I move:
That a supplementary sum not exceeding £10 be granted to defray the charge which will come in course of payment during the year ending on 31st day of March, 1972, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Árd-Chlaraitheora) and certain Services administered by that Office, including Grants to Health Boards, miscellaneous Grants and certain Grants-in-Aid.
The supplementary sum of £10 now being moved will enable the House to discuss the main Estimate for Health for 1971-72 in the sum of £45,912,000, as published in the Book of Estimates for the current financial year, and the Supplementary Estimate of £7,390,000 recently circulated. It will also provide an opportunity for the House, should it so desire, to discuss the Central Mental Hospital, Dundrum, for which there is a separate Estimate.
As in previous years, subhead G is the main subhead of my Department's Vote. The subhead provides for grants to health boards in respect of expenditure on health services during the year 1971-72; there is also the normal provision for payment of balances of grant due in respect of previous years.
So far as the current year is concerned the net health expenditure by health boards as originally estimated and published in the Book of Estimates amounted to £68,200,000. This represented an increase of almost £7,000,000 over the 1970-71 costs, as then estimated, which in turn showed an increase of £6,100,000 over the original estimate for that year. There was thus a total increase of almost £13,000,000 from the original 1970-71 estimate to the original estimate for the present year. These increases are attributable largely to improved pay and improved conditions of service for staff and the rising cost of drugs, medicines, foodstuffs and so forth. In a service with such a high staff cost content inflationary increases in incomes have a very marked effect. The public has been made aware of the reasons for most of these increases in costs. Other factors which have contributed to increased costs are increased accommodation and improved services for the mentally handicapped, improvements and extensions of hospital services and improvements in child health services.
When Deputies are considering the level of Exchequer support for the health services, I would suggest that, having regard to the exceptional circumstances involved in the two years, they should look at the years 1970-71 and 1971-72 together. I have shown how health cost increases over the two years have been exceptionally high. For 1970-71 it was decided that the Exchequer grant which, as I said in my speech introducing the Estimate for that year, had included a special provision based on the original Estimates, to limit rate increases for health services, should be increased to absorb the full excess over the original Estimate. This involved an added liability of more than £5 million on the Exchequer. If it were not for this exceptional arrangement the rating authorities would have had to provide, in the 1971-72 rates, for debit balances emerging at the close of the year 1970-71. In terms of rates, this alone would have meant an average increase of 15p in the £.
Subhead G in the present year's original Estimate provides for the part of the statutory grant of 50 per cent payable within the year and for supplementary grants amounting to a further 6 per cent approximately, which were allocated to all areas in such a way as to confine the increase in the health rate struck for the current year within a limit of 44p in the £.
In addition to the grants paid to health authorities towards their revenue expenses there was provision for an Exchequer contribution of £7,900,000 to the Hospitals Trust Fund, in subhead K.1, designed to supplement the income from sweepstakes so as to meet the revenue deficits of the voluntary hospitals. These deficits arise almost entirely from the discrepancy between the actual average cost of treatment of patients and the capitation rates paid by health authorities for the treatment of eligible patients.
The Supplementary Estimate of £7,390,000 arises, as I have said, mainly from adjustments in the course of the year in levels of remuneration for certain hospital and health board staffs, including the first phase of the 13th round of the national wage agreement, the recruitment of additional staff resulting from improved conditions of employment for hospital staffs, increases in other areas of expenditure due to movements in prices of commodities and increases in rates of allowances approved in the 1971 Budget. The Supplementary Estimate also includes a sum of £1,800,000 for additional grants-in-aid of the Hospitals Trust Fund—that is, £1.5 million extra for voluntary hospitals deficits and £300,000 extra for hospital capital works in the current financial year.
The total additional expenditure of health boards in the current year over the total sum shown in the Book of Estimates is £5.8 million. Of this amount about 56 per cent would, in the normal course, be recouped by the Exchequer, the remainder falling on local funds. The latter would ordinarily emerge as a debit balance in the local accounts and be carried forward to be covered in rates struck in 1972-73. As this arrangement would, however, mean an average estimated increase of 16p in the £, I am again this year, as I did last year, providing for full recoupment of the additional expenditure to obviate the need to carry forward any debit balance. Any further reference by me to the rating position for next year would, of course, be out of order in this debate.
It will be clear to Deputies that the supplementary funds being sought are necessary to meet unavoidable increases in pay and prices. Health expenditure is particularly sensitive to increases in levels of remuneration and to improvement in conditions of employment, as staff costs take up more than half of the overall cost.
The Exchequer also makes a major contribution by way of grants to local authorities in relief of rates on agricultural land—the "Agricultural Grant". The amount of this grant which may be attributed to the health rate relief, is of the order of £9 million for the year 1971-72.
When account is taken of all these subventions from central funds the amount of Exchequer support in the year 1971-72 will be over £62 million towards a gross expenditure of over £83 million, that is a contribution of just 75 per cent of the total cost. Many people do not seem to realise that the Exchequer meets such a high proportion of the cost of health services. However, it must be admitted that in certain towns and cities the health rate forms a higher proportion of the total rates struck.
The total running cost of the services in the current financial year is four times what it was only ten years ago and represents a rate of increase which is much greater than the growth in national production. Indeed, the volume increase in health service expenditure at constant money values has doubled in about a decade.
In common with other countries the objective will be on the one hand to ensure efficiency and to restrain costs, and, on the other hand, to secure a volume increase representing expansion of services and new services at between 3 per cent and 5 per cent per annum.
When the employers and trade unions meet to discuss changes in remuneration it is to be hoped that the repercussions of increases in remuneration on labour intensive services will be noted. The health services are now costing £28 per head per year.
The proportion of the Budget which goes to meet health costs has risen from 7 per cent in 1961-62 to 9 per cent in the current year. This has entailed mounting demands on the rates and taxes and has resulted in great pressure from rate payers in particular for measures to relieve them of the burden. In the face of competition of demands for other purposes, for economic expansion no less than for social services, it has become clear that rates and taxes must be supplemented by other means. This was the background to the introduction of the health contributions scheme in October of last year.
The contribution is at the rate of 15p per week for insured workers and £7 per annum for farmers and others in the "limited eligibility" category who are eligible for hospital and other services. Medical card holders are, of course, exempt from paying the contribution. I do not think that this modest contribution, towards an essential and very expensive service, can be regarded as unreasonable when considered alongside the real increase in living standards over recent years. The total yield of this contributions scheme in a full year is expected to be about £5 million.
