I move:
That a supplementary sum not exceeding £1,300,010 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1969, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an ArdChláraitheora) and certain Services administered by that Office, including Grants to Local Authorities, miscellaneous Grants and certain Grants-in-aid.
As has been done for some years past, I have circulated a statement of vital statistics and of major health building projects. Deputies will note from it that in 1967 there were fewer births than in 1966. From 1961 to 1964, when a peak figure of 64,072 was reached, the number of births was increasing each year. In 1965 the figure dropped to 63,525; in 1966 there was a further drop to 62,215. Last year's figure was 61,307. I do not think we should read too much into this trend. As I have said, 1964 was a peak year. However, the figures are worth studying and, in fact, this study is proceeding in my Department. Another noteworthy feature of the vital statistics is that in 1967 deaths were over 3,700 fewer than in 1966. There is no single feature of overall significance which led to this decline. However, the mild winter and the absence of an influenza epidemic were undoubtedly contributing factors. One noteworthy individual decline in mortality was in respiratory tuberculosis, deaths from which declined from 308 in 1966 to 213 in 1967. I am happy to see a resumption in the downward trend in this area. There had been a slight increase in the figure as between 1965 and 1966.
The original provision for the year 1968-69 came to a total of £24,462,000 and has already been voted. The Supplementary Estimate now before the House amounts to £1,300,010. This includes a sum of £1,080,000 to supplement the finances available to the Hospitals Trust Fund to meet revenue deficits of voluntary hospitals, £220,000 required under Subhead G in respect of grants towards additional expenditure by health authorities in the current year and a token sum of £10 under Subhead A to enable discussion to take place on the main Estimate which has already been agreed to.
I propose in the first place to explain the Supplementary Estimate. The additional requirements of £220,000 under Subhead G arise from increased expenditure by health authorities as compared with their original estimates for items other than increases in salaries and wages. Increased expenditure on salaries and wages due to the eleventh round is not included in this figure; provision arising from additional expenditure by health authorities in the current year in that respect was included in the global Vote for remuneration agreed to on 12th December, 1968. The sum of £220,000 arises mainly from the increase as from the 1st August, 1968, in the allowances for disabled persons and the infectious diseases maintenance allowances in accordance with the announcement made in the last budget.
The main item in the Supplementary Estimate is a Grant-in-Aid to the Hospitals Trust Fund to supplement the moneys available to meet revenue deficits of voluntary hospitals. Despite an increase as from the 1st April, 1968 in the capitation rates payable by health authorities for Health Act patients treated in voluntary hospitals, the revenue deficits of these hospitals are running at a level which far outstrips the resources available to meet them.
Costs in voluntary hospitals have greatly increased in recent years. This is due to a variety of reasons—including shorter hours and improved conditions for staffs, the introduction of block training for nurses, and very substantial increases in remuneration costs due to rounds of salary and wage adjustments. There is only a small balance in the Fund at present and £1,080,000 will be required to meet commitments arising up to the end of the financial year.
I have made arrangements to have the estimates of voluntary hospitals for 1969 examined critically with a view to reducing costs to the minimum consistent with providing a satisfactory standard of service. I also propose from the 1st April next, to increase the capitation rates payable by health authorities for services in these hospitals and thereby to bring the rates nearer to what it would cost health authorities to provide the services in their own hospitals instead of sending patients to the voluntary hospitals. Even with the increased capitation rates, the accounts of many of the voluntary hospitals will continue to show a deficit. These revenue deficits will continue to be met by grants from the Hospitals Trust Fund and the Fund will again need a fairly substantial supplement in 1969/70 from the Exchequer. I will have more to say about this matter when introducing my estimate for next year.
I would like now to turn to the overall expenditure on health services. The health services for the current year were originally estimated to cost £41,050,000, which represents an increase of about three million nine hundred thousand pounds on the figures for last year. Some £800,000 of this increase arises from an adjustment of the capitation rates payable by local health authorities to voluntary hospitals as from 1st April, 1968. Staffing costs continue to be the most significant factor in health expenditure. These costs show an increase of the order of £1 million as compared with last year. The increase results from an improvement in standards by the appointment of additional staff, particularly in mental hospitals, and increased remuneration.
During the last few years expenditure on drugs and medicines provided in the health services, both at dispensaries and in hospitals, has shown a very substantial increase. This year it is estimated that it will again increase and this time by about £150,000 of which £100,000 will be in respect of medicines supplied at dispensaries. Increased usage of drugs is a feature of modern medicine; and since drug therapy and allied preventive medicine practices have undoubtedly helped to keep people out of hospital, have increased bed turnover and have made possible quicker return of patients to their normal life, they have contributed to a more economical use of the services and have been of some significance to the national economy. Therefore we must balance our dislike of increased cost in this area by realisation of these beneficial aspects.
