Seanad Éireann debate -
Friday, 19 Dec 1947

Vol. 34 No. 21

Health Services (Financial Provisions) Bill, 1947—Committee and Final Stages.

Section 1 agreed to.

SECTION 2.

Sir John Keane

I move amendment No. 1:—

In sub-section (3), line 46, after the word "time" to insert the words "by order".

I think the purpose of my amendment is self-evident. I raised this matter yesterday and said that, as far as I understood the section, it gave the Minister absolute power to add or withdraw the health service entirely in his own discretion. I consider that a very dangerous and far-reaching power. He may say he is going to exercise it only to a minor degree. We cannot look at legislation in that way, we have to look at the full implications of the statute. There is the same old grievance that what a sensible man as Minister may do is one thing and what a less sensible man may do is another. We have to look at it at its worst and at its worst it is a very dangerous section as it stands.

I have attempted to bring it into line with general regulations and to give the Oireachtas some control over the Minister's action—very slight, as I admit, because some of us think that the control given over the power of regulation is totally inadequate; but there it is, we have to be content with that, as far as it goes.

The object of this section is to ensure control, not when a Minister adds a service—I do not see much danger there—but when he takes away a service. He may take away a service in whole or in part; as far as I can see, he may declare that one hospital is not worthy of a grant or ceases to be a recognised health service, while another is allowed to continue; or he might say that a service in one health authority is permitted and a similar service in another health authority is denied. That is not fantastic. We know by experience that when authority gets these wide powers it is very inclined in certain cases to abuse them. The object of this amendment is, first of all, that the withdrawal of a health service should be done by Order; and the second amendment provides that the Order should be laid on the Table in the usual form.

Minister for Health (Dr. Ryan)

While I must agree with the Senator that his amendment is reasonable or appears to be reasonable, I want, however, to appeal to him to listen to me and hear the difficulties which it might make for us to have an amendment of this kind brought in at this stage. The coming financial year is very close at hand, and though the Senator may say that he is not concerned with that, I want to outline how the thing is going to work. We have to give directions, if at all possible, to the local authorities before the end of December because they have to make their estimates for the coming year. I have seen a draft of the circular and the list which is being prepared on the assumption that the Bill will pass both Houses. It is a long, cumbrous document, running into several pages, and deals with the various services which are recognised under this Bill, and it will indicate, therefore, to the local authorities what they will presume to estimate.

So far, of course, the Senator's amendment would not affect us, but I would say this, that if, in taking back any of these things, we did it rather hurriedly and had to face both Houses of the Oireachtas to have the regulations taken back, we would have to be very much more particular in regard to the circular and the list.

We must amalgamate the staffs of the boards of health and the county councils and there may be individual clerks working partly for the health services and partly in local government work. The direction will be that the work of such clerks will have to be apportioned and also the expenditure, and the Minister will have to have some say in whether he believes the apportionment to be correct or not. The auditor will come along at some future time and will have to review all that the local authority has done. He will have to decide whether, in his opinion, the work and the salary have been properly apportioned or not between the health services and local government. If the auditor thinks that it has been done unfairly and that the local authority is putting down more salary than the health service, we may have to see that the local authority cuts down the amount allowed. It would be very hard to come to that decision by means of regulations as regulations would be a very cumbersome way to deal with it. For a few years anyway—for we hope to have separate staffs in a few years' time— it would be a very cumbersome method to have to bring in regulations to see whether, for instance, a certain health authority had put down £10 more on the health side of a clerical officer's work than it should have. I think that the Senator will agree that the auditor must be, if not the final arbitrator, at least the final adviser in this apportionment.

I do not think it could be possible, even if a Minister were so, let us say, malignant, to cut out a certain hospital because the directions go to the local authorities in general and lay down what is to be done with all hospitals and all institutions. I do not think that we could differentiate between one local authority and another because the circular goes to all local authorities in general.

Senators have suggested, and the argument is sometimes used, that a sensible Minister may do so and so but that a Minister might come who is not sensible. If the Dáil ever elects a Minister who is not sensible it is no use trying to provide beforehand for keeping him right. They must put up with him and that is all. I am afraid that an amendment like this is not going to give him sense whatever else it may do. I do not think there could possibly be anything in what the Senator said because all these regulations will be general and will go to all the local authorities. The present appeal I want to make to the Senator is to consider what a colossal job it is now to notify all the local authorities of the very, very long list of things which they might regard as health services. When we get the replies from the local authorities we may have to make amendments, maybe very small amendments, and for a year or two anyway until we get things straightened out, it might be better to leave a free hand.

