Seanad Éireann debate -
Wednesday, 31 Mar 1943

Vol. 27 No. 19

Hospital Finance—Motion.

Sir John Keane

I move:—

That the Seanad requests the Government to set up a commission to inquire into and make recommendations upon the matter of hospital finance generally; and, more particularly, upon the relations between the voluntary hospitals and the State, with a view to the establishment of the organisation best suited to the efficient operation of the whole hospital system.

For some time past I have felt that a motion of this kind was overdue, and I felt it especially when we were discussing the St. Laurence's Hospital Bill. A number of questions arose there which really raised a wider issue than that which the Bill itself covered, and although, through your indulgence, Sir, we were allowed to discuss certain things that may not have come within the scope of that Bill, I felt that I could not deal with a number of matters, within the scope of that Bill, in a properly comprehensive way. Accordingly, I have drawn up this motion in general terms —terms which appear to me to admit of the widest possible discussion of hospital finance and policy. I need hardly say that if the Government were to accept the principles involved, it would be necessary to consider, in much closer detail, of course, the terms of reference that would go before any commission that may be appointed.

Now, my reason for feeling that an inquiry, on the lines of the motion, is necessary, suggests that I should refer very briefly to the background of this whole hospital question. Up to the time that the Sweepstakes were established, a certain practice had grown up as a result of experience. We had the old traditional system of voluntary hospitals, arising out of the necessities of the poor, and which were intended, mainly, by their charitable founders, to give treatment to the poorer classes of the people. As a result of that system, over a large number of years, you had hospitals founded which were supported, in the main, by voluntary subscriptions. Certain hospitals, such as the group with which we dealt in the recent Bill, were financed, mainly, by State funds. Then, as time went on, the needs of the sick poor were not adequately covered by the voluntary system, and, going back to the early days of the poor law system, you had the dispensaries and other services provided by local authorities. As I say, the whole hospital service developed, more or less, on those lines, until the Sweepstakes came along; and the Sweepstakes came along largely because the source of voluntary contributions proved to be inadequate for the services required. Certain hospitals were getting into financial difficulties owing to increased expenses and declining subscriptions, and it was felt that some other form of assistance should come to their aid, and, as you all know, the Sweepstakes came into existence.

Now, in the early days, the Sweepstakes were a comparatively modest affair, but they grew to such an extent that it became necessary to regulate the new position that they brought about. I quite agree that it would have been quite impossible to allow the, if I might call it so, unseemly scramble that took place among certain hospitals in the beginning of the Sweepstakes to get funds and spend them as they thought fit, whereas other hospitals were excluded. The result was that the whole thing became almost a national problem, and I quite agree that the State or some other authority had to step in and regulate and control the distribution of these considerable sums of money that had, somewhat unexpectedly, and rather surprisingly, come in. A committee was set up, therefore, to deal with that matter, but I say that the present system is only an improvisation brought about by some exceptional needs resulting from the advent of these Sweepstakes funds.

The present system is in the nature only of an improvisation; it never has had in view the wider needs of hospital treatment and medical services for all classes of the community. That is a much bigger problem, which I feel, in preparation for post-war conditions, now falls due for comprehensive examination. Those of us who feel that inquiry is necessary have to ask ourselves: is the present system of control—brought about, as I have said, largely by the Sweeps—satisfactory? If it is a regulated and co-ordinated system, capable of meeting the needs of the future and the new conditions we will have to face, well and good; I would then be the last person to ask that it should be changed. But, personally, I have grave doubts—many people with whom I have discussed the matter also have doubts—that the present system is best suited to the very important work that lies ahead, to the new conditions that we are likely to have to face, and to the general desire to provide better services for the sick among all grades of our community, not merely the very poor, who cannot afford to pay, but those of small means who can afford to pay a little, and those of larger means who can afford to pay a good deal more.

The system at present—I am speaking mainly in regard to general hospitals—is in this form: you have in existence the old hospitals under the voluntary system, a number of them teaching hospitals under their own peculiar regulations, some attached to universities, and, which is only right and proper, all with their own special characteristics arising out of their origin. Then you have, as a result of the control that became necessary when the Sweeps money came on the scene, a body called the Hospitals Commission. That body is not an executive body. It is an advisory body; I think I am right in saying it is merely there to advise the Minister as to the needs of existing hospitals, mainly with regard to the distribution of the Sweepstake funds. I should be the last person to suggest in any way that that body has not done very admirable work. One has only to look at their reports to see the vast amount of information they have collected, in many cases the very valuable suggestions they have made, and the enormous industry shown by the large volume of statistics they have compiled, but we realise that that body has no responsibility to anyone except to the Minister in an advisory capacity. As I said, it is not an executive body, but it is one that imposes an element of worry, and, I would suggest, a certain element of delay in reaching final decisions which are the responsibility of the Minister.

I should like at this stage to make certain references to the publications of that commission. We have a series of reports dating from 1933-34. In the course of a rather detailed inquiry I was met by certain not very important but puzzling features. I am a little bit puzzled because, in respect of the forwarding and acknowledging of the reports, I am met by the Irish language. Elsewhere in the reports I am dealing with my own tongue, but in regard to the forwarding and acknowledging of them I am a little bit puzzled as to the exact particulars. I notice that the 1933-34 report was forwarded without date, and it was acknowledged in Eanair, 1936—I do not know what that month is—by the Minister's Department. The next report I come to is for the year 1935-36. It was forwarded in Deire Foghmhair, 1937. Again, I do not know what that month is. You will note that it was forwarded in the year following the report, and it was acknowledged in the same year. Both those letters were dated. Then we come to the year 1937. The report was forwarded in Meitheamh, 1938. Now, here is a curious thing; it was forwarded in 1938, and was acknowledged in a Ministerial letter without a date. It is rather strange to find an undated letter issuing from a Government Department. Then we come to the report for the year 1938. It was forwarded— here I am almost sure I have correctly translated the name of the month—in July, 1939; it is given here as "Iul, 1939." Again, it is acknowledged without a date, so for two years in succession we have an undated acknowledgment. It is a small matter, but it is puzzling.