A detailed explanatory memorandum on the health contributions scheme is contained in the document circulated to Deputies. The assistance towards heavy expenditure on drugs and the abolition of in-patient and out-patient charges must be considered when discussing the contributions scheme.
The Government have decided that by 1976 all Government Departments will be operating a programme budget system. Already nine Departments, including my Department, are at various stages in the introduction of programme budgeting.
Programme budgets will identify for five years ahead, not alone the estimated cost of programmes, but also the expected results and will thus provide the Government with information on which national priorities can be planned for a number of years ahead.
The health boards and my Department will be involved in planning on the basis of programmes designed to achieve defined objectives. The three overall programmes adopted by the boards are: community care, general hospital care, and special hospital care. In these programmes the focus will be on positive and preventive measures; for example, health care for target groups such as children, old people, persons suffering from mental illness and physical or mental handicap et cetera; and on hospital specialities such as medicine, surgery, obstetrics and so on. The aim will be to define desirable standards of provision across the whole spectrum of health services and to draw up plans to bring existing services up to these levels, taking account, of course, of the resources available to meet them and consequently to establish an order of priorities.
The programme budget system, when fully developed, will reflect the plans for developing health services over a five year period ahead, the minimum for which effective forward planning can be done with estimates of the costs involved and the benefits expected.
The management structure for the health boards aligns with the three programmes to which I have referred. Thus in all health board areas there will be a programme manager for community care. In the larger areas there will also be separate programme managers for general hospital care and for special hospital care while in the areas of the smaller boards the same person will fill the role of programme manager for both general hospital care and special hospital care.
In developing the programme budget system my Department's immediate task is to translate the traditional estimate for 1972-73 into programme budget form. When fully developed, programme budgeting for the health services will serve the needs not alone of the Government and the Department of Health but also of the health boards and voluntary hospitals, by facilitating the development of good management techniques and securing economy coupled with effectiveness in the operation of existing health services and their development to meet future needs.
The health boards and voluntary hospitals have shown a most co-operative attitude.
When I spoke to the House on the Estimates for last year I was about to put before it the draft regulations for the establishment of the health boards. I would now like to review some of the major events of the reorganisation which has taken place since then, to refer briefly to the changes in services which have been made over the last year or so and to look forward a little to the next steps which we hope to take in effecting the changes to be made under the Act.
I have given in the documents circulated to Deputies details of the membership of the health boards, including an interesting break-down of the membership by occupation. This illustrates the broadly-based representation which has been achieved on the health boards and augurs well for our achieving the community involvement which I would hope to see carried right through the affairs of the health boards.
The boards are now fully involved in the administration of the health services and will be considering their priorities in allocating the necessarily limited amount of resources in relation to the tremendous demand for services. This is, of course, a key function of the health boards. They have inherited a large body of decided policy; they now come to the stage where they can begin to make their own contribution to key decisions. I have every reason to believe that the boards will be a success and I am very heartened to learn how well the different interests on the boards are working together. Let me say straightaway that neither I nor my Department are in any way complacent about the major tasks which lie ahead for the boards. We must, all of us, guard against complacency and constantly seek better ways of doing things and higher standards of performance.
In this, their first year of responsibility, the health boards have been enormously helped by the ready co-operation and assistance of the local authorities which previously operated the health services, their managements and staffs and I would like to pay a special tribute to those for this vital contribution.
I would now like to refer briefly to the management organisation and processes which are being adopted under health boards. As all of you know, we have had the benefit of a very comprehensive report from McKinsey & Co., management consultants, on three key aspects of the health boards' affairs, that is to say, (1) the division of functions between the boards and their chief executive officers; (2) the management organisation which would appear to be best suited to achieve the objectives of the health boards; and (3) the management processes to be adopted by the proposed organisation. The first two parts of the report, which dealt with the division of functions and the top management organisation, have been accepted by all of the health boards. At present the health boards and my Department are considering the recommendations made in the last two parts of the consultants' reports on planning and on the organisation below the top management level.
The basis of operation is the requirement that part-time health boards must be presented with detailed reports on (1) performance of each branch of the service; (2) evidence of efficiency or equally the need for stepping up productivity consistent with good service; (3) accounts and budgeting statements; (4) a list of long and short term priorities for implementation based on, (a) national health policy as presented by the Minister for Health, (b) available current and capital resources.
The boards can make their decisions on priorities in framing each year's budget. The boards can make representations to the regional hospital boards about major hospital projects, and make representations to the Minister for Health on contentious matters during the year and there is no lack of communication facilities.
There has inevitably been some criticism of the recommendations made in the reports and of the extent to which it may be necessary to increase the number of people engaged in top and middle management in order to put the recommendations into effect.
My policy can best be described in the following extract from a book entitled Management and the Health Services: With so many competing claims on the national budget and obvious limitations in manpower and other capital resources, it has become imperative to use them wisely, and careful priorities have to be worked out for the promotion of health and the prevention, diagnosis and treatment of sickness. Sound management of health services can only be achieved if the men and women in key executive positions are knowledgeable and well trained. The modern health service administrator can no longer operate effectively and efficiently on hunches and guesstimates. He needs hard data with which to formulate his plans and work out his programmes and budgets. He needs to know what objectives he is seeking, the most efficient and economic way of achieving them and whether, in fact, the community is getting “value for money”.
With regard to the question of cost, I have already stated in public that in the current year the overall cost of administration of the health services is about 3 per cent of the total expenditure. The cost of top management in the health service at present represents about one-quarter of 1 per cent of the expenditure on these services; and if top management make the contribution expected of them then the enhanced value for money obtained through greater efficiency and effectiveness will far outweigh any additional cost.
Some difficulties have been experienced in filling the top management posts under health boards. The document circulated gives a list of the appointments made to date. At present a competition is under way to fill the remaining programme manager posts.
The establishment of the health boards and the changes in organisation and management processes have naturally led to a considerable increase in the need for consultation and agreement with staff organisations regarding the members' interests. The consultative council which I established to smooth the transfer of staffs from local authorities to health boards played a most useful role in dealing with the difficulties which arose and I would like to pay tribute to the members of that council for the valuable contributions which they made. The experience gained during this consultation will be of invaluable assistance to us in establishing permanent consultative machinery for the health boards.
When the White Paper on which the proposals to set up the health boards was under consideration in 1966, there were some protests from local interests, including local authorities, against the proposal, on the grounds that larger units would tend to lead to remoteness and excessive bureaucracy in the operation of the health services. I have made it clear on many occasions that the larger health administrative area is based on the following principles. First with the growth of consultant specialisation and consultant team work and the development of laboratory techniques, the reorganisation of the hospital services must be administered on a regional basis particularly if the number of patients sent to Dublin from rural areas is to be kept at the lowest acceptable level. Secondly, the decentralisation of services for the community, comprising out-patient psychiatric clinics, psychiatric social worker services, general medical services, the public health service, the development of all-embracing all-purpose social service councils inevitably, of course, means the retention and improvement of locally-based decentralised administrations and medical staff.
