Seanad Éireann debate -
Wednesday, 28 Jun 1961

Vol. 54 No. 9

An Bille Toghcháin (Leasú), 1961. - Hospitals Federation and Amalgamation Bill, 1961—Second Stage.

Question proposed: "That the Bill be now read a Second Time."

Minister for Health (Mr. MacEntee)

This Bill is designed to provide machinery which will enable seven Dublin voluntary hospitals to form themselves first into a federation and then permit them in course of time to be integrated as one group, governed by a single body. The seven hospitals concerned are the Adelaide, the Meath, Mercer's, the National Children's, the Royal City of Dublin, Sir Patrick Dun's and Dr. Steevens' hospitals.

About two years ago it came to my notice that some seven of the hospitals in Dublin were considering some form of association. I thereupon contacted the hospitals concerned and asked their representatives to meet me in the Custom House in May, 1959. Arising out of this meeting a committee was set up under the chairmanship of the Secretary of my Department to consider the matter. That committee found it possible to evolve a plan for close association between the seven hospitals, which has been accepted fully by all of them and is the basis of the Bill before the House. I might add here, that this text has also been approved by each of the seven.

I need hardly tell this House that the contribution of the seven institutions covered by the Bill to the development of hospital medicine in Dublin has been great indeed. The establishment and development of every one of them has been closely linked with the social history of this city; and a spirit of deep solicitude for the sick poor permeates the Acts and Instruments under which they were founded. Associated with this concern for the sick was the honourable ambition to develop the art of healing and to foster medical teaching so that not alone would they carry on the fight against the sickness and disease which flourished here but, in addition, would, by being generally beneficial to sufferers everywhere, win fame for their city. The hospitals throughout their history have been amongst the foremost in adopting modern advances in medical science and in fostering nursing skill. But the spectacular developments in medicine and surgery which have been such a feature of this generation have made it necessary to reorganise their activities so as to secure a more rational allocation of special functions between them. The reorganisation will require time and patience to accomplish; for between them the seven hospitals have some 1,200 beds, which is more than one-third of the general hospital beds in the city; and their annual expenditure is in the region of £¼ million. But it is essential that it should be undertaken if the hospitals are to maintain their particular place in our medical life; and the sooner it is effected, the more assured will the future be for all concerned.

I should now like to explain to the House the main provisions of the Bill. Section 1 contains the sundry definitions required for the other provisions of the Bill. Sections 2, 4, and 5 are related. They provide for the appointment of a day to be the "establishment day" and for the bringing together on that day in a rather tight form of federation, the seven hospitals set out in the Long Title to the Bill. This federation, or hospital group, as it is described in Section 4, is to be known in accordance with that section as the Federated Dublin Voluntary Hospitals. The coming into being of the group of hospitals and of a Central Council to take over from the individual hospital boards certain of their functions will be simultaneous. The usual powers of a corporate body are provided for the Central Council. I shall refer more fully to Section 3, in conjunction with Section 19, later. It provides for the ultimate integration by consent of the hospitals concerned.

Sections 6 and 8 of the Bill provide that on the establishment day the existing governing bodies of the hospitals will be reconstituted as statutory hospital boards.

Section 7 deals with the membership of the proposed Central Council. It is proposed that each of the hospitals will appoint five members, two, but not more than two, of whom must be members of the hospitals visiting medical staff. These hospital representatives, together with five members to represent the Dublin Health Authority, will constitute the Council, which will thus have a total membership of 40. This membership, however, may be increased by the appointment of two additional representatives from each university, college or other institution which enters into an agreement with the Central Council for the clinical instruction of medical students. The section prescribes the period for which the members appointed respectively by the various participating hospitals and by the Dublin Health Authority hold office. Briefly it will be three years in the case of members appointed by the hospitals and by teaching institutions, but five years for members appointed by the Dublin Health Authority. The five years is fixed for the latter because it is the period between local elections.