After that, we have no more reports; the last report is for the year 1938. I would ask the Minister to tell us why, after having had consecutive reports covering a period of five years, each forwarded within the year following the period with which it dealt, we then have a complete blank for a period of four years, four years during which important work must have been done by the hospitals? It is a great handicap to anybody who wants to discuss hospital policy to be without those valuable reports for four years. On the St. Laurence's Hospital Bill, I asked the Minister why this was so, and he rather expressed surprise that it had been so. In any case, he said he would inquire into it. Presumably, that was the first time he knew that there had been this long delay in publishing these reports.

I do not want to make invidious comparisons, but it does seem strange that some Government Departments are much quicker than others. For instance, we already have the report of the Land Commission with reference to last year's activities. We also have the report of the Electricity Supply Board, a very complicated organisation covering a vast field of commercial activity. We get that report with extraordinary regularity and punctuality. In the case of this commission, there has been no report for some years. I cannot help feeling doubtful that the commission is entirely responsible for this delay. This commission, for five years, presented its reports punctually, and then suddenly in 1938 it dried up and has remained dried up ever since. I think we are entitled to a full explanation of the delay.

When you examine these commission reports, you find an extraordinary volume of statistics. I welcome statistics, but I always like to be satisfied as to the purpose they serve. Statistics collected merely for the sake of collecting them, and which do not appear to be capable of much use, are, to my mind, an unnecessary waste of time and money. I doubt the value of some of the statistics contained in the large volume covered by some of these reports. For instance, you have, in relation to the general hospitals, a segregation of expenditure under a number of headings, such as provisions, surgery, domestic, miscellaneous, and so on. You have then in relation to the total number of occupied beds, covering two or three pages, and in relation also to the total number of beds available. I am not an expert in hospital management or control, but I fail to see how anybody, however expert and however closely concerned in hospital control, would require such a large volume of statistics set out separately both for occupied and for available beds. We might like to know the total number of occupied and available beds, and we might like information as to the degree of occupancy—that is all separately set out—but why there should be so many statistics under other headings, puzzles me.

I also question whether, when certain information is not given, very much value can be got from these statistics. For instance, looking at surgery and dispensary, I notice in the case of two hospitals, the Adelaide and the Drumcondra, that no figures are available. I can understand that the Adelaide, not being associated with the Sweepstakes, does not consider itself under an obligation to present any figures, but the fact that there are no figures does make a serious gap in any investigation. I come now to an extraordinary discrepancy. In one hospital I see that the cost per occupied bed is £16; the lowest is £14, and the highest is £41. I feel that cannot be so in reality, and that there must be some rational underlying explanation of a discrepancy of almost £30 in regard to an occupied bed. There is no explanation given for that, however, and, in the absence of any explanation—looking merely at the bald figures—I doubt if such a large volume of statistics is really worth all the trouble taken in its compilation.

I pass on to the appendices, the statistics of illness, and I am interested to find there a new feature in our Government publications. I find three languages—rather a hopeful sort of international outlook. I notice the omission of Irish as a heading—I do not know that that matters very much. We have English, French and German headings for these various categories of illness. Perhaps they may be valuable for foreigners studying hospital statistics; it might be interesting for foreigners to notice the incidence of disease in Kerry County or in Cork City, but I question whether the whole thing is of any practical value. I am rather driven to this conclusion, and I say so with all due regard to the valuable work that the Hospitals Commission has done, that I am afraid it is a body that is growing into merely a statistics-collecting body and, to a certain extent, these statistics are drawn up merely to justify existence, without regard to need. I do not feel that the work this body is doing is worth the money that must be spent upon it—I do not mean all the work, but I do mean the minute statistical work—and I cannot escape the feeling that that body is, to a certain extent, collecting this large volume of figures merely to justify its existence.

One thing I should like to refer to in relation to statistics is the total absence of any costings. I find—and I hope the Parliamentary Secretary will agree with me—that the only statistics that are of any use for the purpose of control are statistics got out on a unit-costing basis. There is nothing of that kind being done. I know there has been difficulty about it, but I feel that over the period of eight or nine years some attempt might have been made to give some figures which would carry confidence as showing the true costings.

On the question of finance, speaking in round figures, up to the year of this last report, 1938, the hospitals had received a total of approximately £13,000,000 from the Sweepstakes. At the present date, approximately £8,000,000 remains as a fund under the control of a vesting body, the Hospitals Trust. The titles in these cases are rather misleading, but I am referring now to the body having control of the investments.

Mr. Foran

Would it be in order for me to second the motion at this stage? I have another meeting to attend at 4.30.

Leas-Chathaoirleach

It would not, Senator. The motion can only be seconded when the mover has concluded his speech, putting it before the House.

Mr. Fitzgerald

Some other Senator can second it.

Sir John Keane

£8,000,000 remains and the hospitals have had the balance between them. Over £1,000,000 has gone to the rate-aided hospitals—the county hospitals—and, roughly, the remainder has gone to the general hospitals. That capital sum of £8,000,000 is, as far as can be seen, required to finance the present growing deficits of the general hospitals. Perhaps £1,000,000 of it may be free, but the remainder of that £8,000,000 is earmarked to meet those growing deficits.

I would ask the House to bear in mind that, in its first report, the Hospitals Commission recommended, among other things, an increase of 600 beds in the bed accommodation of the Dublin general hospitals. There were other recommendations in the report regarding rebuilding, amalgamations, and some other things that I need not go into at present. There was, however, this substantial recommendation, based, I am sure, on inquiry, that the general hospitals in Dublin required 600 additional beds. That was in the year 1933. If the census figures are any guide. I imagine that the need for additional beds has grown in the meantime. In spite of the fact that the sum of £13,000,000 has come into the hospitals' system from the Sweepstakes, how many beds, do Senators think, have been provided in the Dublin general hospitals? The large number of 25 beds over a period of nine years. That is the number, although the sum available was £13,000,000. The Parliamentary Secretary may be able to explain it, but, on the face of it, it will take some explaining. I know, of course, that the hospitals have benefited in other directions, that nurses' homes have been substantially improved, and that certain necessary equipment has been provided; but, even so, I feel that the need of additional accommodation to the extent of 600 beds should, over this period of nine years, have been met to a greater extent out of that large sum of money. The nominal addition of 25 beds is, surely, not adequate, looking at the thing by and large.