The contacts between the public and the health board services at local level is, of course, continuing.
Thirdly, for the development of communal services whose double effect will be an improvement of service and a reduction in the growth of hospital in-patient service, it is absolutely vital to have managerial and professional expertise of the highest calibre and a career structure designed to encourage the best talent. There must be first-class organisers for social work developments, the child health service, et cetera. The development of decentralised services could absolutely never have been achieved by a staff system related to single counties. I might mention that, in the Dublin area, the health board is initiating a process of decentralisation by establishing a pilot project to test the feasibility of the provision of community services in the city and environs through integrated community-based teams of medical, ancillary and support staff. While important policy decisions have been concentrated in the health boards, much remains for decision at local level and more will be so decided in the future. That is the policy recommended to me by the management consultants. In passing on this recommendation to the health boards I endorsed it and look forward to their work developing on these lines.
The regulations establishing local committees under section 7 of the Health Act, 1970, were made recently. Local authorities can now proceed to appoint members to these committees and the health boards will be inviting nominations for appointments to the committees from the bodies representing the medical and other professions concerned. These local committees will advise the health boards on the provision of health services in their areas and will maintain contact with local needs.
I am particularly pleased that it has been possible during the past year to reach agreement with the organisations representing the medical profession and retail pharmacists in regard to their participation in the choice of doctor scheme for persons entitled under the Health Acts to free general practitioner services. I have circulated for the information of Deputies the main features of the conditions agreed on. The arrangements for the scheme will provide special inducements aimed at retaining doctors and pharmacists in the less populated rural areas.
As I have informed the House already, it is proposed that the new scheme will come into operation on 1st April next in the Eastern Health Board area and in the remainder of the country later in the year.
In regard to persons entitled to the new service I might mention that at the end of September, 1971, there were 861.256 persons covered by medical cards. Each CEO is now in the process of preparing for the area of his board means assessment regulations of a consistent pattern, the hardship clause, of course, being retained.
Changes in the medical card lists for each area are in the main attributable to such factors as significant upward revision of income, migration from the district and, of course, the death of a medical card holder. These factors are normally brought to notice on the occasion of the periodic review of the register of medical card holders which health boards are required to undertake. Pharmacists serving the Eastern Health Board are at present being invited to participate in the new service.
The participation of private medical practitioners and retail pharmacists in the new service will represent a notable landmark in the development of our health services and will remove finally whatever discrimination still exists in the provision of family doctor services for those who cannot afford to pay. But now that we are on the eve of the dissolution of the dispensary system, I am glad to pay a tribute to the dispensary doctors who over the years have provided such a high standard of service for the public patients in their care.
The Eastern Health Board has now almost completed the task of getting the many thousands of persons covered by medical cards to make a choice from among the 400 family doctors who have provisionally agreed to take part in the scheme in Dublin, Wicklow and Kildare. This necessary preliminary work has proved tedious and troublesome and I must compliment the staff of the board on the manner in which they have coped with a difficult assignment.
I have recently established a special consultative council which I have asked to take a thorough look at all aspects of general medical practice and to advise me as to the manner in which it might be placed on a footing where it can derive the maximum benefit from the advances of modern medicine and where it can be co-ordinated in the fullest sense with the other elements in the health services. Far too many of our people are being admitted to institutions because they are sick or infirm. Apart from the upset that this means to the individual concerned and to his family, there is the purely economic consideration— namely, the great drain on public funds for both the capital and running costs of these institutions. The family doctor is the great bulwark against hospital admission and it is my policy to do all I can to facilitate him in that role.
For some people not covered by medical cards the cost of hospital treatment and drugs for long-term illnesses can be a hardship. This situation has been improved considerably under regulations made by me which came into effect on 1st October last. These regulations give power to health boards to provide drugs and medicines, free of charge, to persons suffering from mental handicap, cystic fibrosis, epilepsy, diabetes and a number of other conditions all of which are long-term and involve the suffer in continuing expenses on drugs and medicines. This scheme will apply without regard to the individual's income. For most of these conditions hospital treatment will be free for children under 16 years old, also irrespective of means.
I think the House will agree that this scheme represents a worthwhile step forward in alleviating the hardship of long-term illness.
The document circulated to Deputies contains the usual annual statistics about births, marriages and deaths and tables showing deaths from various causes. The birth rate in 1970, at 21.8 per 1,000 population, is showing no sign of declining. The marriage rate, at 7.1 per 1,000 population, is the highest ever recorded in this country. The death rate at 11.5 per 1,000 population, is about the average figure for the past few years.
The death rate from heart disease went down slightly in 1970 as compared with the previous two years. The death rate from all forms of cancer was the same as in 1969, which was higher than in previous years. Unfortunately, the death rate from lung cancer continues to increase and in 1970 reached a rate of 32.6 per 100,000 population, which is 50 per cent higher than the 1963 figure. I will be speaking later of the main cause of lung cancer deaths—cigarette smoking.
Deaths from accidents in the home totalled 462, the same as in 1969. Both these figures are higher than in former years, thus highlighting the need for extra care in the home, particularly as regards young children and old people. Nowadays more than twice as many people die as a result of accidents in the home than from respiratory tuberculosis.
Infant mortality in 1970, at 19 per 1,000 live births, was the lowest on record. The maternal mortality rate was much the same as in the previous years. It is low; but could be lower and I hope will be lower in future years. In general we are among the top countries when judged by expectation of life and other vital statistics but standards are improving and complacency is entirely unjustifiable.
The advances made over the past decade in regard to the more significant infectious diseases, to which I referred last year, continue to be maintained. The number of new cases of tuberculosis registered showed a decrease from 1,641 cases in 1968 to 1,397 cases in 1970. These incidence figures represent a decline of roughly 15 per cent over a short period of two years.
The position in regard to other diseases is equally encouraging. No cases of poliomyelitis or of diphtheria were notified during 1970, while only two cases of typhoid were notified. In the latter part of 1969 a booster campaign against polio was initiated and a highly satisfactory response of over 90 per cent of children under 18 years was achieved.
Another important immunisation service has been introduced recently. This is the vaccination scheme against rubella (German measles) under which girls will be protected against a disease which, if contracted early in pregnancy, can bring a very real possibility of serious congenital defects in the unborn child.