I might also mention, at this point, that there was a considerable expansion in the scheme under which health authorities supply medicines to persons outside the lower income group. This scheme is intended to benefit persons in the middle and higher income groups on whom the cost of medicine imposes an undue hardship. In 1967 health authorities spent £61,000 on supplying medicines in over 5,000 such cases. This expenditure on the scheme increased by 75 per cent over the previous year and the number of people assisted showed a rise of almost 50 per cent. More up-to-date figures are not yet available.
In July, 1967, I introduced a scheme for the free supply to diabetics, irrespective of income, of the normal range of insulin preparations, other drugs and items needed for the treatment and control of their condition. The scheme is working satisfactorily and on the 31st September last, 4,985 persons were availing themselves of it. The figure does not include diabetics receiving free drugs and other medicinal requirements as members of the lower income group.
The maximum weekly allowance was increased as from 1st August, 1967 by 5/- per week for an adult and 10/- per week for an adult with an adult dependant. A further increase of 7/6d. per week for an adult and of 15/- per week for an adult with an adult dependant came into effect from 1st August, 1968. As from that date the maximum allowance for each dependent child was also increased by 2/6d. per week.
The higher rates of allowances, hitherto payable only in the County Boroughs of Cork, Dublin, Limerick and Waterford, are payable since 1st August, 1967, to recipients living in the Borough of Dún Laoghaire and in any other urban area with a population exceeding 7,000 persons.
These 1967 changes are estimated to cost £6,200 extra this year. The 1968 changes are estimated to cost an extra £16,000 during the current financial year and £24,000 in a full year.
An interesting point is that, while the amount paid in allowances during the year ended 31st March, 1968, which amounted to £196,654 increased by £5,450 as compared with the previous year, the number — 1,442 — in receipt of such allowances on 31st March, 1968, was 119 lower than the number in receipt of allowances at the corresponding date in 1967, mainly due to the decreased incidence of tuberculosis.
As from 1st August, 1967, the maximum rates payable were increased by 5/- a week to £2 12s 6d per week in the case of a person without means, and in all other cases to £2 7s 6d per week. A further increase of 7/6d per week in the maximum rate of allowance, effective from 1st August, 1968, brought the rate to £3 and £2 15s per week respectively.
Since August, 1967, the payment of an allowance may be continued by a health authority for the period up to eight weeks while a recipient received institutional services. Previously, payment was suspended while the disabled person was maintained in a hospital or institution. The new provision is intended to offset the hardship which could arise if a disabled person who had to enter hospital for a short period had to meet continuing commitments such as rent. The number of recipients of disabled persons allowances on 31st March, 1968, was 21,445 as against 20,210 on the same date in 1967. The total cost of allowances for the year ended 31st March, 1968, was £2,288,685, roughly £380,000 more than the expenditure in the previous year. It is estimated that the revised provisions operating from 1st August, 1967, will cost an extra £100,000 this year and that the 1968 increase will cost an extra £285,000 approximately in the current financial year and about £430,000 in a full year.
The maintenance of patients in the additional accommodation provided in homes for mentally handicapped children and additional expenditure on services catering for old people are expected to cost health authorities £200,000 more this year than last year. I will be dealing with these services in somewhat more detail later on. An estimated increase of £130,000 on mother and child services arises largely from the payment of increased fees to doctors providing maternity care. The appointment of more dentists and district nurses is estimated to cost an additional £100,000. Food costs in local authority institutions including mental hospitals are estimated to increase by £200,000 and the cost of repairs and maintenance by £150,000. Specialist services show an estimated increase of £100,000 and superannuation for hospital and other staffs is estimated to increase by £150,000 The balance of the increase in expenditure arises under a variety of headings and spread over the full range of services — including ambulance services, administrative costs, replacement of furniture, equipment and appliances.
The latest estimate of expenditure by health authorities in the current year is £43,040,000, an increase of £1,990,000 on the original estimate. In dealing with the provision in the supplementary estimate I have explained how the increased costs arose in the current year.
I now come to the explanation of the basis upon which grants to health authorities are being provided in the current year. At this stage I would like to make the point, which seems to be missed by quite a lot of people who complain about the cost of health services, that these costs have to be borne by the community. The Minister for Health is criticised because he does not relieve the rates to a greater extent than has been found possible this year. In reply to this criticism I would point out that the percentage extra assistance given to the rates over the statutory 50/50 division of cost varies from four per cent to eight per cent for individual health authorities, averaging roughly six per cent over the whole country. When one is dealing with a total cost figure of the order of £43,000,000 I think that Deputies on all sides will accept that a percentage of six per cent represents a very sizeable additional contribution from the Exchequer. Again I would remind Deputies that what the Exchequer pays must, of course, be raised from the people just as money contributed from the rates also must be raised. The only justification for a transfer of responsibility for any portion of the cost of the health services from the rates to the Exchequer is that general taxation is a more equitable way of raising money than by increasing local rates; but the fact remains that the total cost must be met by the public.