Finally, I would like to say to the Senator that up to the moment, whatever Government has been in power, whether a British Government or a native one, grants have been given to local authorities entirely at the discretion of the Minister. That is not to say, of course, that he could use his discretion in an unjust or unfair way. Up to this the Minister has the authority to say how a scheme, let us take the milk scheme, the venereal diseases scheme or the tuberculosis scheme, should be worked, the various items that should be put in to have recognition given to them and the items which might have the effect of withdrawing recognition.

The matter of grants for health services to local authorities has been worked, up to the moment, on the basis that Senator Sir John Keane thinks it would be a mistake to continue.

Sir John Keane

The Minister is very plausible. It is a pleasure to debate with him but he evaded the principle altogether. He simply says that he wants these absolute powers on account of administrative difficulties. If we had time I am perfectly certain we could find some means of giving him power to adjust matters as between the various authorities. However, as we have not time, that is another matter. It is the penalty for having to do our business in such a hurry. I cannot see my way to depart from the stand I have taken. I consider that the powers the Minister is seeking are dangerous. If they are going to be used as he says, well and good, they are reasonable; but that is not what they carry. They carry very wide powers indeed. I am not going to take up the time of the House any longer. I have made my protest and while I thank the Minister for his courtesy I cannot say that I agree with his argument.

Amendment, by leave, withdrawn.

Amendment No. 2 not moved.

Question proposed: "That Section 2 stand part of the Bill."

Sir John Keane

From what I gathered from the report, the Minister was not very explicit in regard to the policy of meeting deficits of voluntary hospitals. I take it voluntary hospitals are entirely a health service and that they will come under the regulations. Perhaps the Minister might at this stage say when we may expect the main body of the regulations. I take it that, in the main, the deficits will be health service. Could the Minister give us any forecast of his policy with regard to any differentiation between hospitals? He said that some are much more extravagant than others. I have been on a hospital board and I have seen circulars which were sent out enjoining economy.

If there is going to be any discretion the matter would require much more deliberate investigation than the commission have hitherto contemplated. A hospital may appear to be more expensive than another but it may, possibly, be able to give a very good explanation. I do not want to widen the debate unduly but could the Minister, at this stage, give any indication of his policy with regard to meeting the deficits of voluntary hospitals and of the way in which he proposes to differentiate between those which he regards as better managed and less well managed?

Dr. Ryan

This Bill does not deal with the question of voluntary hospitals. I suppose it might touch on them if, say, the local authority were paying for certain people in the voluntary hospitals. It would then lay down what part the local authority should pay and what part the State should pay. Voluntary hospitals, as such, do not come under this Bill.

What I said with regard to deficits, I think, was that they vary very much. Some of them are much higher than others. It would, therefore, appear that some voluntary hospitals are more extravagant, if you like, than others which are able to get along without a deficit. I have not had time or, in fact, been able to think of any way of dealing with that problem. Within the past few days I have authorised the payment of the deficits for 1946 which were lately presented. We may be able to have the question considered. However, I can assure the Senator that we would not come to any definite conclusion with regard to these deficits without consulting the voluntary hospitals themselves. In fact, I should even like to ask the voluntary hospitals to come together to make some suggestion because some of the deficits, especially, are getting very high and I should like the matter to be regularised.

Sir John Keane

I am rather uneasy as to what the Minister says. Am I right in saying that the deficits of the voluntary hospitals will not be a charge upon this contemplated increase of £5,000,000?

Dr. Ryan

So far, they are paid out of the Hospitals Trust Fund.

Sir John Keane

Has the deficit to be the subject of a separate Vote over and above the sum of roughly £5,000,000?

Dr. Ryan

The deficits are paid out of the Hospitals Trust Fund so far and, therefore, they do not come before the House as an Estimate.

Sir John Keane

That is very important. The Minister is going to alienate the capital of the Hospitals Trust and the foundation of the present income will, therefore, go. Where is the new income to come from? I thought it was going to come out of part of these health services for which the Minister contemplates, over a period of ten years, a further expenditure of between £4,000,000 and £5,000,000. Am I wrong in saying that the hospital deficits will be included in that sum or will they have to come from entirely new sources, presumably to be voted by the Oireachtas, over and above the finance contemplated in this Bill and completely divorced from the Hospitals Trust capital which is going to be alienated?