The number of cases of gonorrhoea and syphilis show no significant upward change. However, some patients seek treatment privately particularly for gonorrhoea, some cases of which are not notified to the Department. I have had the matter under close examination over the past year and I can say that some positive steps are about to be taken in an effort to insure that, as far as possible, this country will not find itself faced with a problem of the appalling magnitude prevailing elsewhere, resulting from the escalation of these diseases.
The control of communicable diseases in international health is now becoming increasingly important in the light of the considerable increase in the volume of international traffic and the ease and speed of travel. The westward spread of cholera over the past year demonstrates this. To alert the public to the danger to health which may be involved for travellers abroad, I have had special advisory leaflets circulated through travel agencies. A leaflet was also issued as a handy summary of information for medical practitioners who might be asked for advice by persons intending to go abroad for holidays.
In recent years it became evident that the lack of adequate facilities available to the official side, represented by the County and City Managers' Association, was creating difficulties in dealing promptly and effectively with the staff side on wage claims and other conditions of service. It was decided that the most appropriate way of improving the situation was the establishment of a corporate body to provide the necessary staff and other resources to enable managers collectively, and the chief executive officers of health boards, to discharge fully, efficiently and expeditiously their functions in this field. With this in mind, the Local Government Services (Corporate Bodies) Act, 1971, was enacted in the early part of last year and under its enabling provisions the Local Government Staff Negotiations Board was established last July. The board will provide such services as may be required for the purpose of staff negotiations, including proceedings under any scheme of conciliation and arbitration for local authority staff and also Labour Court proceedings in respect of staff who have recourse to the Labour Court.
A chief officer to the Staff Negotiations Board has been appointed and the other necessary staff are at present being recruited. In addition to the steps taken to improve the facilities for negotiations by the official side, a special review has been undertaken of the existing conciliation and arbitration scheme for local authority officers with a view to bringing about some improvements. The existing scheme, which was introduced in 1963, has worked reasonably well but in the light of the experience gained since its introduction it is considered that some amendments may be desirable. The current review has been undertaken by a working party representative of the staff and employer sides and the Departments of Local Government and Health.
I feel confident that these developments will improve staff relations generally in the local authority field and will lead to more meaningful negotiations through the more effective machinery that is being made available. Initially the Staff Negotiations Board will act on behalf of local authorities and health boards. When they have become firmly established it is intended that they will extend their activities to embrace other bodies, such as voluntary hospitals and their staffs.
While I am on this theme of methods of improving staff relations, I should mention the recent strike by psychiatric nurses in the mental hospital service. This strike, which I very much regretted, must have caused acute distress to many of the patients and great anxiety to their relatives.
The insistence by the trades unions representing the nurses that promotion in the psychiatric service should be based solely on seniority has been an issue between management and staff since 1959. Management were gravely concerned to improve nursing standards as an essential element in their efforts to up-grade the psychiatric services and were convinced that a new basis for promotion in which seniority was not the over-riding consideration must be found. They pointed out that the existing system had evolved when mental hospital services were largely custodial and that a change was essential in order to meet the challenge presented by modern methods of treating psychiatric illness. The staff side on the other hand, wanted to retain seniority as the determining factor. In the rest of the public service the promotion of staff is, in general, on the basis of merit, seniority being taken into account.
The promotion system was the subject of a special investigation by the Joint Industrial Council for psychiatric hospital nurses in 1965. The agreement then reached between staff and management representatives, which provided for promotion by open competition, but with concessions and safeguards for existing staff, was rejected by the main body of the staff. In 1968 the dispute was heard by the Labour Court and was the subject of a recommendation to the effect that 50 per cent of vacancies should be filled by competition and the other 50 per cent filled on the basis of seniority. This recommendation was rejected also by the staff side.
Regarding the recent settlement terms I feel I must record my genuine concern that under these terms promotion in the psychiatric nursing service will still be based primarily on seniority. The best interests of the patients must be our first concern in this matter. I am convinced that the best possible nursing service, which involves the maximum of patients activation and group therapy, can best be assured only on the basis of promotion by merit. A person may be reasonably good as a nurse working under direction but he or she may lack the qualities necessary to lead, to instruct, to control and to encourage other staff. In such a case I do not think he or she should be placed in charge. Under the terms of the settlement the position is to be reviewed when the report is available of a working party who are examining the whole question of the psychiatric nursing services. When this report is available I can only express the hope that the staff side will give full consideration to the interests of the patients, and not to the interests of nurses only.
I have spoken with frankness on the subject of strikes in the health services. I have had experience of industrial relations problems for ten years as Minister for Transport and Power and did my utmost to encourage the adoption of the most modern practices in improving management-staff communications. In many countries of Europe strikes in essential industries never take place, arbitration being freely accepted by management and staff. I do not question the fundamental right to strike. I repeat again that I regard strikes in the health and hospital services as normally unjustifiable, since the only effect is to injure and depress the sick and infirm. The health and hospital staffs have a measure of built-in security of service which should make it possible for them to accept arbitration on an agreed basis. The psychiatric nurses' strike took place a week before the open hearing of the Labour Court. The action taken was, in my view, indefensible.
No one in the House can suggest that I have shown a lack of sympathy in regard to branches of the health administration where there was an obvious need for improving conditions of service, or the wage level.
Therefore, in making this observation no one can suggest that I am over-conservative. Indeed, decisions by agreed arbitration are more prevalent in those countries with advanced private enterprise plus a socialist intervention type of administration.
The recommendations for re-organisation and integration of general hospital services contained in the Fitzgerald Report on Hospital Services are of critical concern in the regional centres of Dublin, Cork and Galway and very positive steps have already been taken towards the development of integrated facilities in these areas, in general accord with the ideas outlined in that Report.
The initial steps taken in Dublin included the setting up of bodies to run St. James's Hospital, formerly St. Kevin's, and the James Connolly Memorial Hospital at Blanchardstown. The development of James Connolly Memorial Hospital as a general hospital is a specific recommendation in the Fitzgerald Report. Following negotiations between the then Dublin Health Authority and the three voluntary general hospitals in north Dublin —the Mater, St. Laurence's and Jervis Street—and with their full agreement, I made an order under the Health (Corporate Bodies) Act of 1961 setting up a body known as the James Connolly Memorial Hospital Board which leased the Blanchardstown hospital from the Dublin Health Authority with effect from 1st April, 1971. The board intend to provide a general hospital which initially will have a bed complement of 120. In order to achieve this object certain reconstruction works, involving operating theatres, X-ray and out-patient departments are necessary. This work is now under way. The full provision of 120 beds will not be feasible until the reconstruction work is carried through, which we expect will be completed during 1972. However, the board have already made a modest start in the admission and treatment of medical and surgical patients. The ultimate objective here is a considerably larger hospital than the initial 120 beds, and the board are considering the further development that will be necessary.