The question of the arrangements to be made for financing health expenditure in the year 1969/70 is at present being urgently considered. As Deputies are, no doubt, aware I have had strong representations that I should try to provide further relief for the rates in respect of increases in costs next year. All I can say at this stage is that the existing proportion of each health authority's expenditure which is being met from the Exchequer will not be reduced.
Rising costs require us to make the most effective economic use possible of health services and to see that the full resources of preventive medicine should, as far as possible, be brought to our people and availed of by them. Effective preventive services lessen the demand on the curative services. In many branches of medicine, attention is now being directed to the early diagnosis of disease so as to limit disability. I referred briefly in my Estimates speech for 1967-68 to the Phenylketonuria Service. I want to take this particular development as illustrative of the new screening services in preventive medicine and to show you how valuable a contribution they can make.
Phenylketonuria is a condition in new-born infants which may result in severe mental handicap if the condition is not diagnosed and treated. A special service aimed at screening all new-born infants was initiated by my Department in February, 1966 and was offered without charge to all doctors and to all maternity hospitals and homes. A minute blood sample is taken from the newly-born infant and tested. When the condition is found to exist treatment can be successful in most cases, particularly when commenced early. Treatment involves a special diet which can be quite expensive and I have asked health authorities to look sympathetically at all requests for assistance towards the provision of such a diet.
The tests commenced in February, 1966 and from that time up to 31st December last, 82 per cent of all infants born in the country were screened for this condition. The figure for last year was 91 per cent, a good response, but I hope that it will be improved on in the future. That the scheme is a useful one is demonstrated by the fact that so far it has turned up 37 cases of this condition. Most of those would not have been detected in time were it not for this service. They would have represented an economic loss to, or an economic burden on the community apart altogether from the tragedy to the children themselves and their families which, of course, is a far more important consideration.
I commented last year on the considerable under-use of some of the preventive services. I am happy now to report that the public seem to be developing an increasing appreciation of the value of these services, although there is still some way to go before the situation can be described as satisfactory.
The position in regard to diphtheria immunisation has improved somewhat. In each of the years 1966 and 1967 63 per cent of pre-school children were immunised against the disease as against 49 per cent in 1965 and 56 per cent in 1964. While the percentages for 1966 and 1967 are the highest for the past seven years, they still fall short of the desired target figure of 70 per cent. Therefore, I would again exhort health authorities to intensify their efforts to bring home to parents that suffering, or even death, of their children from diphtheria can be prevented if they will co-operate by having their children immunised. The immunisation service is free of charge from health authorities and is easily obtained.
The number of persons who came forward for X-ray under the mass X-ray service in 1968 was 365,884. This was a slight drop on the 1967 position when 387,815 persons were X-rayed. This drop was probably caused by the restrictions on movement to prevent a foot and mouth epidemic here. But here again there is room for improvement in the response of the public. I cannot understand why more people will not take the small amount of trouble to check their health by mass X-ray. This service is provided practically on their doorsteps; it is free; it takes only a few minutes and its benefits are self-evident.
I referred in speaking on the 1967/68 Estimate to the good response to the oral polio vaccination scheme introduced by my Department in 1965. No case of the disease was notified in 1967, but two were reported in 1968 and so far this year, there have been seven cases. This must surely make everyone realise that the disease is still one to be reckoned with. Those who have not been immunised are particularly vulnerable. I cannot too strongly impress on parents their grave responsibility to ensure that their children receive protection. The services again are available free of charge through the health authorities. All that is needed is the interest and co-operation of the public.
We have sought, by the wide distribution of the free booklet entitled A Summary of the Health Services and by other means to increase public awareness of health services. I have found it surprising how many people in spite of constant publicity remain not fully aware of their entitlement to these services and I have urged health authorities to set up information offices, identified as such by advertisement in the public press. The public, too, must play their part. People unfortunately have a tendency to wait until illness strikes before seeking information about their eligibility and later still before making a claim. It is often then too late and the health authority will not, quite reasonably, always entertain a claim for retrospective assistance.
I now come to the question of the control of drugs. At the end of 1967, the National Drugs Advisory Board commenced monitoring drugs so as to keep a check on their toxicity and possible adverse effects. This means that drugs being introduced in this country for the first time are now, with the general co-operation of the pharmaceutical industry, subjected to close scrutiny by the Board.
The Board has also made arrangements for collecting and assessing reports on adverse reactions to drugs already in use, which are submitted to it by doctors, dentists and hospitals throughout the country. The Board will, in turn, supply any necessary information or advice to the medical and dental professions arising out of the pooling of data made available in this way and from other sources. I feel that the Board deserves the fullest support in this important work and I know that the members of the medical, dental and allied professions can be counted on to co-operate fully in this valuable work.