Sections 9, 10 and 11 contain provisions relating to the time and place of meetings, the tenure of office of the chairman and vice chairman, which will normally be for three years, and the procedure at meetings of the Council. There is nothing unusual about them.

Under Section 12, the Council will be empowered to appoint committees. These committees may consist of Council members only or of Council members and other persons, the latter not, however, making up more than one-fourth of the total membership of any committee. For practical purposes the Council may decide that certain of its functions would in the normal way be administered by a committee and it is obviously desirable to provide for this. It is necessary, I submit also, that the the Council should have the power to appoint to a committee persons from outside the Council who because of their special qualifications or experience would be equipped to assist the Council in considering special problems.

Section 13 provides for the employment by the Council of the necessary staff. In Section 14, the functions which are to be assigned to the Council are specified in some detail. They include major administrative functions in relation to finance, staffing, assignment of specialties and professorial units, the apportionment of beds amongst the visiting medical staff, and medical and nursing education. In the financial field, for a period of four years after the establishment day, the Central Council will examine the estimates of the participating hospitals and may suggest amendments to them. After the expiration of four years, the estimates will be subject to approval by the Central Council.

It should be noted also that under this section individual hospital boards will cease after the establishment day to appoint visiting medical staff. Instead the Central Council will make such appointments to the group as a whole and assign the appointees to the individual hospitals. Safeguards are included in the section to protect the position of a hospital of a particular denominational character in relation to assignments of visiting medical staff and also in relation to the education of nurses. Any rights of the present visiting medical staffs of individual hospitals will be protected by subsection (5) of the section.

Section 15 inhibits the hospital boards from performing any of the functions assigned to the Council. Except for these, however, the Boards will continue to perform the functions of the present governing bodies, with one notable restriction which is imposed by sub-section (3). That sub-section provides that moneys collected by a hospital by public appeal will not be used for capital purposes by the board without the approval of the Council. The provision will enable the Council to control expenditure on capital projects by members of the group, so as to co-ordinate it with the requirements of the group as a whole.

Sections 16 and 17 provide for the amalgamation of two or more hospital boards with their consent and for the dissolution of a hospital board with its consent. Necessary adjustments in membership of the Central Council would be made on the dissolution of a board. Section 18 gives the Central Council power to make an agreement for joint action with a hospital outside the participating hospitals.

I have already mentioned Section 19 in association with Section 3. Section 3 provides for the appointment of the "transfer day" by the Minister. The "transfer day" marks the second and final stage of the development which the Bill provides for. On that day the complete integration of the seven now separate institutions will have been accomplished, and, under Section 19 they will cease to exist. They will not, of course, be wiped out summarily. Certain rights are reserved to the participating hospitals under Section 3, notably the right to dissent from the appointment of the "transfer day" and the right at this stage to opt out and leave the Federation. Furthermore an order appointing the transfer day cannot be made without the consent of two-thirds of the hospital boards which exist at the time.

Under Section 19, the separate hospital boards will be dissolved on the transfer day and their staffs, assets and liabilities transferred to the Central Council. The provisions of the Second Schedule will govern these transfers to the Central Council. This Schedule contains provisions to protect persons employed at the time of the transfer day against any disimprovement in their position arising from the change. Where the services of a person are terminated because no suitable position for him exists under the Council, he will be paid such compensation as the Council consider fair and reasonable. The Council's decision on this matter will, however, be subject to an appeal to a person designated by the Minister.

Section 20 of the Bill relates to the expenses of the Council before amalgamation and provides that these will be divided on the basis of bed complements. Section 21 will make a change in the procedure for appointments of the hospital members which is a consequence of the abolition of the separate hospital boards on the transfer day. Obviously, the triennial appointments of these members could not be continued after the boards are dissolved and it was therefore necessary to provide that vacancies after the transfer day in that part of the membership of the Council previously filled by the hospital boards would be filled by co-option. The hospital board members of the Council in office on the transfer day will continue in office until death or resignation, unless they are disqualified under Section 7 for failure to attend meetings. Periodic appointments of members by the Dublin Health Authority and any appropriate teaching body will still take place after the transfer.