Other big recommendations made by the commission have, I suggest, been equally sterile. As far as an outsider can see, no progress has been made as regards amalgamations. No doubt, discussions on the matter have taken place between the Government and the hospitals concerned, but we are still awaiting the necessary legislation to make amalgamation possible. Finance is now very largely dried up, so one must feel that the possibility of amalgamation taking place is becoming more remote. Finance, or no finance, we feel that it has taken an unduly long time—whoever the parties concerned may be—to produce the necessary preliminaries for any effective scheme of amalgamation. The reason why I ask the House to say that this matter needs inquiry is because the evidence seems to show—I have given, I think, satisfactory indications in that direction—that the present organisation is not the one which is best suited to the needs of an efficient and progressive hospital system. The delays that take place in getting decisions are notorious. Hospitals get letters from the Hospitals Commission, letters which, no doubt, are courteous in their terms, calling attention to their growing expenditure and asking for economies. Everybody knows that expenditure is growing. How can it be otherwise in the present emergency, and with the increased cost of living? They also get letters in almost similar terms from the Minister's Department, many of which are produced in duplicate. They are almost in the nature of circulars with perhaps a little paragraph at the end dealing with the needs of a particular hospital. The complaint is that on some small matter on which a business man would expect a reasonably prompt reply—it may be just a demand for sanction for some comparatively small expenditure—the delays that occur are unending.

I think the Parliamentary Secretary will hardly attempt to deny that there are very long delays. There was one— I do not say that it may not have been exceptional—brought forward in the Dáil. It related to the site for the new Cork Street hospital. No doubt, there had to be some inquiry in that case. I do not know who is to blame, but these delays seem to be endless. I think anyone familiar with the day-to-day work of hospitals will agree that, when a thing must be done sooner or later, the delays that take place in getting sanction are excessive. From all that I draw the conclusion that the present organisation is not the one best suited to modern needs.

The underlying reason for this motion is the belief that, on the whole, there is a much wider outlook needed on the future of hospital policy and finance. At present, with regard to finance, the position is really baffling. The Hospitals Commission was set up, and large schemes were forecast, based on a continuance of the Sweepstakes income. The funds have been greatly reduced, but the schemes are still there in people's minds. What is going to happen, and what view have the Government about what is going to be done, if the Sweepstakes are not revived, or if they are just revived on a more modest scale? I feel that, in the main, some of the reforms suggested, such as building and amalgamation, are not merely not luxuries necessitated by the large amount of the Sweepstakes income, but are needed. Whether the Sweepstakes are revived or not, they are necessary, in the public interest. That is a matter that, I think, should be examined: where the money which is to finance them is to come from if the Sweepstakes are not revived. Personally, I feel it is the duty of the State to find the money. That is only my own personal view.

It is not a matter, however, that should be done without inquiry. I feel that the need is so great, and the demands for better hospital services so pressing, that the money should be found by the State, the State, in turn, taking a lien on future sweepstakes. If that income is not there, then, in the last resort, the cost should be borne by the taxpayer.

Then, for a large number of other things, a long-term examination is required in the light of better things promised in the new world. A multitude of things is required. There is the question of the medical treatment of persons of moderate means. There is a distinct need at present for some better service, or rather for one at a more moderate cost to people in the £500-£600 group who become ill. They are prepared to pay something more than for the treatment accorded on the same lines to the very poor. They certainly cannot pay for expensive nursing homes. The problem of reasonably priced treatment for such people requires examination. Then there is the question of the interaction of hospital services with, possibly, compulsory insurance in future, if we get anything on the lines of the compulsory insurance outlined in the Beveridge Plan. I think the interaction of hospital policy, in relation to compulsory insurance, is a matter that should be thoroughly considered, even at present, when there are considerations of a less wide character in question. There is also the question of specialisation in certain diseases by certain hospitals. I hope that Senator Rowlette will follow me and, for that reason, I want to be very careful to explain that I am not, as a layman, in any way suggesting matters outside my province for the medical services. I know those who feel that hospitals, in the light of modern science, should specialise in some diseases. I think Senators will agree that it is very desirable that tuberculosis cases should not be dealt with in the present general hospitals, and mixed up with other diseases which are not in their nature infectious.

There is also the important question of the out-patient services. The present condition of out-patient services in Dublin could be described as little short of chaotic. The free dispensary service is notoriously unable with the large flood of out-patients, not having the equipments, the space or the staffs. These out-patients, according to the way they feel, get the best treatment in any hospital they deem fit to attend. But I do not know that there is any attempt to regulate the inflow of out-patients or the diseases from which they suffer. Certainly control of the whole out-patient service is overdue for examination. In connection with that I should like to mention that out-patient costs, according to figures given in the Hospitals Commission Report, are the costs per occupied bed. The total is got by including the costs of out-patients' beds, figures which vitiate any conclusion. An attempt should be made before now to segregate costs of out-patients in statistics that are to be of any value.

There is another very large question which I suggest is not satisfactorily dealt with now, that of how to blend the existing voluntary system with a growing measure of State control. We must now realise that a time has been reached when the voluntary system cannot remain with all its former features. We have to accept the fact that voluntary subscriptions have practically dried up, and that it is desirable in many ways to consider an inevitable measure of State control. I do not think the Minister, responsible as he is for a Department, liable as he is to political influence, and affected as he must be by popular feeling in the manner of his decision, is the best person to administer long-term hospital schemes. When we started the Electricity Supply Board it was deliberately organised to be free largely from political control. I cannot help feeling that a commission examining this matter would try to seek some solution along the lines of that service, amongst bodies representing the medical services, the voluntary hospitals, and perhaps a preponderating measure of State control, so that there should be one executive body entrusted with the administration of funds and to control hospital policy. That is my own personal view of the future. It can only be decided after full inquiry by a commission which would hear evidence and have all the necessary authority.