Apart from the safety angle, there are problems connected with distribution in the broadest sense. There are many complex matters to be considered under this general heading, notably the question of quality control. I would assure the House that this question is receiving the closest attention in my Department and I propose to seek the approval of the Government to the introduction at an early date of legislation to deal with these questions of the safety and quality control of medical preparations. I am at present engaged in consulting interested parties on my suggested legislation. Whilst our basic aim in endeavouring to achieve a comprehensive and up-to-date system of control must be to safeguard the health of the community, it is worth remembering that such a system is necessary and desirable if we are to adapt ourselves to conditions of free trade in the Europe of the future. To compete effectively in the Europe of today the pharmaceutical industry here must inform itself of and participate in, the developments in the manufacturing, wholesaling and marketing end of the industry there and be aware of and conform to the up-to-date controls imposed in these countries. To this extent we are already partners in a uniting Europe and I have directed my Department to maintain the closest liaison with the pharmaceutical industry, with other Government Departments concerned and with the international bodies concerned in this field.
I also propose to take powers to deal with the problem of drug abuse— for example, making the unauthorised possession of certain drugs an offence. Such powers have, in fact, been included as a part of the draft legislation on safety and quality control to which I have referred earlier. I have, as Deputies know, set up a working party to advise me on certain aspects of drug abuse. It has commenced its work and I look forward to its report in due course. It is important that we take the correct measures in dealing with the problem to guard against any explosive increase in the misuse of drugs, as has happened elsewhere.
I have taken steps to bring under the controls provided for in the Dangerous Drugs Act, 1934, certain synthetic narcotics which did not hitherto come within the scope of the Act. This will be effected by Government Order.
In dealing with the 1967-68 Estimates, I said that the recommendations submitted by the Poisons Council regarding a comprehensive code for controlling the distribution, etc. of poisons were being examined. A first draft of regulations has been prepared and sent to the council for their comments. Needless to say, other interested bodies must be consulted when the council have commented. I should say also that in formulating these draft comprehensive controls certain minor amendments were found to be necessary in the Poisons Act, 1961, to give effect fully to them and I propose to avail myself of the opportunity presented by the contemplated legislation on quality and safety control to make these changes. In the meantime, existing controls have been maintained and are being enforced.
During last year, I made regulations under the Poisons Act, 1961, declaring paraquat to be a poison. The regulations confine the retail sale of this substance to pharmacists and to certain other sellers already licensed to sell agricultural poisons. In addition, they forbid the sale unless the poison is in the manufacturer's original container, and unless the word "Poison" is legibly written on the container together with a warning notice that the contents should not be taken, should be kept out of the reach of children and should not be repacked from the container, and that the container should be destroyed when empty. This substance has been responsible for a number of deaths in recent years. Nevertheless, its efficacy as a herbicide is such that its ready availability to the farming community is necessary. However, if the controls now imposed are rigorously adhered to by all concerned the dangers associated with it should be removed.
In this regard also, I would appeal to the general public to treat all these poisonous substances with extreme care. No matter how comprehensive the controls over the sale, labelling, etc., are, once a poison arrives in a home, it is only the head and other senior members of the household who can ensure that it is stored in a safe place away from children and that all precautions are taken in its handling. If you are doubtful about any substance, do not take a chance. Above all, nobody, for any reason, should decant a poison from the original container into a lemonade bottle or such like container.
In regard to community care of the aged, while, in the past, there was widespread agreement that old people should not have to go into county homes or other institutions unless this course seemed unavoidable, it is only in the last few years that local communities have begun to organise supporting activities such as meals on wheels, old folks' clubs, chiropody and visiting services to help old people to stay in their own homes. This growing public interest is most heartening and it is most encouraging to observe the pace at which local groups are being formed to help the aged, the varying methods of approach in each area and the variety of services provided. I am in complete sympathy with the desire of local communities to shoulder responsibility for organising this kind of social service. They need have no fear of a take-over bid by the State. On the contrary, they can look with confidence to my support. Wherever a soundly-based community body exists, I should prefer, as a matter of principle, to entrust it with responsibility for domiciliary services for the aged.
I have recently introduced a new scheme which is designed to give a fillip to the development of community social services in general and specifically to increase substantially the financial assistance given by health authorities to voluntary bodies which care for the aged in the community. I have encouraged and authorised health authorities to give grants within a total of £50,000 in the current year and £75,000 next year towards the running costs of voluntary bodies providing community services for the care of the aged. The annual level of grants towards current expenditure is about £13,000 at present, so that the new scheme will represent a big increase in aid to voluntary bodies.
Under the scheme, each health authority is being allocated an amount proportional to the total number of persons aged 65 and over living in its functional area. The scheme has several important innovations — for instance, within the limits of the allocation the prior sanction of the Department will not be required and this will enable health authorities to act speedily in making grants to local bodies; the health authorities are being encouraged to have an experimental approach in evolving the community service best suited to the needs of old people in their particular areas; they will be free to support social services which in a narrow context might not be considered as health services but which do, in fact, make direct and real contribution to the health and well-being of the old people. This scheme, taken as a whole, gives to the local health authorities the capability, the responsibility, and the scope for initiative in developing community services for its aged.