Section 22 provides for the making of any necessary amendments in the Acts and Instruments of Foundation of the hospitals and Section 23 for altering, with the consent of the governing body concerned, the composition of the governing body of a participating hospital (other than the Meath Hospital, which is regulated by the Meath Hospital Act, 1951). Under Section 24, orders under the Act will be laid before the Houses of the Oireachtas, which will have the usual power of annulment.

Section 25 provides for the confirmation of an agreement a copy of which is contained in the Fourth Schedule to the Bill. This agreement, which was made recently between Trinity College, Dublin, the Royal College of Physicians and Sir Patrick Dun's Hospital, relates to arrangements which exist between the three bodies under the will of Sir Patrick Dun and the provisions of statutes of 1800 and 1867. The will provided for the vesting of Sir Patrick Dun's estate in the Royal College of Physicians to meet certain payments, including the salaries of four professors of Trinity College known as "King's Professors" who had the right and duty to teach in Sir Patrick Dun's Hospital. There are also, at present, arrangements for certain other members of the staff of Trinity College to lecture in Sir Patrick Dun's.

The agreement now made will put an end to all existing rights and obligations arising from the will of Sir Patrick Dun and the statutes of 1800 and 1867, some of which are inconsistent with the present Bill. It has been agreed to realise the value of the property and to distribute it equitably amongst the contracting parties.

Before I conclude, I would like to say this. The history of attempts at amalgamation between various Dublin hospitals dates from at least the year 1855. It has been a most tangled story of difficulties and disappointments. My own efforts to bring at least one aspect of it to a successful conclusion have been made possible by the zeal, devotion and interest displayed at all times by the representatives of the participating hospitals. Without the complete co-operation which they have shown, it would not have been possible to proceed with this Bill.

I am gratified to have reached the present stage in the enactment of this very desirable measure and I confidently recommend it to the House.

Professor Hayes

I think this Bill will find favour with everybody. As a Dublinman, I find myself familiar with all these hospitals and I have great sympathy with them in whatever difficulties they may have. I was never, thanks be to God, a patient of any of them. They are nearly all on the south side where I was born. I have been in every single one of them in the capacity of a visitor and once in another capacity altogether. They have all done, to my knowledge and, indeed, to the knowledge of everybody, very great work for the sick and the poor. Owing to the situation of some of them, at particular moments of intense troubles, as they have been called, in the city, they were called upon to deal with a few casualties and they did that in a manner with which people were completely satisfied.

I know and everybody knows that the buildings are manifestly in some cases old and unsuitable. Some part of the buildings in every case is old and unsuitable. They are part of the history of Dublin and, indeed, of Ireland. They go back, as the first section of the Bill mentions, to a pre-Union Act of 1729.

They have now reached the stage when they need, as the Minister says, to be reorganised and, as the phrase goes nowadays, rationalised. That is very desirable and we are all in favour of it. We would all join with the Minister in congratulating the people who finally, after considerable difficulty, have got over all the problems that arise in such an amalgamation and reorganisation.

I should like to say this. I think that such an amalgamation and federation is desirable but for my own part I hope that this federation and amalgamation will not give us one huge hospital; that it will be so worked as to provide that the smaller hospitals will remain each with a character and tradition of its own because each of them has a character and a tradition which are, I think, very desirable. I think though that I am correct in interpreting the Bill and scheme as being one which will enable each hospital to retain its own character. That would be more desirable than that there should be amalgamation into one huge rather insensitive unit. I hope that the reorganisation will work out satisfactorily and I join with the Minister in commending the Bill.