In south Dublin, following negotiations between Dublin Health Authority and their successors, the Eastern Health Board, and the Federated Dublin Voluntary Hospitals, agreement was reached on the establishment of a similar corporate body to develop and manage St. James's Hospital, formerly St. Kevin's. The intention is to develop medical, surgical and teaching facilities on the site, including services now being provided in a number of the constituent hospitals of the federation. The intended scale of development here will be very substantial and will include new in-patient accommodation providing not less than 350 beds.
The Dublin Health Authority and their successors, the Eastern Health Board, have negotiated with the voluntary hospitals in a most helpful and co-operative way in these initial attempts at hospital rationalisation, and I am convinced that the progress of these projects so far augurs well for the future of the hospital services in Dublin.
The planning of the Cork Regional Hospital is practically completed and I expect that the Cork Hospital Board will be in a position to invite tenders by the end of next March. The new hospital will be an up-to-date teaching hospital of 580 beds planned in full consultation with medical teaching interests. There will also be a small hostel of 20 places, to cater for patients who need overnight accommodation convenient to the hospital facilities.
Special provision is being made for medical education in lecture theatres and a library in addition to ward teaching facilities. There will also be a nurses' training school.
A new hospital will provide a regional pathology service and will cater for specialist clinical investigation procedures and research.
In approaching the problem of providing modernised hospital organisation in the west it is fortunate that Galway Regional Hospital of 567 beds is a comparatively new building, having been completed in 1957. This hospital and large modern complex at Merlin Park originally provided as a regional sanatorium are at present in process of being integrated. The emphasis in Galway can usefully be placed at this stage in the building up of specialist staff. In the last three years the following additional appointments there have been approved: 2 surgeons, 2 physicians, 2 pathologists, 2 obstetrician-gynaecologists, 3 radiologists, 1 paediatrician, 1 geriatrician. Some of the new posts have not yet been filled.
These developments in Dublin, Cork and Galway represent a substantial contribution to the practical implementation of the recommendations in the Fitzgerald Report. This has been done by ad hoc negotiations between the bodies concerned—the Department, the voluntary hospitals and the health boards. The Fitzgerald Report, however, recommended that there should be permanent formal machinery for achieving co-ordinated development of the services and this recommendation was endorsed in general by the Health Act, 1970, which provided for the setting up of special bodies to achieve this co-ordination. These bodies will be Comhairle na nospidéal and three regional hospital boards, based on the medical teaching centres in Dublin, Cork and Galway. Since the Act was passed, I have had discussions with a number of the interests involved on the setting up of these bodies and I have now reached the stage where the formal consultation with all interests involved which are required by the Act are in train. Very prolonged informal consultations have already taken place.
A draft of my proposals for the regulations setting up these bodies and spelling out in detail their functions was circulated at the end of November. I had hoped that the draft would come before the House for discussion and, approval, in February. As, however, a number of organisations have asked for further time to consider the proposals I had to extend the time for the submission of comments until 29th February, 1972. On this basis consideration of the draft regulations by the Oireachtas will not be feasible until after the Easter recess. In the mean-time, I do not wish to comment in detail on the proposals.
I have emphasised previously the importance of management in our health services, and it was never more important than now when we are faced with ever-rising costs, a substantial hospital re-organisation which will involve very considerable capital expenditure, increasing demands made by the public on our health services generally, particularly our hospital services, and the continuous impact of scientific development and medical progress. I believe that the management teams as worked out for the new health boards are a good beginning in that field. Increasing development and running costs, which as yet show no tendency to level off, necessitate radical managerial thinking in regard to priorities and the need to select from a variety of options, if the resources developed in our health services are to provide maximum benefit to the community. This type of management operation must have available better information on which to base decisions than we have at present. Within any organisation concerned with health services, and more particularly with hospital services, we must look for an adequate feedback of relevant information and statistics on which decisions can be taken. The in-patient survey being carried out by the Medico-Social Research Board with the co-operation of the hospitals should be of great value in the study of needs and priorities. In this area, too, there will be much need for expertise in looking at the over-all picture and I would envisage that Comhairle na nOspidéal and the regional hospital boards when functioning should give valuable light and guidance to management at the policy level.
The necessity to give the most active attention to efficiency and economy in the day-to-day running of the service is also beyond question and we must look to management to maintain a most active interest here. I have taken the initial steps to set up a unit in my Department which will concern itself with work-study and management generally and the services of this unit should be of great value to hospitals in achieving increased effectiveness, particularly in relation to personnel organisation which is such a heavy factor in hospital costs.
Continuing attention to "throughput", or the number of patients treated per bed over a specified period, must also remain a necessary concern of management and indeed of the hospital organisation at every level. The continuing increase in the numbers requiring admission for acute hospital treatment poses a special challenge, and every line of approach which would forestall unnecessary increase in acute hospital beds and consequential operating costs must be adopted if we are to contain the demand for services within available resources.
When all the steps possible are taken to reduce the intake into hospitals so as to shorten length of stay, to induce better administrative management, to co-ordinate and integrate hospital services, to keep as many old people as possible at home, I must make it clear that if one out of every ten people spends some time in an acute care hospital every year the cost of the hospital service is going to increase and will have to be paid for by the community.
In conformity with the policy of extending consultant out-patient clinics and providing specialist treatment in our hospitals, I have sanctioned the appointment of 49 consultants in the last two years.
The statement circulated to Deputies contains lists of the major hospital building projects completed since April, 1970, projects under construction at November, 1971, and projects at an advanced stage of planning on that date.
Capital expenditure on hospitals, in common with other public capital expenditure, is governed by the overall control measures which it has been necessary to apply in the public sector generally. Despite this constraint, however, it is expected that some £4.2 millions will be spent on hospital building works in 1971-72, of which £2.65 millions will come from the Hospitals Trust Fund and £1.55 million from the Local Loans Fund and other sources.