There is also the question of the future of the convalescence services. Everybody will agree that the convalescence side of the treatment of disease is largely undeveloped and needs great expansion. That is a matter that would have to come within the purview of any inquiry. There is also the question of business management. Experience in other countries has shown, and gradually in a small way it is beginning to be felt here, that an increasing degree of business methods will be needed in future to control hospital management. I am only attempting to picture the large field that would have to be covered by any commission that could take a satisfactory long term outlook. Incidentally, I might mention the question of pensions for nurses. The nursing service is one that needs inquiry and treatment. There is the basis of my case, that the present organisation has grown up in the nature of an improvisation due to the advent of the Sweeps. If the Sweeps had never come I suggest we would have had the present organisation. The question should be approached now on a much wider and more comprehensive basis. I believe that the present organisation is not satisfactory, and is not fitted to meet the needs of the future, as well as to plan a long term view for the hospitals, and for that reason I ask the House to support the motion.

Mr. Fitzgerald

In the absence of Senator Foran I second.

Dr. Rowlette

I have been interested in the motion that Senator Keane has brought before us and in the manner in which he has brought it. His motion demands an inquiry into the present system but it leads up to an argument in favour of greatly increased State control. There are many of the remarks and criticisms that he has made with which I am in entire agreement and there are some with which I am not quite in agreement.

I agree with the Senator altogether in his reference to the need for managing the hospitals on more strict business principles than those on which they are managed at present—that is, in regard to their financial administration. Many people who manage hospitals are business men who give their time voluntarily and generously—and many of them give their money also— to keep the hospitals going. But they sometimes look on business management as if it were a matter of collecting money from patients. In many cases, such patients cannot contribute for the treatment they receive and it has been a fundamental principle of the voluntary hospitals up to the present—a principle which I should be sorry to see disappear—that they depend on charity and that they do their work largely out of charity. I quite agree with Senator Keane that modern development renders it necessary to deal with a class of patient in voluntary hospitals which was not thought of at the time those hospitals were established—nor thought of for some decades, or even centuries, after their foundation. That class of people is called the contributing patient.

If we are stressing this importance of business methods, I think we ought to bear in mind that business methods must be applied to business matters and should not be applied to something which should still remain a matter of charity—the performing of the fundamental function of the hospitals. A great improvement has been made in the administration of our hospitals in the last half a dozen years by the appointment of almoners whose duty it is to adjust the payment to the means of the patients and not to press for payments which it would be hard for patients to meet. Those almoners also make themselves acquainted with the home and financial conditions of their patients, and try to assess, in agreement with such patients, the financial basis of the contribution. With a little more experience of that, the business arrangements covering payments by patients to hospitals should be still further improved.

Senator Keane has given certain portions of the history of what the State has done during the last ten or fifteen years in regard to voluntary hospitals. I wish to point out that, up to 1937, the State did still contribute some small sums to some of the voluntary hospitals, in respect of grants which had been established originally by the Irish Parliament prior to 1801 and which had remained in existence since then. They were all small payments, except in the case of one hospital with which we dealt at considerable length a few weeks ago. When the sweepstakes were established, the State decided to abolish all those grants, and they were abolished, I think, in 1937. Since that date, the hospitals have got no assistance from the State in any capacity—financial or otherwise. Their funds have been "docked" by the State in different directions and yet they have had to carry on.

The Senator also referred on several occasions to the sweepstakes system. The sweepstakes were invented by the supporters of a few of the voluntary hospitals some fifteen or sixteen years ago—I am not sure of the date, but it does not matter—in order to pay the debts which were overwhelming some of those hospitals and to renovate, add to or re-build some of the other hospitals which were in a bad way. As we all know, the sweepstakes proved to be an extraordinary success for some years. There were great advantages, but there were also great drawbacks, in that they attracted the attention of undesirable people — notably the Oireachtas, which saw very large sums of money coming into the country and going to a purpose which they deemed proper and useful but which did not contribute directly to the upkeep of the State or of the hospitals which previously had depended for their upkeep on the rates. As a consequence, very large sums of money were diverted from the sweepstakes receipts for the purpose of relieving taxes on the one hand and of relieving rates on the other hand.

I have not any document before me at the moment, but I cannot help thinking that Senator Keane may have made an error in quoting the sums of money given to the voluntary hospitals. Perhaps he would favour me with a quotation from a recent report, in order to give a comparison of what has been given to the rate-supported hospitals.

Sir John Keane

I can quote £13,000,000 as being, roughly, the receipts—of which sum approximately £3,000,000 was granted to participating hospitals; £1,159,000 to the rate-aided hospitals; and £9,000,000 remains with the Hospitals Trustees. Some of that £9,000,000 has been distributed but some £8,000,000 still remains with the Trustees.

Dr. Rowlette

The figures which Senator Keane has read out do not tally with those in my memory, and I am glad he has brought the correct ones to my mind. People who bought sweepstakes tickets with the intention, in the first instance, of contributing to the relief of the sick poor—which is the work of the voluntary hospitals in this country—now find that something more than a quarter of the funds—about one-third, I think—has been devoted to the relief of the rates. A large sum has also been devoted to the revenue of the country.

As to the difficulties in which Senator Keane sees the voluntary hospitals at the moment, and his summing up of them, I am, in the main, in agreement with him. That trouble is due to those who have been rifling the funds for which the sweepstakes were originally established, and to which, as the previous Minister for Local Government and Public Health frankly admitted in the Dáil, they should primarily have gone. The primary purpose of that collection was the aid of the voluntary hospitals. Had that money gone to the voluntary hospitals, the difficulties that Senator Keane sees to-day would not have arisen. Those difficulties arise, in my view, from the tampering by the Government, through the Oireachtas— quite legally, of course—with a situation which did not, in all equity, concern them at all.

For those funds the State has given no service to the voluntary hospitals, but certainly has given the services of the Hospitals Commission. I would like to join with Senator Keane in his remarks regarding the very valuable work done by that body. In its early years it made a very useful survey of the condition of the country as regards its hospital services, and very carefully planned to deal with the hospital service systematically on an efficient and adequate basis. That that plan is not being carried out is not the fault of the Hospitals Commission. Senator Keane gave us instances of the fact that it takes a year or two to get even an acknowledgment from the Custom House for a certain document sent across from Upper Mount Street. Those of us who had to do with the plans put forward by the hospitals and with the recommendations made by the Hospitals Commission do not know with accuracy, but do know in general, the length of the delay, and that the delays are so wearisome and tedious that the recommendations made and the plans put forward are almost forgotten before a reply can be obtained from the Department.