Dr. Ryan

It is not a simple matter. If the local authorities were to pay for the patients within their own areas in the voluntary hospitals and pay what would be regarded as a fair amount per week then one would expect that there should be no deficit in a voluntary hospital. The matter will not be solved as easily as that, however, because there will still be a deficit. That is the problem to which I do not see any easy solution. We certainly shall have to consider, within the next year or two, the long-term way of dealing with these deficits. I have no intention of solving that matter myself without consulting the voluntary hospitals before coming to any conclusion.

Sir John Keane

I shall not pursue the matter any further beyond saying that I consider that the Minister's statement will create considerable anxiety among the voluntary hospitals because he has in mind no fund from which a deficit can be met. It is left to the uncertain future. If I understand the Minister correctly the position is that where a voluntary hospital comes under a regional authority its expenses can be met under this Bill. The point is that most of the voluntary hospitals are in Dublin. They certainly cannot all come under the finance of whatever the Dublin health authority may be.

I am talking really without accurate knowledge of how the new scheme is going to work. Obviously, as the Minister knows, the grants coming from the corporation will go a very small way indeed to meet the deficits of the voluntary hospitals. I hesitate to widen the scope of this debate but it can be argued that the sweeps were started in the first instance for the voluntary hospitals. Under this measure they are being taken over entirely by the State and the voluntary hospitals are being left out in the cold, as far as I can see, if the idea is to leave them on the long finger and use the money which was originally intended for them to build fresh hospitals——

Dr. Ryan

That is right.

Sir John Keane

However, I feel that that is a self-contained subject which should be dealt with in a separate debate. I think the Minister has said quite enough to make the hospitals rather anxious about their future.

Dr. Ryan

I think it would be better to debate that matter on another occasion.

Remaining sections, Schedule and Title put and agreed to.

Bill reported without amendment.

Agreed to take the Fourth Stage now.

Question—"That the Bill be received for final consideration"—put and agreed to.

Agreed to take the Fifth Stage now.

Question proposed: "That the Bill do now pass."

Sir John Keane

On the last stage, I wish to raise one point of principle. Is the Minister satisfied that in this broad question of health we are maintaining a satisfactory balance between health and housing? A great many people believe that the long-term remedy to better health, or the main contribution to better health, is better housing. As long as housing is as we know it a large amount of this heavy expenditure now contemplated will be wasted. Is not the expenditure now contemplated under this Bill rather staggering? It represents a capital debt of £300,000,000. Nine million a year at 3 per cent. represents £300,000,000. That is a very big sum. It is a question for serious consideration as to whether it would not be better to spend substantially more on housing and thereby avoid having to spend so much on health. The two problems are closely allied. There should be no need to spend £9,000,000. We assume that that £9,000,000 will be spent over the next nine years. One might argue that if people are normally healthy nothing like that sum should be needed. Much better health could be secured by better housing. The two services—health and housing—are interlocked. I would ask the Minister, now that his Department is being reorganised, to consult with his colleagues in an effort to discover whether we are really maintaining a proper balance between housing and health. Both have a bearing—one a short term and the other a long term—on our national health. It is a very important matter. It is no good pretending that we are grand people in spending £9,000,000 on health. By spending substantially more on housing we could improve the general health of the community in a more satisfactory way.

Mr. Duffy

I think there is something more in this than appears from the statement made by Senator Sir John Keane. Not merely are health and housing interlocked, but health, housing and nutrition are interlocked. It is not sufficient to spend a million or two on housing unless at the same time we raise the standard of living of those who are to occupy these houses so that they can afford to pay the rent required without cutting into the amount of food consumed by themselves and their families. I think that is one of the most important problems of this age. We have adopted a rather extraordinary method of solving it by divorcing the services, the one from the other. Up to the 1st of January one Minister was responsible for health and housing. We have now made sure that there will no longer be one Minister in charge of health and housing. We have created a new Ministry of Health under the charge of a Minister whose function it is to look more or less objectively at health while the big factor towards the creation of good health, housing, is the function of a totally different Minister. The Minister who will be responsible for housing and who will determine the rents charged by local authorities has now no responsibility for health. It will be no part of his function to consider whether a new housing scheme is going to involve an increase in rents that will force many thousands of workmen to purchase one or two loaves of bread less per week.