Dr. Sheehy Skeffington

I should like to support what Senator Hayes has said in welcoming this Bill and to congratulate the Minister on his introductory remarks on it, which have been very full. He brought the House through it section by section and showed the full implications of the Bill. Senator Hayes said that he has never so far been an inmate of one of these hospitals but I have. As far back as the year 1937, I found myself a patient in a public ward in Sir Patrick Dun's. I have had the honour to be on the Board of Sir Patrick Dun's Hospital since 1942 and I cay say that, as a member of the Board, I was greatly helped by having first seen the hospital from the viewpoint of a patient in a bed in a public ward.

It is a kind of necessary apprenticeship. I can say in all sincerity that what I saw was very good. I learned I think, a great deal about the working of this type of hospital. Both the Minister and Senator Hayes have spoken in praise of the work. It is very difficult, in fact, to exaggerate the amount of work that, as the Minister said, has been done by this type of hospital in Dublin down the years.

As I say, I have myself been associated with Sir Patrick Dun's as a member of the Board since 1942. That is nearly 20 years now. I have seen, therefore, from another angle the way in which the hospital and the medical staff work. I have seen the way in which the work of the nurses is carried out and supervised and the way in which a number of lay governors have got together and put enormous work into the service which very frequently gets not only no recognition but no thanks at all.

Personally, I feel that we in this country, whether or not it is a matter for congratulation, are going towards the era of State medical services. Personally, I think that is a good thing. While saying that, I think one would be lacking in one's duty if one did not recognise the enormous amount of voluntary work done by these voluntary hospitals, by both the staff and the members of the Boards. I mention no names because it would be invidious— there are, in fact, very many—but I can think of several of the senior governors on the Board of Sir Patrick Dun's when I came on as a relatively young man and of their devotion to the hospital. I am conscious of the enormous amount of time they spent doing things for the hospital and, by their active and sympathetic presence, enabling the work to be done in a friendly and humane way without ever getting themselves into the limelight for it but happy in the knowledge that they were achieving most valuable work. In thinking of those men, I am quite sure they had their counterparts on the Boards of each of the other hospitals which have now agreed, under the provisions of this Bill, to federate.

I feel that this federation is, as the title of the Bill indicates, avaluable step towards amalgamation and that the time will come when, more and more, the State will find it necessary to assume more and more responsibility in all the services. I welcome that trend. If we can keep in mind, as the Minister did, the type of work that is being done by voluntary committees I think we will be able, under State medicine, to get the best of both worlds.

I have followed in the background, as a member of the Board of Sir Patrick Dun's, the work carried out for the purpose of reaching the agreement embodied in this Bill. I realise, and it should be put on record, too, that each hospital, in agreeing to come together with the others, has made a very real sacrifice of sovereignty. I think that is the phrase one might use. Very big concessions of one kind or another have been made by all of the hospitals in a genuine effort to bring the hospitals closely together in a coordinated first federation and, it is hoped, later amalgamation.

The process of drafting this Bill, and of reaching this agreement, has been slow. I am afraid perhaps that the first years under the new Bill may not immediately show a very big dividend in results. I am quite happy for the movement that will be started under the rights granted by the Bill to be slow provided it is a sure forward march towards more and more coordinated effort on the part of these seven hospitals.

At this juncture, I think I should say—because I learned that also, step by step, as we went in the negotiations —that the Minister deserves the greatest praise for the manner in which he welcomed the suggestions, first of all, and personally intervened for the purpose of smoothing out difficulties which appeared in the path of the negotiators. I would say he has been more than co-operative. He has shown an active interest and a most helpful concern—which we could feel in his speech here today—to bring this federation into the world of reality. We are grateful to him and to the hospitals concerned for the production of this Bill which is potentially, and I stress the adverb, a very good Bill provided it means a going forward on the basis of its provisions.