I should like to bring the House back to consider what is the distinction between voluntary hospitals and others. I take it that a voluntary hospital is an hospital which, primarily, is dependent on voluntary funds. That does not rule out, of course, contributions, as were made in the past, from other sources, such as the small grants formerly given by the Irish Government towards voluntary hospitals. But, in their foundation and maintenance they are almost dependent on voluntary funds. The second point is that they are administered by voluntary workers, a matter of considerable importance, because people are not going to take on the arduous duty of governors unless they are interested in the work, and have a human and real live interest in carrying it to success. For those who value hospital work, it is a duty to express, whenever the occasion arises, the gratitude of the public to the men —very often business men with plenty of work of their own to look after, and sometimes men and women who are retired from other professions—who give their leisure time to the administration of voluntary hospitals, which requires very great ability, great consideration and a great expenditure of time. Thirdly—and this one is also of importance—voluntary hospitals are staffed by voluntary professional workers. Incidentally, I may point out that in any development, such as Senator Keane seems to look forward to, that last item may make a considerable difference in the financial position if the hospitals have to pay salaries to staffs of a considerable size who at present, and whose predecessors throughout the centuries, have given gratuitous service. These characteristics of the voluntary hospitals have to be kept in mind when discussing their future.

Senator Sir John Keane expressed the opinion that the present organisation is not satisfactory. I am sure that if that organisation had been given a free hand for the last 15 years the position of the voluntary hospitals would be satisfactory to-day. It has been held up. I am sure that the natural development of that organisation, with the resources which were unexpectedly opened at that time, could have been brought to a very successful issue by now if it had not been for the rifling of the funds in the two directions I have mentioned.

Senator Sir John Keane, near the end of his speech, drew attention to certain faults in the present hospital service. I agree that he is right in some of these criticisms. Most of these criticisms have already been submitted to the boards of governors by the medical staffs in order to improve the service. He spoke particularly of the lack of system, I think, in the out-patient service. I quite agree that where the out-patient service has been better developed, as has happened in other countries, the out-patient service, instead of being as it is here, at any rate in the scope of its treatment and the class of people who attend, almost synonymous with the poor law dispensary service, becomes a series of specialised departments, and casual droppers-in do not come into the hospitals in such places simply to meet friends and have a chat for an hour or so in a moderately comfortable room and to get attention for ordinary illness. They are sent for consultation. They have already seen other medical men—their club doctors, private doctors, or poor law doctors—and they are sent for consultation in special cases; cases where special apparatus may be needed or special skill required for diagnosis. Here in the out-patient departments of the hospitals you will find the same class of people that you will find in any poor law dispensary, and cases in which such special lines of diagnosis and treatment may not be necessary. I believe that hospitals would be far more useful if they did limit their out-patient clientele in that way; that they could do a good deal with conditions which could not be adequately dealt with elsewhere, and would save a great deal of time and energy spent on work which could be competently done by any medical man without any special skill. I think Senator Sir John Keane is not, perhaps, quite familiar with the degree of specialisation which takes place in many of the departments of the hospitals, judging from some of the things he said. The out-patient departments are not all such general reception rooms as I have mentioned, but very definitely serving a particular specialised purpose.

Again the Senator said that it was not good to have tuberculosis patients in general hospitals mixed up with the others. I entirely agree with him. I think it is quite right that general hospitals should have a special ward or wards for dealing with tuberculosis cases. There is no other provision in the country for dealing with them and they have to come to these hospitals. One of the main difficulties at present is that other cases of sickness have been crowded out of the wards of general hospitals owing to the necessity for dealing with tuberculosis cases, because there is no room for them anywhere else in the country. We have had talk of the establishment of sanatoriums, but nothing happens. In the meantime the methods of treatment of tuberculosis cases have developed very differently in recent years and they may require more special and surgical treatment than was customary even ten years ago, and much more than was customary 20 or 30 years ago. The only place at present for dealing with them is within the general and voluntary hospitals. I agree that they should not be mixed up with the other patients and that there should be isolation wards. In the present conditions, owing to the shortage of beds to which Senator Sir John Keane referred, it is quite impossible to segregate them as they should be segregated.

Senator Sir John Keane, at the end of his speech, pleaded for a large measure of State control. He expressed the opinion that it was admitted that a larger measure of State control was required. My view would be that the control which the State has begun to exercise, because it obtained the right of administration of the sweepstake funds, should be steadily diminished and disappear altogether. I quite agree with Senator Sir John Keane that the voluntary hospitals would have to do a great deal of reorganisation. The difficulty at present is that they are not masters in their own house or of their own funds and have not found such a degree of State control as has been exercised helpful to the development of the hospital services or to the efficiency of the hospitals. I see no reason to suppose that a larger measure of State control would give any more efficiency.

As to the other point which Senator Sir John Keane referred to, most of us have been thinking of how the general medical service could be developed in future to reach a larger class of the community than it does now, but I am not going to discuss, it at present. He suggested that such activities and discussions as have been taking place in a neighbouring country arising out of the Beveridge Report have set us here thinking—that is quite true—and that certain developments which take place in future which may or may not be similar to developments which take place in Great Britain. But, at the moment, I would try to emphasise that the problems here are very different from those in England or Scotland, and that while we have problems to be dealt with we would be making a grave mistake if we jumped to the conclusion that the sort of solution which is put forward in a neighbouring country is the sort of solution which will suit problems in this country. That was a mistake made 30 years ago in the matter of national health insurance, where a system devised with special reference to an industrial population like that of Great Britain was applied in this country, truncated, it is true, of its most important element. A system was applied in this country that was almost identical with the system applied in England. We have not altogether recovered from that, though in recent years, it is right to say, the system has undergone a great improvement. But we should in any radical changes which may be made in the health system of this country be careful to get a system which will suit the conditions of the country and not be merely adopted because it has been found or is believed to be suitable to the conditions in another country.

I cannot agree with the recommendation that Senator Sir John Keane asked the Seanad to make, that a commission should be held, seeing the rather tendentious nature of the commission which he would like to see established. For my part, I think that steps in the direction that he suggested in regard to increasing the power of the State and diminishing voluntary control and voluntary work would be detrimental to the health of the country instead of improving it. I could not support Senator Sir John Keane in his recommendation in that matter.