One particular class of old persons, namely, those living alone, has been singled out for priority attention under the new scheme. There are 35,000 old people living alone and they are likely to be at greater risk and in greater need than old people living with relatives. The district nurses spend much of their time visiting old persons living alone but the help of the community is needed if many of them are to continue to live happily in the community. It should surely be the ambition of every civilised community to ensure, through local social services and local good neighbourliness, that old people on their own no longer live in dread of becoming ill or helpless and unable to contact anyone.
While health authorities have been given no rigid guidelines under the scheme as to the way in which the services for the aged should develop, I have brought to the attention of all of them that in some areas a broadly based community council, co-ordinating and augmenting the activities of voluntary organisations, has evolved. I see great advantages in such community councils since they draw on the knowledge and ability of the various agencies in the social field and they appeal to all sections of the local community. Health authorities should take active steps to encourage their formation where they do not exist.
There is at the present time a growing pressure for the appointment of social workers in the community to deal with a wide range of social problems which are outside the scope of any existing State service. There is particular need for this type of service in rapidly changing urban areas. A number of health authorities have appointed social workers to deal, for example, with the organisation of services for old people, or to work closely with a voluntary body in the development of social services for a particular area. In addition, some voluntary bodies — for example in Kilkenny— have themselves employed social workers and the health authority may contribute indirectly, by means of a grant, towards the cost of their salary. I see a real danger that the emerging social worker service may not harmonise efficiently with the existing medical and social services of local authorities. Care must be taken to eliminate competition, duplication and undesirable overlapping.
It is very important that all who work in the social services — health authority staffs, voluntary social workers, charitable and religious organisations—work in harmony and co-ordinate their activities so that their collective efforts will have the maximum impact in the community. There need be no question of "take-over bids"—the attitude should be one of anxiety to combine and not to compete, in doing good for our not-sofortunate brothers and sisters in the community and to deploy resources in the most advantageous way.
While on this subject, I should like to say how sorry I am that the Queen's Institute of District Nursing decided to discontinue their nursing activities including their training scheme. Most of us know of the valuable contribution made by them in the past and I want to pay tribute to their work and to their nurses who gave such devoted service. Every effort was made by my Department and by health authorities over many years to encourage this nursing service to continue and grants of an increasingly generous nature were made available from public funds. However, the decision to discontinue was regrettably taken by the Institute itself. I am heartened by the fact that many district nursing organisations have decided to carry on independent of the Queen's Institute and that the Lady Dudley Nursing Scheme will also continue. They can count on my continued practical support — financial and otherwise.
I should say, too, that nurses employed by district nursing associations which have discontinued their activities are being appointed as public health nurses by the local health authorities concerned provided they are suitably qualified. I should also say that it gives me considerable pleasure to be able to tell the House that a superannuation scheme for nurses in the voluntary hospital service has been introduced with effect from the 1st January last, which provides benefits comparable to those enjoyed by local authority staffs. The scheme which is open to permanent wholetime hospital, para-medical, technical and administrative staffs, will also cater for nurses employed by district nursing associations.
While the development of community services for the care of the aged is a primary objective in our planning, we must at the same time continue our efforts to provide effective institutional services for those old people who cannot remain at home. In the development of such services, assessment and diagnostic centres will be the cornerstone. In a fully developed service patients for whom long-stay care may be necessary would be referred in the first instance for assessment and diagnosis at a fully equipped centre. When a patient's condition has been thoroughly checked any necessary medical care would then be given. Where a further period of care is required or intensive rehabilitation services are needed, the patient would be referred to accommodation specially designed for this purpose. If, despite intensive therapy, it becomes clear that the patient could not effectively care for himself in his own home surroundings or be supported to live in the community with the assistance of relatives and the aid of community care services, then he would be referred to suitable long-stay accommodation. Such a concept cannot be brought into full effect immediately. Some of the organisational changes necessary will be affected by the decisions to be taken on the pattern for hospital and specialist services in the future.
Variations to suit local conditions will be necessary. For example, in more populous areas attendance at day-hospitals, backed by efficient domiciliary services might be feasible and apart from keeping the old person looked after satisfactorily, this method would considerably ease the strain on the institutional services. Furthermore, the institutional services cannot be planned in isolation. There must be effective co-ordination of all services designed to care for the aged, from housing to hospitals, and of all the agencies, whether public or voluntary, that play a part.
Meanwhile, it is essential to improve the institutional services for the care of the aged. It is hoped as far as possible to develop the long-stay hospital units in as close association as possible with acute hospitals. The long-stay units will be adequately staffed and equipped to deal with the rehabilitation or care of patients. Planning is proceeding with the aim of providing long-stay units on the sites of the county hospitals at Tullamore, Nenagh and Cavan. Proposals on the same lines are under consideration for Kilkenny. This approach represents a major departure from the older concept of re-planning the old county homes completely on existing sites. In addition it is intended that further diversification will take place through the provision of welfare homes for the aged in suitable centres away from the existing county home centres. However, flexibility must be the keynote. In some areas, for example, at Longford, it will be already advantageous to avail of the improved services already provided for long-stay sick patients. I propose, however, that in such instances the accommodation to be made available in the future for the aged who need accommodation of a welfare type will not only be domestic in character but that some provision will also be made for married couples and for some other suitable persons in sef-contained units where they can continue to live in some degree of independence. In other areas, for example, County Clare and County Roscommon, some accommodation for people needing care for social rather than medical reasons is to be provided at the main county centre and the balance is being planned for other towns—namely, Kilrush and Boyle. I expect that work will commence on the residential homes at Kilrush and Boyle in the present year.
