. If the Deputy will furnish me with particulars of any specific cases which have come to his notice I shall have them investigated.
Neither am I aware that it is common practice on the part of dispensary doctors, as Deputy Tully stated, to query their patients as to their entitlement to hold medical cards. Likewise, if the Deputy wishes to furnish particulars of specific cases in this matter I will have them investigated also.
I am in full agreement with the view expressed by Deputy Tully that if a dispensary doctor has reasonable doubts as to the entitlement of any of his patients to hold a medical card the position should be dealt with in accordance with the General Medical Services Regulations, that is to say, that the patient should be treated and the question raised with the health authority and not with the patient.
Deputy Tully referred to the circular which in 1961 I caused to issue to health authorities drawing attention to the fact that they were authorised to supply drugs and medicines in cases where the persons concerned, through the financial hardship involved, were unable to meet the cost of these requisites. In the light of his remarks, I shall again draw the attention of health authorities to their functions in this matter.
Deputies Tully, Leneghan and Kyne raised the question of dental services. I concede that the public dental services are capable of improvement. Their defects are, however, due in great measure to the shortage of dentists and our shortage of money. I am doing my best to remedy the former by improving the remuneration of dentists employed in the local health service; and the Minister for Finance is struggling with the latter.
Deputy Leneghan held that there is no outside nursing service at all in County Mayo. In saying so, the Deputy overlooked that, apart from five public health nurses attached to the office of the Chief Medical Officer, who are engaged in the School Health Examination Service, the Child Welfare Service, the Immunisation services, and so on, there are no less than 17 nurses engaged wholetime on district nursing duties.
Deputy Esmonde expressed concern at the extent to which non-nationals— doctors, I presume—are employed in local authority hospitals and claimed that the number is increasing. A year and a half ago, arising out of a Dáil Question, I sought information from health authorities as to the number of non-nationals employed in these hospitals. The particulars furnished to me showed that of approximately 800 doctors employed, only 46, or about 6 per cent—all temporary and all in the registrar or house officer grades—were non-nationals. I doubt whether the position has substantially changed since. May I say in relation to the specific case which, I think, Deputy Esmonde had in mind, of a doctor who is employed in the health services in Wexford, that on enquiry I have ascertained that the doctor in question was born in Dublin and therefore is not an non-national.