Mr. Brennan

I think Senator Sir John Keane has done a very useful service in putting down this motion, because the discussion so far has been of considerable value. At the same time I feel—if he will forgive me for saying so—he has made a very poor case. With regard to Senator Rowlette's remarks, I desire to say that I am not an advocate of complete State control. On the contrary, my view is that what the individual—and that is true of the individual hospital as well as the individual man—can do reasonably well, the State should not do at all. At the same time, I do not think the proposer of this motion suggested in anything that he said that all was well and all was perfect with the voluntary hospitals before the advent of the sweepstakes. I do not think that anyone in this House could argue that the hospital position is other than improved as a result of the sweepstakes.

Senator Rowlette, I think, has suggested in his speech that all was not well, that all was not healthy, with the voluntary hospitals. That would seem to indicate that some measure of State control is inevitable. For my part, I hope the extent of State control will be as slight as possible. Nevertheless, if things are not as satisfactory as they ought to be with the voluntary hospitals, I do not think the idea of State control should be eliminated. Senator Rowlette—I want to be quite fair to him—suggested that there should be a diminution of such State control, and I am not against him in that, but there can be a diminution of State control only if the work of the voluntary hospitals is carried on satisfactorily. I am not alleging that the work of the hospitals, whether voluntary or State controlled, is 100 per cent. efficient or 100 per cent. perfect. Even in the present system, I feel it is not right, for example, that the inefficient hospital should be quite content to continue in its inefficiency and to apply to the Hospitals Commission for whatever deficit it may incur in the course of a year's working. I feel the less encouragement given to that sort of thing by the Hospitals Commission the better.

The hospitals should be conducted as efficiently as possible. I do claim that the hospitals as a whole, are to-day far more efficiently conducted and far more effective as a result of the sweepstakes. I think it is undeniable that in our hospitals, in Dublin and throughout the provinces, we have facilities, such as up-to-date x-ray apparatus, that we would not have were it not for the sweepstakes. I am afraid a number of the critics forget that there have been these immense improvements in hospital equipment throughout the country. To my own knowledge, in quite remote parts of the country, operations can be performed which in my younger days could have been undertaken only in Cork or Dublin. That improvement has been brought about as a result of the work of the Hospitals Commission.

We would all like to feel that it would be possible to continue to maintain our hospitals by charity and by charity alone, but the extent of the charity given to our voluntary hospitals was not adequate to provide them with the up-to-date equipment which is now available in those hospitals which have been assisted by the Hospitals Commission. If we had allowed these hospitals to continue as they were, without enabling them to move with the times, without giving the patients the facilities to which they were entitled, merely because, in principle, we were against sweepstakes, we would merely have revealed the lack of a Christian outlook on the part of the Legislature.

It is quite true that in the past the needs of the poor were given very great consideration by the hospitals, but that does not mean that they were given adequate consideration. In my view, they were given far from adequate consideration. I feel they ought to be given even greater consideration in the future. Under the system which has been in vogue during the past ten or twelve years, very considerable improvements have taken place in that direction, and throughout the country to-day the poor, or even the near poor, the people with £200 and £300 a year, are getting hospital facilities that were unheard of in this country 25 years ago. Surely, that is all to the good. It must be admitted that in the past the needs of the poor were not adequately catered for. I am not claiming that they are adequately catered for now, but certainly the position is far better than it was some years ago.

Senator Sir John Keane agrees that the State had to step in to regulate the large sums made available by the sweepstakes. The only thing that remains for us to consider is whether the present system of control is or is not satisfactory. I do not think it is unsatisfactory. I think it was necessary to set up something like this Hospitals Commission. I think it has performed a tremendous amount of useful work and I feel that were it not for the Commission a large number of the improvements which have taken place would not have been possible. While I say that, I have no sympathy whatever with the inefficient hospital, which relies on the Commission to meet its deficits. Where these deficits are unavoidable I think it is all to the good that the hospital should have some body such as the Hospitals Commission to make them good, but so far as they are avoidable, I would rely on the Hospitals Commission, in view of their record of good work, to secure that that state of affairs must not continue. Senator Sir John Keane suggested that the present organisation was merely an improvisation and, therefore, not satisfactory. In moving his motion, I do not think that he gave us any examples of unsatisfactory results on the part of the Hospitals Commission. From what I could gather from Senator Rowlette's speech, he would agree with my view in that respect. One of Senator Sir John Keane's criticisms had reference to the dispensary service. In the course of my life, I have gone to places in all the thirty-two counties. I think that we have inherited a service which we have much improved. We can be quite proud of the service given by our dispensaries. The dispensaries are extraordinarily good and, on the whole, the service given to patients, if not ideal, is extremely creditable.

The fact that we have a larger measure of State control now than formerly, and that the sweepstake has made these large funds available is no reason why charitably disposed persons should not help the hospitals. I have heard it frequently urged against the sweepstakes innovation that they killed the voluntary system in regard to the hospitals. It is a poor type of charity which is withdrawn for such a reason. If something remains to be done for the poorer patients in these hospitals, charitably-disposed persons should not be deterred from exercising their charity to such extent as they can afford by the fact that a certain amount of assistance is forthcoming from another source. Senator Sir John Keane suggested that the Minister was not the best authority to exercise widespread control over the hospitals. I presume that he was not referring to a particular Minister but to the Minister for the time being. If there is to be State control, it must be exercised by some Minister. In this case, the Minister who exercises control is the Minister for Local Government. If there is to be State control, it must be exercised by somebody who has got parliamentary sanction, as the Minister for Local Government and every other Minister have. The Senator said something about Ministers being swayed by political influences, but he did not give us any evidence that the work of the Hospitals Commission, or the attitude of the Minister with regard to the hospitals was politically influenced.

I was hoping that the Senator would elaborate his views on the Beveridge plan, though, goodness knows, this House, in view of the Intoxicating Liquor Bill, should be tired discussing "beverages" of any kind. The Senator did not, in fact, develop his views on that question. He merely told us that something in the nature of the Beveridge plan would have to be considered some time in the future. The Beveridge plan has not come yet. Although I would concede some measure of State control for hospitals since they are in receipt of State moneys, when it comes to a question of insurance, I am not in favour of State-controlled control, or anything in the nature of the Beveridge plan. In insurance, I think that the individual will fare better without State control. Virtually the only criticism in Senator Sir John Keane's speech was his suggestion that there were endless delays in obtaining Ministerial sanction. That may be the fault of the system. No matter what Minister is in office, it is inevitable, when the expenditure of public moneys is involved, that these delays will occur.