Considerable progress has been made on the schemes for the replacement of outmoded accommodation in county homes. Over the past few years new or reconstructed accommodation has been provided for about 900 patients at Mountmellick, Stranorlar, Longford, Castleblayney, Clonakilty, Ennis and Trim. Schemes in progress will provide places for about 1,250 patients at Stranorlar, Killarney, Carrick-onShannon, Castleblayney, Clonakilty, Castlebar, Roscommon and Athy. A special scheme to provide about 70 places for homeless persons is in progress at Usher's Island, Dublin. A scheme for accommodation for about 120 persons at Regina Coeli Hostel, Dublin, will be commenced shortly. The total expenditure since 1966 to date on county home improvement schemes already completed or in progress is £2.8 million approximately. The amount required to complete the works in progress for which tenders have been invited or sanctioned is estimated at about £1.7 million.
I am happy to be able to report that the population of our mental hospitals fell by 16.5 per cent in the period 1958-67, and that further decreases are anticipated. A greater proportion of the mentally ill nowadays are old people showing symptoms of senility, confusion and disturbance. Psychiatric treatment can relieve these symptoms in old people but, to make the best use of the psychiatric care available, it will be necessary to avoid an imbalance developing in our hospitals with psychogeriatric patients taking up an undue amount of time of psychiatrists and nurses. I think that it will be necessary for our mental hospital authorities to be more critical of applications made for the admission of old people for psychiatric care and treatment and to try to ensure that because old people are admitted for treatment they are not, by reason of age and its symptoms alone, going to remain inpatients for the rest of their lives. Unless the number of aged persons in our district mental hospitals can be kept at reasonably low level the most effective use of our psychiatric services will just not be possible.
While the population of our district mental hospitals has fallen, there were nevertheless 16,732 patients in such hospitals on 31st December, 1967. This figure is too high and we must strive to reduce it. I hope that the greater development of community mental health services will help further to reduce the number of persons in psychiatric hospitals. A good community mental health service requires adequate out-patient clinic facilities, suitable arrangements for domiciliary visiting, a sufficiency of day hospitals and hostels and a significant involvement of general medical practitioners, public health nurses, social workers generally, voluntary bodies and the public at large in the problem of those who are psychiatrically ill. I hope that the provision of further psychiatric units at general hospitals will help to accelerate acceptance of the idea that psychiatric illness is not one to be hidden away or to be ashamed of and that early treatment can achieve excellent results.
The attendance at out-patient psychiatric clinics continues to rise. In 1960 the number of patients attending them was 6,174. In 1967 it was 28,405. The standard of service given, the frequency of clinics and the accepttance by the community of this service have been responsible to a large extent for the reduction in the number of in-patients in mental institutions.
One of the greatest pressures I have experienced since becoming Minister for Health has been for hospital accommodation for mentally ill children. Accommodation for such children, including autistic children, is provided at St. Loman's Hospital, Ballyowen, County Dublin. This is fully taken up. A further unit of 24 beds is nearing completion at Beaumont in Dublin. In addition, I have approved of another unit of 20 beds at Stillorgan and planning of this unit has already commenced. I have also given approval to the provision of accommodation for some 20 children in Cork under the auspices of the Cork Polio and After Care Association and preliminary planning of this project is in progress. I have arranged that these projects be pushed ahead with all possible speed and, in so far as lies within my power, there will be no avoidable delay in getting them into operation.
Psychiatric disturbances and delinquency in adolescents are matters which have been receiving some publicity recently. In regard to Dublin, I am pleased to say that work is proceeding on the adaptation of a building at St. Brendan's Hospital in which special care will be available for disturbed adolescents. The Dublin Health Authority have proposed, and I have agreed, that a post of clinical director be created with responsibility for forensic psychiatry. This is the first step, I hope, towards a linking of the services provided in the Central Mental Hospital, Dundrum, with the services of the Dublin Health Authority, and this link should enable an improved service to be provided for the majority of psychiatric patients, including delinquent disturbed adolescents, who come to the notice of the courts, and who need to be treated in a setting where the necessary high level of security can be attained.