One of the most important elements of the current hospitals capital programme is the provision of extra accommodation and facilities for the mentally handicapped, to which I will refer in more detail later. In so far as general hospitals are concerned, the new St. Vincent's Hospital at Elm Park, Donnybrook, Dublin, replacing the old St. Vincent's Hospital at St. Stephen's Green, became fully operational early last year. A new central laundry and sterilising service for hospitals in the Dublin and adjoining areas is expected to be completed by the end of March. Other projects nearing completion or just completed include new operating theatres at the Mater Hospital, Dublin, and the Sheil Hospital, Ballyshannon, and new nurses' homes at Temple Street Hospital, Dublin, Sir Patrick Dun's Hospital, Dublin, and the North Infirmary, Cork. Work is expected to commence early this year on a major scheme of improvements at St. Laurence's Hospital, Dublin, to enable it to carry on its essential services until such time as new facilities are provided elsewhere, as part of the proposals for reorganising the hospital services. Planning is in progress on a number of other hospital projects which are expected to commence in 1972, including a new X-ray department at Our Lady's Hospital, Crumlin, kitchen and staff dining accommodation at the Meath Hospital, Dublin, reconstruction works at Linden Convalescent Home and extensions to St. Joseph's School for the Blind, Drumcondra, and St. Mary's Home and School for the Deaf, Cabra.
During the past year or so work was completed on a scheme of extensions at Sligo County Hospital where 100 new beds have been added, including maternity, gynaecology, ENT, ophthalmic and paediatric beds. Other additions included a new out-patients' department and a pathology laboratory. Three blocks of flats to accommodate 54 nurses are nearing completion. The extended hospital will be able to cater for about 228 patients and will provide specialist services in paediatrics, ENT, and ophthalmology on a regional basis for Counties Donegal and Leitrim as well as County Sligo.
Work has commenced on the erection of a new health centre at Ballymun at which child welfare, antenatal, ENT, ophthalmic, immunisation, psychiatric, dental and welfare services as well as general practitioner services will be provided.
Planning of certain important works at area health board general hospitals has reached a stage where it is expected that tenders will be invited this year—for example, new units at the County Hospital, Wexford, which will cater for maternity and medical patients and extra operating theatre accommodation and laboratory facilities at Limerick Regional Hospital.
Deputies will recall that when introducing the Estimate last year I dealt at length with the recommendations of the Commission of Enquiry on Mental Illness and indicated the progress which had been made in this connection. The process of implementing the commission's recommendations has continued since then.
However, I should make it clear that the report of the Medico-Social Research Board indicates that there is a very much larger number of first entrants, both urban and rural based, to mental hospitals in the 25 to 34 years age group largely due to schizophrenia than in the neighbouring countries. This has caused me to revise priorities. The Medico-Social Research Board will be investigating the socioeconomic conditions relating to this age group of patient.
With the advice of psychiatrists in my Department and outside it, I have decided to give priority to important schemes which will have the greatest impact on the younger age group. These schemes include short stay units at general hospitals, industrial therapy and workshops, the appointment of psychiatric social workers and the stepping up of social community services.
The Commission on Mental Illness were very concerned at the very high numbers of in-patients in our psychiatric hospitals. The latest figure available of 15,392 patients on 31st December, 1970, shows a reduction of 3,250 (17.4 per cent) since the commission reported. This is very conclusive evidence that the new intensive care approach enables patients to be returned to the community much earlier. Accommodation in some hospitals is still overtaxed but a reduction of 17 per cent must permit a better use of facilities and an improvement in the lot of those patients who may have to remain in hospital. At the same time attendances at out-patient clinics have increased from 83,769 in 1965 to 150,244 in 1970.
The scheme of the division of the psychiatric service in Dublin city into seven separate areas has progressed during the past year. Each area has its own team of psychiatrists, nurses and supplementary staff and the aim is to provide an acute unit in each area. As recommended by the commission, the co-operation of the private mental hospitals has been sought in providing such acute units.
The programmes for 1970-71 and 1971-72 include accommodation for in-patients and the provision of out-patient clinics at St. John of God, Stillorgan, St. James's Hospital, James's Street, St. Vincent's Hospital, Fairview, and at the former private mental hospital at Cluain Mhuire, Blackrock, County Dublin.
I would like to express my gratitude to the private hospitals concerned for their willing co-operation and participation in the new scheme. It posed for them a challenge which they gladly accepted and I am certain that much good will result for the hospitals and the general public.
In Cork a great deal of success has attended the new psychiatric units established in St. Fachtna's, Skibbereen, and at Sarsfieldscourt. I am hopeful that in a few years the success of these units will result in reducing appreciably the much criticised overcrowding in Our Lady's Hospital, Cork.
I have long been conscious of the need to improve recruitment of medical staff for the satisfactory operation of the psychiatric service, even though the number of psychiatrists per 100,000 population compares well with that in Great Britain. With this in mind I felt it was essential to give consultant status to senior psychiatrists employed in the service and to bring their remuneration in line with that of consultants in other specialities. Following discussion with representatives of the medical staffs I am glad to say that agreement was reached on revised duties and improved remuneration for the staff concerned. These have been accepted in principle by the health boards and are in process of being implemented.
The Eastern Health Board have appointed an acting director of forensic psychiatry, pending the filling of the post in a permanent capacity. His duties will include responsibility for the administration of the Central Mental Hospital at Dundrum, County Dublin, the administration of which was transferred to the board on 1st September last. He will also be responsible for the new "closed" unit for drug addicts at Dundrum and for the new adolescent centre for behavioural disorders, including drug abuse, which has been established by the board at Usher's Island, Dublin, and which came into operation on 8th February, 1972.
A working party, comprising representatives of the health board, the Department of Justice and my Department, has been established to consider how new buildings, which I have agreed should be provided at the Central Mental Hospital, can best be planned and utilised. Needs in regard to treatment and research will be borne in mind by the working party and the Eastern Health Board.
Last year I referred to the problem of alcoholism. The recent International Conference on Alcoholism and Addiction, organised by the Irish National Council on Alcoholism, has helped to focus attention on this disturbing problem. A recent analysis by the Medico-Social Research Board of first admissions into our psychiatric hospitals has shown that 1 in 7 of such admissions are due to alcoholism or alcoholic psychoses. Last year over 1,000 new alcoholic cases entered psychiatric hospitals for treatment. These figures emphasise the necessity of taking all practicable steps to combat the disease of alcoholism in our society.
With this in mind I have recently requested the council to consider, in the light of the recent conference, what should now be done to deal with this problem and I can assure the House that the measures advocated by the council will be examined and, whereever feasible, implemented with the least possible delay. I should point out that the problem related mainly to community consciousness. I have asked four of the health boards to appoint social workers with the necessary vocational gifts to organise the community services and to highlight the problem of excessive social drinking. I am urgently concerned with the problem of reaching the heavy drinker before he becomes an alcoholic. In this field I feel there should be a real hope, through education, of arresting the progress towards alcoholism and I am confident that the recommendations of the Irish National Council will pay special attention to this aspect of the problem. I might say here that my Department has recently commenced a campaign to draw public attention to the widespread problem of alcoholism.