I am with the Senator in hoping that these delays will be eliminated so far as is possible, but I would agree with Senator Rowlette that Senator Sir John Keane has not made a case for this motion. Everything may not be perfect at the moment, but the improvement in the position of our hospitals to-day as compared with that of 20 years ago is almost miraculous. Unless there is general agreement that some inquiry should be held, I do not think that any case has been made by Senator Sir John Keane for his motion.

Mr. Foran

I am in thorough agreement with Senator Sir John Keane's motion. I think that it is timely and opportune and that the need is very urgent. The voluntary hospital system has given very good service in its time but, under modern conditions, it is almost entirely out-of-date. In a changing world—and this country is changing like every other country— other countries have seen the necessity for reorganising their hospital system. Many of them had more up-to-date systems than we had. Our voluntary hospital system requires attention for many reasons. This country is fortunate in having the Sweepstake funds. In that connection, the sum of £13,000,000 has been mentioned. This amount has been accumulated and made available for the development of an up-to-date hospital system, which I do not believe we have got. From the latest returns published, we find that, in 1938, there was a deficit in the case of 51 hospitals of £158,000. Senators will note that that was for the year 1938. Not much imagination is required to realise the difference in the charges from 1938 to 1943. We can assume that the charges on the hospitals have gone up very substantially. There, in itself, Senators have a justification for an inquiry into the financial position of the voluntary hospitals. If that reason stood alone, it would justify an inquiry. It shows that the system, if allowed to continue as at present, will be heading for bankruptcy. Whatever inspired wealthy people in the past to make bequests and legacies to the hospitals, these have now disappeared. More and more, the hospitals are being thrown on the resources of the Hospitals Trust Fund. That is the source from which their deficits have to be met, and we may assume that they amount to considerably more than £200,000 per annum to-day. I do not think it requires any more from me to impress on the Seanad the need for an inquiry. That alone would justify action in regard to inquiry and investigation.

For over 30 years, this country has had a system called the national health insurance system—a misnomer, of course, because they never did anything to deal with health propositions. They gave out weekly allowances and so on, but they never touched at all on the question of public health. By amalgamation, a certain amount of funds have been accumulated, and it is proposed to spend something in the neighbourhood of £200,000 per annum on health services from the national health insurance. A sum of between £50,000 and £60,000 is to be made available for hospitals and £75,000 per annum for dental benefits. There are to be considerable sums for convalescent homes treatment and specialist and surgical institutions, while money is also to be provided for the treatment of rheumatic, neurotic and other patients, the total being about £200,000 per annum, and, so far as national health insurance is concerned, they have no say whatever in respect of the voluntary hospitals.

I do not want to dwell unduly on this point because the matter is in dispute at present. Some people, in their wisdom or unwisdom, before the matter has been settled, rushed into print in the Press, but I do not want to do anything which would further jeopardise the very desirable end of an agreement between the voluntary hospitals and the National Health Insurance Society. I think that, there, is to be found another reason for asking the Government to set up this inquiry. The voluntary system is all right in its way. It served a purpose in the past, but it is not moving with the times and is not in keeping with modern conditions. Some steps ought to be taken to bring it more into conformity with modern conditions.

I have seen it stated that any development on these lines would put the doctors in the position of underpaid civil servants. I am sure nobody wants to bring that about, but I do not think that as a whole civil servants are underpaid, and I do not think they are any less competent than any other section of the community. I think that a considerable measure of State control is necessary, and for the reason that every voluntary hospital is a self-contained unit. There is no co-operation between them; they are a law unto themselves. Each hospital has its own equipment. Senator Brennan spoke about that modern equipment and about equipping the hospitals down the country with it, but if Senator Brennan sees a virtue in equipping these hospitals with modern equipment at enormous cost, when they lie idle for eight-tenths of the year, whereas in a thickly populated centre these machines and their operators could be exploited and used every day, I certainly do not. I think it is unwise expenditure. The patients could very easily be brought to these machines, or the machines could be made more mobile and brought around to the patients. Instead of going to enormous in providing up-to-date machines which are very rarely used, and which are badly wanted in thickly populated centres, it would be much more economical to have them in places where they would be of the best possible service. That is not the case now and that is another reason why we should have an inquiry—to see that the big expenditure from these funds is used to the best possible advantage for the sick people.

Another aspect of our voluntary hospital system is that it is usual in a number of these hospitals to close down some of the wards—not beds, but wards —during the summer period, ostensibly for cleaning and painting, but really because the staffs have to get holidays, and rightly so. In the meantime, illness and the need for beds do not grow less, but the beds are not available because there is no one to attend to them. That is a serious matter and one which I, and other like me, have stressed on various occasions. If you take into account the bed costs, overhead costs and so on, and the enormous expenditure involved in these institutions, to have a large portion of them lying idle, so to speak, when there is a big demand for them, is a very important matter for all concerned. Senator Brennan referred lightly and rather sneeringly to the Beveridge plan. We must have some plan, whether it is a Beveridge plan or any other, to deal with the situation here, and I submit that while the funds are there and before they are diminished any further, we ought to have a commission to inquire into the whole position of hospitalisation.

I have not gone to the full limits of this matter, but I will say that if we had a properly equipped and organised dispensary system, we could do away with some of our hospitals by dealing with the people before they became chronic cases. In that connection, there is very little segregation of the chronic and the acute cases in the Dublin hospitals. In many of the hospitals, chronic cases occupy beds for as long as two or three years. I do not know that that is economic; I do not know that it is good for the hospital system; but I know that it is keeping acute cases out of the various hospitals. There are many other phases of this matter that would be more proper to put before a commission of inquiry, or such a commission as is suggested in this amendment, and I sincerely hope that the Government will listen to this timely appeal of Senator Sir John Keane to set up such an inquiry, because the need is there and the matter is comparatively urgent. That need, certainly, will not be lessened by putting the matter on the long finger, and I think that, as the war goes on, and at the close of the war, the need for hospitalisation in this country will become even greater than it is to-day. At any rate, I see no other source from which these annual deficits can be met except the Hospitals Trust Funds, and they are exhaustible. Accordingly, now is the time to take steps to remedy that situation. I may say, in conclusion, that I am not at all in favour of the State taking over these funds and using them for hospitals which are the entire responsibility of the State. However, these are matters which would be very proper for a commission of inquiry, and I sincerely hope that the Minister will see his way to approve of this motion and have a commission set up.