Two new acute psychiatric units have been provided at Clonmel and Castlebar and I have approved of others at Galway, Limerick and Letterkenny. The units are beside the regional or county hospital as the case may be at these centres and will function in association with them. Accommodation no longer required for tuberculosis patients at St. Stephen's Hospital, Cork, will be used for acute psychiatric treatment and long-stay care. Proposals for the establishment of other acute treatment centres are under active consideration. In order to eliminate planning delays to the maximum extent possible, standard schedules of accommodation and outline plans have been drawn up in my Department for the guidance of health authorities providing such centres. The same is also being done in connection with the planning of industrial therapy units.
Apart from what I have mentioned, the main activity on the mental hospital building side, at present, is in the up-grading of existing institutions. The total estimated cost of schemes in progress and in planning is about £4.2 million. One important such scheme of which I have recently approved is the provision of 100 new beds at Kilkenny to replace unsuitable accommodation there.
I am glad to be able to report continued progress in the services for the mentally handicapped. At the end of 1968 there were 3,981 places in the special residential centres as compared with 3,760 at the end of 1967. Over the past four years 880 additional places have been provided at these centres and in addition a number of health authorities have opened small temporary units for the care of severely handicapped children.
An important development has been the growth in the numbers being dealt with satisfactorily on a non-residential basis. The numbers attending special day-schools and day-centres or attending residential centres on a day basis increased from 1,430 at the end of 1967 to approximately 1,800 at the end of 1968. At the end of 1964 the number in receipt of services on a non-residential basis was only 632 and this three-fold increase over the four years gives some idea of the rapid expansion of special day-schools and day-centres.
We have still a fair distance to go before we can regard the services for the mentally handicapped as having reached a satisfactory level but the foregoing figures indicate that steady progress is being made.
Considerable further developments are planned, both in regard to special residential care and day-care. In all, we hope to provide about 800 extra residential places over the next two to three years. These, added to the 880 places provided over the past four years, will represent a total increase of about 55 per cent in a period of seven years.
The improvement of the public dental services has been hampered, for many years, by difficulties in recruiting and retaining wholetime dental staff. In an effort to improve the recruitment position the conditions of service of these staffs were improved with effect from 1st January, 1968. Wholetime dental officers may now work two dental sessions per week outside normal working hours in health authority clinics, for which they would be paid the approved sessional rate. In addition, satisfactory experience outside the public service before appointment to that service, is now allowed to rank for increment purposes. These concessions applied to serving officers as well as to newly-appointed officers.
Following these improvements in conditions of service, recent competitions held by the Local Appointments Commissioners have been much more successful than formerly in obtaining candidates for public dental officer posts. There are some areas, however, where it is still very difficult to obtain the services of wholetime dental staff. The health authorities concerned and the Local Appointments Commissioners are continuing their efforts to fill vacant posts in these areas. To some extent the shortage of wholetime dentists in these areas is being met by the employment of private dentists on a sessional basis.
The total population now receiving fluoridated water exceeds 1,100,000. The fluoridation programme is being pressed ahead as quickly as possible and, when completed within the next two years, the total served by fluoridated supplies will exceed 1,500,000 people.
The possibility of extending the use of fluorides in the prevention of dental decay is being examined. This procedure would be very beneficial for rural school children in those areas which will not have a fluoridated water supply. Pilot schemes of fluoride mouth-rinsing have already been commenced in six areas, to determine the best method of proceeding.
In recent times there has been a growing appreciation of the need to reshape our general hospital services to fit them to discharge their function more effectively in terms of current and future medical needs. The need for a radical re-organisation is generally recognised by those involved and the problem is to define the pattern most appropriate to our situation. A combination of developments in the field of hospital medicine has sparked off this rethinking. Broadly these are: increasing specialisation combined with the need for greater teamwork to deal with particular conditions; the development of more sophisticated and complex equipment, the heavy capital cost of which can be justified only if it is fully utilised; and the need to improve consultant staffing ratios to cope with the steadily-growing volume of demand for hospital care. All of these developments point to the inescapable conclusion that a significant concentration of general hospital in-patient services, in larger units than have met the needs of the past, is essential if we are to provide, within our resources, a fully effective service for our people. This does not apply to consultant out-patient services. Indeed, I would hope to see some expansion of these facilities because it is only by the association of good modern out-patient diagnostic and treatment services with acute in-patient diagnostic and treatment services, that the most economical and effective services can be provided.
Early in 1967, the Irish Medical Association and the Medical Union engaged in a series of discussions with officers of my Department as a result of which it transpired that there was a substantial measure of agreement about changes necessary in the structure of the health authority general hospital service. The discussions, however, did not cover the voluntary hospitals, which by reason of their teaching function and the extent of their patient complement must be considered the senior partner in the partnership. Accordingly, in November, 1967, I set up a consultative council, composed of consultants in both the health authority and voluntary hospital services, to advise on the re-organisation of the general hospital services as a whole. This body's report was presented to me just over six months later. When one considers the wide area which had to be covered, the complex nature of the many problems to be investigated and the exceedingly heavy demands on their time, the members of the council set a headline for all advisory bodies in presenting so comprehensive a report in such a short time.
