At the end of the last session of the Seanad I was discussing what seemed to me the essential principle in the St. Laurence's Hospital Bill, and I had just come to the point that one of the principal points apparently underlying the Bill, and provided for in the Bill, is the transfer of the hospital to another site. That is a matter to which I think the Seanad should give very close and very careful attention. The Dublin medical school is on somewhat different lines from any other medical school in these islands in the sense that it has sprung up and prospered and has done well in a number of separate institutions. I am speaking now of the Dublin medical school as a whole, and not of any particular school. The history of the Dublin hospitals is similar in many ways to the history of hospitals in some other centres, notably, for instance, in London, in that the hospitals were founded at different times and in different centuries by the charitable public almost altogether. There are some exceptions. The hospital we are particularly dealing with in this Bill is not one of those which have sprung up as charitable institutions primarily. It started its life as a Government institute, and the Government, both before the Treaty settlement and since, has had a considerable control over the hospital.
I suggested on the last occasion the Bill was before the House that one of the objects of this Bill or one thing that springs out of the Bill from even a cursory examination of it is that the Government is tightening its control in many particulars above what was practised at any rate in the past—whatever might have been the legal position of the Government in relation to the hospital. When medical schools as distinct from hospitals came to be founded they were founded quite distinct from the hospital and had little or no connection with the hospital. That is a position which is peculiar, I think, to Dublin. It does not arise in Belfast to anything like the same extent because there are only two major general hospitals in Belfast and the teaching courses at both of them are recognised by the university in Belfast.
Here in Dublin there are ten general hospitals and the clinical course given in each of them is recognised officially by the three medical schools which exist in Dublin at present. None of them is under the control of a medical school but there is a happy association between the work carried out by the hospitals and that by the medical schools. One result of that is that the whole course of medical education is not given at one site or in one locality.
Students attending one of the medical schools—University College, Trinity College or the College of Surgeons— can attend any of the hospitals for their clinical courses. They choose the hospital according to family associations, convenience to their residence or other considerations of that kind. In London the case is quite different. The medical schools there have arisen as annexes or extensions to the hospitals or vice versa, and the hospital and medical school are either in the same building or are immediately adjacent to each other so that there is only one location which is concerned with the student's education. Here the student is attending some of his lectures at a medical school—the three of them are situated fairly centrally—and he is attending for his clinical instruction at a hospital which may or may not be convenient to the school, but which is generally fairly convenient to a residential district. It may be convenient both to the residential district in which he lives and to the hospital.
A great deal of the anxiety that has arisen from the apparent determination to change the site of the Richmond Hospital is due to the knowledge that such a change is likely to interfere greatly with the convenience of students attending the hospital and to interfere greatly with the classes in the hospital. Hospital lectures begin at 9 o'clock and it is not easy for a student to attend a hospital which is several miles distant from his residence.
In choosing his residence, the student has to take into account its proximity to the hospital, and also its proximity to the medical school which he is attending. If the Richmond Hospital, to give it its common name, is transferred from a fairly central position to a position in the suburbs or in the neighbouring countryside, it is likely to interfere greatly with the possibility— I said "convenience" a moment ago, but it may extend even to the possibility—of students attending a class in that hospital, and the class is likely to diminish very much. Liveliness, or the life of the teaching, depends very much on having a sufficiently large class to encourage the teacher. There is nothing more depressing for a teacher than to have to address a small class, or nothing more depressing for students than to feel that they are in a small class. I do not say that very large classes are desirable, but certainly, for clinical teaching, unless there is an active and fairly numerous class attending the hospital, the teaching in that hospital will suffer, and the attraction of that hospital to leading men, surgeons and physicians, seeking staff posts, which are always unpaid, is likely to diminish if they have not a class to encourage them. I do not overlook the fact that the income of the visiting physician or surgeon depends to a large extent on fees received from students. He is not paid anything by the hospital. He gets certain fixed fees from the students. These fees are set out in the syllabus and the student or his parent knows what the fees are going to be during the student's normal course.
For both these reasons, an active and fairly numerous class is necessary to ensure that the hospital will retain a thoroughly competent staff, the best staff available. No doubt the members of the staff get other advantages. They are teaching students who are going to be the practitioners of the country in after years. The good word of the students is one of the things that will help members of the staff towards a good practice in future, a consideration that no teacher can afford to neglect. Again, the fact that they are attending patients in a hospital with a good reputation maintains their reputation with the public generally. From that point of view, the fact that the school may be gravely damaged, possibly almost destroyed, by a movement of the hospital to a site which is not convenient for the attendance of classes is one to which the Seanad should give close attention.
There is another point of view, which is the essential one as regards the hospital. That is that the hospital must be within a convenient distance of the population which requires its services. The Richmond Hospital is situated in a very congested area of the city but, fortunately, plenty of space is available for building an extension to the existing hospital or building a new hospital. It is not part of a slum but a slum area comes right up to the door of the hospital. It is in a very thickly populated area but there is plenty of space available immediately beside the hospital for an extension of the building.