Mr. Healy

When I saw this motion, I expected that there would be some definite charges of incompetence or otherwise against the voluntary hospitals. I have listened to Senator Sir John Keane and, as I have some know ledge of different hospitals in the city, and their management, I think it is my duty to answer to some extent some of the points that were made. I think that one of the first points made by Senator Sir John Keane was that some of the hospitals had money to spend whilst others were not so fortunate. I presume that the reason why some of them were not so fortunate was that they would not partake of the proceeds of the Sweepstake funds, and therefore it was their own fault if they did not get support from these funds. It seemed to me that the greater part of the criticism to-day was directed towards the Hospitals Commission, instead of towards the administration of the hospitals themselves. In that criticism, Senator Sir John Keane referred lovingly to the national language of this country. It is wonderful the interest that some people take in the national language at times. Possibly, the Senator did not like to see the national language coming in, in connection with the distribution of the Sweepstake funds. He also referred to the fact that the Sweepstake funds may be dried up. Well, let us hope that this emergency will not continue for all time, and that, when it is over, the Sweepstake funds will return to their former prosperity.

The Senator also referred to the building of Cork Street Fever Hospital. It is true that the question of building a new fever hospital has been under consideration for some time. The site for the hospital has been purchased, and no loss has been experienced. Out of evil, however, sometimes cometh good, and would not the Board of Cork Street Fever Hospital be placed in a very awkward position at the present time if a contract had been given and the whole thing held up, or if some clause in the agreement with the contractors were used to get more money out of the Board in connection with the building of that hospital?

The Senator also referred to the out-patient departments in city hospitals, and I understood him to say that they were in a state of chaos. I do not know if that is the case. I have not heard any evidence of that, and I know something about the hospitals in the city. I think that if there was anything wrong about the out-patient departments of the hospitals, we would very soon hear about it. The Senator also spoke about the necessity for having businessmen on the boards of management of our hospitals. I can tell the Senator that there are both businessmen and business women on the hospital boards of this city. One of the hospitals to which the Senator referred was, I think, the Richmond Hospital. The management there originally was appointed, chiefly, by the Lord Lieutenant. Of course, that matter now comes under the Minister for Local Government and Public Health, but I can assure Senator Sir John Keane that if he will come to some of the boards of management of the hospitals in this city, he will find very many efficient businessmen on these boards—some of the most successful men in business and commercial life that there are in the city.

I certainly was surprised at the attitude adopted by Senator Foran in the points that he raised. We know the headway that has been made in connection with the different hospitals, in the way of buildings, and providing suitable instruments for these hospitals, which were badly needed. Senator Foran has recently become a member of the board of one of these hospitals, and he must know the headway that has been made in connection with that hospital, the amount of money spent in building, and so on, and that applies to a good many other hospitals.

Mr. Foran

Do not bring that up against me.

Mr. Healy

The Senator also referred to the fact that certain instruments, or machines, as he called them, were lying idle in some of the county hospitals. Well, I think it was very wise of those county hospitals throughout the country to try to provide the necessary machinery, equipment, or utensils, to deal with emergency cases. For instance if, down the country, you had a case of a person suffering from a perforated duodenal ulcer, would it not be necessary to have some machine, or some instrument, to deal with that immediately? I do not think any case has been made against the management of the hospitals. It seems to me that Senator Sir John Keane has directed his argument against the Hospitals Commission, and accordingly I do not see why I should vote for this motion.

Mrs. Concannon

I regret very much that I was not here when Senator Sir John Keane and Senator Dr. Rowlette were speaking on a subject which must be of particular interest to women. I speak as one without any expert knowledge of the subject, but I think it would be common sense to oppose the resolution as it stands now, on the ground that it is inopportune. The reason I take this stand is that the hospitalisation of the country cannot be dealt with alone; it is part of a much greater thing, the whole medical and health services of the country, and if a commission is set up it must take cognisance of that fact. For that reason, I would plead that, if this motion goes to a vote, the House will not pass it. At the same time, it is a very good thing to direct attention to any form of health services, and especially the hospitals. I should like to take this opportunity of impressing on the Minister that the nurses play a very important part in our health services, and I hope that, if anything is being done, their position will not be overlooked. If we do not improve the position of our nurses, there is a danger that girls who would make excellent nurses will be attracted to hospitals in England. I know that the Minister is interested in this matter; with Senator Miss Pearse, when we were both in the Dáil, I had the honour of leading a deputation of nurses to him, and again when the Minister for Finance was Minister for Local Government he also received the three women Senators in connection with this matter. I know, therefore, that the Minister and the Parliamentary Secretary are interested in the position of the nurses.

Some people seem to be rather frightened at the idea of State control. It seems to me that the State is what we make it, and, if it is right for a small group of people to be charitable and to help the poor and the suffering, then it is also right that the entire body—call it the State if you like— should be charitable, and if the State can do the work better there is a very good case for State control. I cannot help thinking that, although we owe a great debt of gratitude to those who organised the sweepstakes, and rejoice at their success, it is not altogether to the credit of a Christian country like this, which recognises its duty to the poor, that we should be dependent on that particular form of finance. It would be much better to face up to the fact that we, the whole Irish people—that is what I mean by the State—owe a duty to our sick and suffering brethren, and anything we can do to improve the hospitals will help them. I heartily agree with the idea that there should be an inquiry, but the hospitals should not be dealt with by themselves; the inquiry should be into the whole health services of the country. For that reason, I am not in favour of the motion as it stands now.

Sir John Keane

I would be quite prepared to accept an amendment to widen the scope of the inquiry to cover the whole health services. Nothing would suit me better.

Debate adjourned until later to-day.

Business suspended at 6 p.m. and resumed at 7 p.m.