I think the present Minister for Health is responsible for a nutritional survey which has now been going on for some considerable time. I do not know whether any results have accrued from that investigation. I do not know whether the Minister has been able to form any general opinion as to the condition of public health. I would urge very strongly on the Minister and on this House that in voting large sums of money for health services we should ensure that steps are taken to protect the health of the community and to prevent illness rather than merely to provide hospitals. In nearly all our relations with these problems we seem always to look at the wrong end. We are prepared to spend large sums of money on building new streamlined hospitals, but we are not prepared to spend anything worth while on maintaining the people in good health rather than in curing them when they fall ill. Notoriously, malnutrition is prevalent in this country. Tuberculosis is also prevalent. I submit that tuberculosis or rickets or any of these other ailments so much talked about to-day are due almost entirely to two causes—under-nourishment and bad housing. We are simply throwing money down the drain so long as we vote these large sums for a health service which in fact is not a health service at all, but a patchwork quilt created by people for the cure of illness, while they are reluctant to spend a penny on preventing the people falling into disease.

Mrs. Concannon

The speeches we have just listened to would suggest that we may be putting the cart before the horse. I have no fear about that in respect of the present Minister because, as Minister for Agriculture for very many years, he was well acquainted with conditions in rural Ireland. I am sure that nobody holds more firmly than he does that the health of the people is built up in the homes of the people, which is the burden of the speeches we have heard. That is so true that even the blindest must accept it. The Minister is convinced, as Senator Duffy reminded us, that the homes of the people can only be kept in proper condition and a family properly nourished by good schemes of employment. Another thing is that the women should be properly trained to run a home. The health of the people will be guaranteed to a large extent if we have good homes and proper employment for the men in order to provide for those homes and keep them and proper teaching for the women to run the homes. Proper teaching includes elementary instruction in the maintenance of health. That is very important and part of the Health Bill is devoted to that. I have great hopes that in the hands of the present Minister, with his acquaintance with the rural conditions of the country, that will be looked after. It is fantastic to think that because the Minister is in charge of one Department he is not interested in another Department. We must remember that there is Cabinet responsibility and that they all work together. I am quite sure that Ministers contribute, each his own share, to the discussions for making this country what the Health Bill and other Bills aim at, namely, a place of happy homes well run by competent women, well kept by men in good employment trained to habits of hard work.

Dr. Ryan

One has to agree, if you like, with the principles laid down by the speakers, but I certainly am not going to agree with their conclusions that nothing is being done about certain things. Surely no Senator can say that nothing is being done about housing. The Minister for Local Government is straining at the leash to get another Housing Bill through and giving very generous grants under the new Housing Bill. I think that since Governments were set up here every effort was made to get houses built for the people. Therefore, housing is being carried out at the same time. Do Senators think that I should have done nothing and said: "Wait until all the houses are there and then I will bring in my health measures in 20 or 30 or 40 years' time?" Naturally they are brought in at the same time.

Senator Duffy said that we are trying to cure illness instead of preventing it. The whole object underlying the Health Act of 1947 was to prevent disease. The mother and child welfare scheme, the infectious diseases provisions and so on were all on the prevention side. It is not notorious, as Senator Duffy said, that malnutrition is rampant in this country. It is a fact that people in this country are better nourished than the people in most other countries in the world. There is not the slightest doubt about that.

Mr. Duffy

Has the Minister read the reports of his own county medical officers of health?

Dr. Ryan

If the Senator wants to go on repeating that for election purposes, he is welcome to it.

Mr. Duffy

I ask the Minister to read the reports of his own county medical officers of health.

Dr. Ryan

I do not care what reports I read. The Senator should read the report on national income and the distribution of food in this country as compared with other countries. There is a higher standard of nourishment here than in most other countries. We should be proud of that fact and should not use the opposite as an election stunt. We are trying to improve the health of the people and trying to prevent them from falling into disease. We are trying to improve housing. In spite of what I said, there is much room still for improvement in regard to nutrition of the people. We are getting a nutritional survey carried out. I think the result for Dublin should be ready soon, but the result for the whole of the country will not be ready for about 12 months. If that survey discloses that improvements can be effected, it will be up to us to do what we can.

Question put and agreed to.

Bill ordered to be returned to the Dáil.