A leaflet about the danger of excessive drinking has been prepared—a copy is with the documents circulated to Deputies—and will be circulated as considered appropriate. Incidentally, supplies of this leaflet were recently distributed to public houses throughout the country. This step was taken in agreement with the Licensed Vintners' Association and the Federation of Licensed Vintners, whom I wish to thank for their co-operation in this publicity effort.
A number of short-stay psychiatric units associated with general hospitals have been provided in recent years and it is planned to provide further units at Galway Regional Hospital, tenders have recently been received for this unit, Limerick Regional Hospital, Letterkenny County Hospital, Nenagh County Hospital and Kilkenny County Hospital and also at the projected Cork Regional Hospital and Tralee General Hospital.
Other improvements in the mental hospital field include the erection of a 100-bed unit at Kilkenny Mental Hospital to relieve overcrowding and provide better treatment facilities.
Work continues on schemes for the renovation and upgrading of existing mental hospital buildings, including the provision of new and improved sanitary and bathing accommodation, catering and dining facilities, electrical, boiler and central heating installations, ward and general improvements and staff accommodation. Improvement schemes of this kind are in progress at Ballinasloe, Cork, Ennis, Enniscorthy, Monaghan, Mullingar, Sligo and Youghal Mental Hospitals. Planning is in progress on improvements schemes for other mental hospitals. Tenders for the provision of work therapy units at a number of mental hospitals have been sanctioned. Planning is well advanced for the provision of units at other centres to provide work and occupational activity for suitable patients.
The Report of the Working Party on Drug Abuse was published last May and, as Deputies will be aware, it contains comprehensive recommendations relating to the problem of drug abuse in this country. Most of these recommendations have been acted upon.
I hope to introduce legislation in the current session containing more comprehensive measures for the control of drug abuse. The legislation will propose more flexible powers for the Garda in dealing with drug offences. It will also enable the Minister for Health to exercise certain additional controls in relation to such matters as the safe custody of drugs, the keeping of records and the availability of certain drugs liable to abuse. In addition, provision will be made for dealing specifically with offences involving the forging of prescriptions or their use. Provision will also be made for the working party's recommendations regarding "scaled" penalties depending on the drug involved, with harsher penalities for drug "pushers".
As regard the treatment of drug abusers, the special out-patient treatment and information centre at Jervis Street Hospital continues to provide a valuable service. A 24-hour telephone service is available at this centre for persons wishing to arrange for treatment or to receive information or advice regarding drug abuse.
As I have already mentioned, a special "closed" unit for the treatment of drug abusers has been established at Dundrum by the Eastern Health Board, with accommodation for 10 patients. The need for and extent of any additional accommodation that may be required in the future is being assessed. Patients discharged from this unit may attend any of the psychiatric out-patient clinics provided by the Eastern Health Board during their period of rehabilitation.
I will deal later on in this speech with the measures being adopted in the field of health education in relation to drug abuse.
Last year I explained at some length my approach to the organisation of institutional services for the care of the aged, and my policy in that regard will be reflected to a considerable extent in the future building programme. Progress on the building side continues to be reasonably good. Some 2,400 places have been provided in new or reconstructed accommodation since 1963. Schemes in progress at present will make places available for about 1,230 patients. Tenders have been invited or obtained for further schemes which will provide accommodation for some 328 further patients. The estimated total cost of the schemes completed and in progress and at tender stage is about £7 million. I am making provision in next year's building programme for projects which, when completed, will provide about 560 further places.
A start has been made on the planning of special new assessment and rehabilitation centres for the aged. The new Cork Regional Hospital will have a unit of 30 beds while a 40-bed unit is to be erected at St. Finbarr's Hospital, Cork. Changes are being made in the geriatric unit now in course of construction at the County Hospital, Tullamore, so as to provide facilities for assessment and rehabilitation as well as long-stay hospital care. Similar provision will be made in units envisaged for the County Hospitals at Nenagh, Kilkenny and Lisdarn. This policy will be continued when geriatric units are provided in the future in close association with acute hospitals.
The first of the new style welfare homes to be provided by health boards is nearing completion at Kilrush, County Clare. These homes will provide for frail old people who cannot continue to live in the community, even with the aid of supportive services, but who, nevertheless, do not need to be hospitalised on a long-stay basis. Much of the accommodation will be in single rooms. There will be adequate day-room and recreational space. The homes will, as far as possible, be located convenient to churches and shops. Local voluntary organisations will be encouraged to maintain close contacts with the residents and the general approach will be to avoid an institutional atmosphere as far as possible. Tenders have been received and approved for six other homes at different centres throughout the country. Provision has been made for six further homes in the 1972-73 building programme and I intend to include a number of welfare homes in each succeeding year. While the present series of homes are planned on similar lines I propose to keep an open mind in regard to future developments. I intend to ask health boards to keep in close touch with those responsible for running the homes and to submit recommendations for any changes they might consider to be desirable if further homes were being provided in their areas.
A further experiment is being carried out at St. James's Hospital, Dublin, where a day hospital has been provided. This unit accommodates up to 50 geriatric cases in any one day and its main functions are to provide care for former in-patients who need continuing treatment on an out-patient basis and to provide an alternative method of care for persons who otherwise might need to be admitted as in-patients.
The important role being filled by voluntary organisations in enabling elderly persons to continue to live in the community has received generous encouragement from my Department. In 1971-72 a sum of £200,000 is being made available through health boards to voluntary bodies performing worthwhile social work for the aged. The Department has continued its encouragement to health boards to make full use of this scheme, which gives the boards discretion to make grants, without seeking my specific sanction in each instance. To promote the scheme further, three social work advisers were appointed to my Department to assist and advise health boards and voluntary organisations active in or intending to become active in the community care of the aged. A pamphlet was prepared by my Department and issued for the guidance of these organisations in providing services for the elderly. A copy of this pamphlet is in the document circulated to Deputies.
A wide range of worthwhile services of a health or welfare nature provided by voluntary organisations are supported by grants under this scheme. Grants are paid to support the cost of the day-to-day activities of these organisations. A wide variety of services are provided in or out of local community centres, halls, club houses, schools and convents and other premises. Perhaps the most frequent and most appreciated of these services are the meals for elderly and disabled people, and laundry services, home visitation, and home help for the house-bound. Included also would be social activities in these centres for the elderly, as well as regular outings and parties. Where suitable premises do not exist to provide cooking facilities, arrangements are often made whereby a family will cook and deliver a meal to a neighbour in need.