I should like to pay public tribute here to every member of the council. Many of their meetings were held at night and throughout whole week-ends. Many of the members over the years had developed firm allegiances to particular medical schools and to particular hospitals; yet their recommendations show no trace of any bias. Their unanimity, indeed, is a clear indication that our present organisation could not much longer suvive and that radical changes are necessary.
The report sets out the general principles which should guide the future development of our hospital services, and goes on to spell out in some detail the manner in which these principles might be implemented. Probably the most pressing demands for improvements and re-organisation arise in the Dublin area, where the present large number of relatively small, independent hospitals, many of them old, unsatisfactory buildings, makes it difficult to adopt a co-ordinated approach. Since I received the report of the consultative council I have written to the hospital authorities concerned in Dublin, suggesting the formation of committees representing these authorities and their staffs, to examine and recommend on the manner in which re-organisation might be brought about. A considerable amount of time has been given by the hospital groups on each side of the Liffey to the study of this problem and while definite conclusions have not yet emerged, I am hopeful that this point will be reached within a few months.
One aspect of the council's report, which may cause some concern in different parts of the country, is the change of function of some county hospitals which would arise out of the necessary concentration of acute hospital services. I must emphasise in relation to this point that what is at issue is a change of function and not a discontinuance of hospital activity. In most cases this change of function will develop gradually and will necessarily take a period of years. Furthermore, it will be accompanied by the development and improvement of specialist out-patient services at the sites of all these hospitals. The main effect of the changes will be, therefore, that consultant services on an out-patient basis will be more conveniently available to the public than at present and that, where in-patient treatment is required for a serious condition, it will be provided under the best possible conditions of buildings, staffing and equipment and with the backing of properly developed ancillary services such as pathology and radiology.
The construction of the new St. Vincent's Hospital at Elm Park, Dublin — a general teaching hospital of some 450 beds — is probably our largest general hospital project in recent years. Some of the buildings are now being occupied by staff and others are virtually completed. In a major undertaking of this kind, of course, it will be some time yet before the complete new hospital is fully equipped and functioning.
The planning of the new Regional General Teaching Hospital for Cork is proceeding and the indications are that it should be possible to invite tenders for the work in the spring of 1971. Works of improvement are in progress at the County Hospitals in Wexford and Tralee, St. Kevin's Hospital, Dublin and the District Hospital, Ballina. A major extension is nearing completion at Sligo County Hospital. This will increase the capacity of the hospital by about 100 beds and includes provision for specialised departments. A staff home is being provided at the County Hospital, Nenagh.
Capital expenditure on hospitals during 1968/69 is expected to be about £3? million. This programme will be financed (a) from the Hospitals Trust Fund — to the extent of about £2 million including a grant-in-aid from the Exchequer of £1 million, as shown in the Estimate — and (b) from the Local Loans Fund and other sources — about £1? million. The statement, which I have already circulated to Deputies, lists the major building projects which were completed since March, 1967, those which were in progress and those which were approved in principle and which were being planned during the period.
On the question of capital expenditure on hospitals generally, I feel I must again appeal to all hospital authorities, who propose seeking grants from my Department for capital projects, to endeavour to restrict their proposals to absolute essentials and to ensure that, when such proposals proceed to the detailed planning stage, every effort is made to achieve the desired results with the maximum economy. The implementation of the recommendations of the Consultative Council on the General Hospital Services, to which I have already referred, will require very substantial capital expenditure over the next 10-15 years, most of which would be additional to the normal hospital capital programme. Further capital expenditure will be involved in implementing the recommendations of the Commissions of Inquiry on Mental Illness and on Mental Handicap.
A possible future programme of this magnitude, therefore, will create serious financing problems, and will restrict to a considerable extent the availability of moneys for other schemes, however important they may appear to the promoting authorities concerned. It goes without saying, of course, that capital grants from the Hospitals Trust Fund will not be forthcoming for works undertaken or commitments entered into without my prior approval. It would also be grossly unfair to hospital authorities who adhere to the procedures governing the allocation of grants from the Hospitals Trust Fund if others were to be given grants to cover the cost of projects undertaken without regard to those procedures.
In September, 1967 at the invitation of the Government, the Annual Meeting of the European Region of the World Health Organisation was held in Dublin. The meeting went very smoothly and added a happy chapter in our continued co-operation with the international organisations such as the World Health Organisation and the Council of Europe. Our association with these organisations, to whose work we contribute and by whose efforts we benefit, is of considerable assistance to us in our acquisition of experience and knowledge to fit us for an ever-expanding role in the brotherhood of nations.
In this statement introducing the Estimate, I do not propose to cover the general lines of future policy on the administration, financing and development of the health services. The House will shortly have an opportunity to discuss these on the Health Bill, so I have accordingly thought it fitting that on this occasion, my report should be largely concerned with an account of the operation of the services as they are now. The Estimates with which we are dealing concern the present services. There are, of course, many points on which changes will be proposed. I expect to explain these to the House in the near future.