It has been urged, and urged with a good deal of reason, that hospitals would be better situated in the open country, in country air, than in fairly closely crowded quarters of the city. There is a great deal to be said for that, and the idea has been put into practice in some cases. Some of the old London hospitals have been moved out into the country or to suburbs just outside the city. The same thing was done in Birmingham. A beautiful open site was chosen within about three miles of the centre of the city, but in that case the medical school had preceded it. The medical school, which had been formerly situated in the city itself, was moved to a building adjacent to which the hospital was built. From the point of view of the hygiene of the hospital that was admirable. One factor which did not work favourably for education was that there was not available residential accommodation for students in the immediate neighbourhood. No doubt there is a hostel or residents' house attached to it, but whether that was capable of accommodating all the students, I do not know. Another discouraging feature was that the patients for whom the hospital was intended did not follow it to the suburbs. I had an opportunity of visiting the hospital a few years ago, and certainly in the way of hospital building and planning, I could not conceive of anything much better in present conditions. But, I was informed, the people in the city requiring hospital treatment continued to attend the older hospitals in the city and the new hospital was very much less frequented. The word "abandoned" was used to me, but I think that that was putting the matter too strongly. From two points of view, the movement, though it promised very well, appears to have been a failure— from the point of view of convenience for medical education and from the point of view of the convenience of patients.
From these two points of view, the changing to any distance from the present site of the Richmond Hospital would seem to be undesirable. There is plenty of room around the existing hospital for building. There are the grounds of the old Dublin Union which, I understand, are at present let to a charitable society which, no doubt, could be accommodated elsewhere.
The Minister has made clear that he had a certain neighbourhood in his mind as a site to which he would, so far as his power went, transfer the hospital, leaving, as this Bill provides, some part of the old hospital to continue to be temporarily used as an outpatients' department. That question of keeping the out-patient department in a central situation and moving the beds to a suburban situation raises another point. At first sight, it appears to have much in its favour but it has this in its disfavour—that it makes for the inconvenience of the friends of patients who desire to see them. Patients in a hospital look forward to the weekly or bi-weekly visits of friends and it is important that these friends should have ready and easy access to patients if they are dangerously ill. If a hospital is removed some distance from the centre of population which it serves, there is a considerable drawback in this regard.
This question of the site of the hospital has, of course, been very hotly discussed. It has been a topic of conversation amongst medical and other people interested in hospital problems during the past few years. The Minister, in this Bill, takes power to buy land for the purpose of accommodating the hospital. That, in itself, is a useful provision; because the Minister can better deal with the purchase of land than any other purchasing body, such as the board of a hospital, could. He can deal more efficiently with the matter and make orders which the board of a hospital could not make.
A similar suggestion was made by other hospitals which had plans for establishing a new hospital by the combination of several. There is, however, no control on the Minister in regard to his choice of site. I do not know where the suggestion as to the Cabra site came from. The proposal in the Bill is that the Minister should be empowered to assign funds from the Hospital Sweepstakes, which are under his control at the moment, for the building of this hospital. Most of the activities of the Minister in dealing with the Hospital Sweepstakes funds have been after taking the advice of the Hospitals Commission. I do not know what advice the Hospitals Commission has given to the Minister in this respect. The Hospitals Commission have published very full and useful reports and have published a great many of their recommendations in these reports. I do not think—I have made inquiries from various people on the subject—that they ever recommended that this hospital should be transferred to a site at some distance from the present situation of the hospital. I do not know whether the Parliamentary Secretary is prepared to tell us whether or not the views of the Minister, as expressed, though not embodied in the Bill, follow the recommendations of the Hospitals Commission or whether he made up his mind, within the Department, as to this being the best way of dealing with the matter. Whatever criticism the Hospitals Commission have been subjected to— and any body of men in such a position would be subjected to criticism—they have exercised a very wise discretion in the advice they have given and they have made a very useful survey of the hospital problem in the State. If the Minister has not the advice of the commission behind him, then I think the proposal requires more backing, and that it is not sufficient to throw it into the void, as is done in this Bill, and empower the Minister to purchase land for the building of a new hospital.
I hope the Parliamentary Secretary will be able to satisfy some of the fears aroused amongst many people interested in the hospital service of Dublin and the general social services of the State by the tremendous power given to the Minister in this Bill. I have dwelt largely on what seems to me to be the most dangerous point, but there is hardly a point in the hospital's administration which is not under the thumb of the Minister. Though this hospital has been subject to a certain amount of Governmental control throughout its history, it has mainly been managed by a board of governors, which had power so to manage it, though they had not the full powers embodied in this Bill. I do not think that anybody who has a knowledge of hospital service, as practised in this country, and experience of the people who make use of that hospital service, is enamoured of the proposal to substitute for voluntary service a State-controlled service. In so far as this Bill appears to be a step further in the claim of the Department to control the hospitals in detail, I think the Seanad should hesitate to approve of it.