The lack of a suitable centre does not prevent the provision of a variety of worthwhile services for old people. However, groups who feel restricted in the range of services they provide because of the lack of suitable premises may also obtain a grant towards the capital costs involved in the provision of an appropriate centre. Areas such as Longford, Athlone, Ballinamore and Blackpool, Cork, have been among the centres which have thus benefited.
There is a recognised need to increase the number of social workers employed by health boards and, as a step in this direction, a number of posts of senior social workers in the health boards' service have been sanctioned. It is intended that, where trained social workers are not already employed for statutory services such as child care, these extra social workers will be responsible for this work, will examine and report on the further social work needs in their areas and will co-operate with voluntary organisations in the provision of community social services.
Over the past five years the number of public health nurses employed on district duties has been doubled and a district nursing service has now become established in every area in the country.
New entrants to the public health nursing service qualify in public health nursing following a nine-months training course organised by An Bórd Altranais. Refresher courses are also provided at regular intervals.
The target set in 1966 of having a district public health nurse available in each district has now generally been achieved. Practical problems have, of course, arisen in the operation of the service and I have had representations about a variety of matters connected with it.
After consultation with the appropriate professional bodies, including the Irish Nurses Organisation, I established a working group last May to survey the work-load of the public health nurse and to make appropriate recommendations relating to the service. The working group have completed a pilot survey, with the co-operation of 20 selected nurses, in preparation for the main survey which they hope to commence in February. The main survey will last for a period of four weeks.
Last year I gave the House a review of the services for the mentally handicapped. The steps which I then outlined for the improvement of facilities have been pushed ahead as rapidly as possible. There are now 4,148 residential places available, compared with 3,100 in 1965. Work is going ahead on the provision of additional places. The documents circulated contains particulars of projects completed since 1st April, 1970, and gives the locations of the additional places which are at present in course of construction or in planning providing for 1,500 places in all.
I know that Deputies and the public are anxious about the provision of places for the mentally handicapped. I have mentioned before that there are no accurate statistics here or, indeed, in any country, regarding the numbers of mentally handicapped persons. The programme planned, however, will meet the targets set by the Commission on Mental Handicap and, on the basis of all information available to me at present, I am reasonably satisfied that these targets are realistic ones. I am having the matter kept under continual review, however, to ensure that our programme is adequate.
Side by side with the expansion of residential accommodation, there has been a continued growth in the numbers being cared for on a non-residential basis. The numbers now receiving care in this way have increased from 600 in 1965 to 3,000 at present. Day care permits fuller development of the personality of the mentally handicapped person and avoids the difficulties which could arise after a prolonged period in a residential centre. The co-ordination of residential and community services coupled with the development of a wide scale of educational and social training will, it is hoped, help to maintain in the community all those mentally handicapped who can be so maintained.
While it is hoped that it may be possible in the future to achieve a situation where the majority of the handicapped will be able to live in the community, there will always be a need for lifetime residential care for many of the more severely handicapped for whom such care is unavoidable. For these patients it is my policy to ensure that they will be adequately housed and that they will be given the opportunity of being trained, including training in sheltered workshop activities, to the extent that their disabilities will permit.
I am happy to say that a comprehensive assessment service for handicapped persons on the lines recommended by the commission is being developed for the whole country. This service is based on teams and a multi-disciplinary approach is being adopted in the formation of these teams. Skilled personnel for medical, psychological and social aspects are included. The full assessment, which could involve examinations over a period, will go into all aspects of the patients' handicaps and chart the measures considered necessary for their care, and their education and training to fit them into normal community life.
It may be of interest to the House to know that the facilities already available and in course of expansion in this country for providing residential care for the mentally handicapped are proportionately greater than in Great Britain. I am told that, in general, our service bears favourable comparison with that of most countries in the world. We are keeping in close touch with progressive developments elsewhere. In the schemes for new places we are changing over to a large extent to small chalet-type accommodation, wherever possible, rather than continuing to use the traditional larger units.
I should like, again, to express the country's gratitude to the religious orders and voluntary bodies and to the health boards who provide the backbone for these services. Without their active participation we would not have achieved the advances we have made in providing accommodation, care and training of our mentally handicapped.
Current expenditure by the State and health boards on the maintenance of the mentally handicapped, excluding capital expenditure, is now running between £4½ million and £5 million a year. The current programme for building is estimated to cost up to £4,000,000, excluding the cost of schools which is the concern of the Department of Education. It is estimated that the maintenance costs of mentally handicapped patients will increase by over £1 million a year when the present building programme is completed. This is an indication of the extent to which the State is prepared to go to ameliorate this tragic human problem.
A new child health service, which aims at identifying physical and mental ailments of children at the earliest possible stage and at referring them for appropriate treatment was introduced in the larger cities in October, 1970. This service will provide three detailed medical examinations for children while they are under 2 years of age. Initially it is confined to towns with populations of 5,000 and over. It is intended that, as part of a four-year programme, the service will be extended to children in other areas.
Detailed statistics from health boards relating to the operation of the new child health service will be available soon. An initial review of the operation of the scheme was undertaken, in conjunction with chief medical officers, about five months after its inception. It emerged from this review that, of these children entitled to be examined at the age of six months in this period, 84 per cent had been given appointments and 83 per cent of those given appointments had attended for examination. In general, the appointments system operated well and the response of parents to the scheme was excellent. My Department is continuing, in consultation with the health boards, to review the progress of the scheme.
As I mentioned last year, I established a working group to design new pre-school and school medical record cards on which a child's progress could be systematically recorded. Those records systematically record and track the health progress of the child and greatly facilitate the supervision of his or her health particularly in regard to early diagnosis of health defects and their correction. In 1970, 41 per cent of the national schools were visited by the school health team and almost 139,000 children were given school medical examinations.
Revised procedures for the school health service were introduced during 1971. A comprehensive initial screening examination for six-year-olds attending national schools has been introduced in a number of areas and also a selective health examination of some nine-year-old pupils. Other children may be examined in any year at the request of the parent, or, with the parent's consent, at the request of the teacher or the nurse. I have recommended to health boards that they should retain the routine medical examinations of school leavers for the next few years to ensure that there will be no break in the service to children because of the introduction of the revised procedures. It is my intention to develop the concept of the school health team comprising doctors, teachers, nurses and parents, pooling their knowledge to ensure that each child will obtain the greatest benefit from the services being provided.