Senator Hayes made the point that he would not like to see one gigantic hospital. I feel he is right in that provided he recognises and we recognise that there is probably an optimum size and that it is possible that some of these hospitals are below that optimum size although it is certain that to go beyond that optimum of perhaps 400 or 500 beds would be a mistake. It may be that under amalgamation one or other of these hospitals will eventually disappear by reason of pressure of these circumstances but Senator Hayes is to be supported in the view that we do not want one gigantic hospital while recognising that the optimum size has not yet been reached by some of the individual hospitals that have agreed to come together in this new federation.

The work, then, of these hospitals will be carried out under the terms of this Bill—with permission granted, as it were, by this Bill—in a far better coordinated manner and the hospitals themselves, as a result, will be better equipped both for the treatment of illness and for the teaching of medical students. Both of those are extremely important and the co-ordination implicit in this Bill will serve both of those ends admirably.

The Bill represents, therefore, an effort at rationalisation of the treatment and teaching in these hospitals and also rationalisation of the whole area of specialist treatment in the hospitals. Part of the aim is to enable certain hospitals to specialise perhaps solely in certain aspects of disease and not to have that special service duplicated where duplication is not useful. Therefore, there will also be on the part of the new council, an effort at rationalising the specialist services and that, too, is a matter to be welcomed.

The Bill represents an attempt to rationalise all the problems of staffing, equipping and administering these seven Dublin hospitals which have agreed to come together under this new federation and to go forward to what will be the new amalgamation. In welcoming the Bill, one should stress, as has already been done, the long and honourable record of service of each of these hospitals to Dublin's sick and poor.

Mr. O'Quigley

This is a Bill which will find a great deal of favour with all sides of the House. It should get as speedy a passage as possible. The Bill represents agreement between the seven hospitals involved. I join in the tributes which have been paid to the hospitals for surrendering their autonomy. I rather think it must have caused quite an amount of heart-searching by the people who had built up and fostered these institutions over the years to surrender their autonomy, to federate and ultimately to amalgamate and lose their identity in the interests of the poor and the sick people of this city. The Governors of these hospitals at the present time are deserving of the fullest commendation.

The speech which has been made by Senator Sheehy Skeffington was a very pleasant revelation. It disclosed, in spite of all the diehard socialist views that have been expressed by the Senator from time to time and the hopes he harbours that, more and more, State medicine will come to the fore, that he has all the time been working—I am certain he has worked as hard on the hospital board as he works in this House; I am certain he has worked very hard, indeed—as a member of a voluntary health institution. That is one of the gratifying things that this Bill has produced for me, personally. From now on, we must all take a much kinder view of the ideas and opinions which Senator Sheehy Skeffington expresses. I realise that behind the mask which he puts on there beats a very warm heart that has a tremendous interest in voluntary effort. He even spoke of having the best of both worlds as a result of this Bill.

I am sure that those who planned this Bill do not intend that it should ultimately lead to a situation in which the amalgamated hospitals would become State institutions. I expect and I hope that the purpose of this Bill will be that these private institutions will amalgamate into a larger unit which will be able to survive on its own and give greater service to the sick of this city. It has been interesting to find that the Minister for Health has been the balm poured out where difficulties arose between the various parties to this agreement. The Minister has been the coagulating force which brought those hospitals together and has been instrumental in bringing about this agreement. We all hope that this kind of disposition in the Minister will manifest itself in other directions and that before he leaves office—I expect he is holding office for the last time—he will have made it up with another great institution which renders help to the sick people of this city and the country generally.

The Minister indicated that the purpose of this Bill was to reorganise the activities of these hospitals. Without awaiting the date on which these institutions will be amalgamated, I hope that the hospitals will attend to one or two small matters which could, in my opinion, do much to make the burden of sickness a good deal lighter, without in any way imposing any great hardship or financial burden on the hospitals themselves. Like Senator Sheehy Skeffington, I was a patient for many weeks in one of these voluntary hospitals on one occasion. That was back in the 1940's. I am well aware of the kindness which I experienced at the hands of the authorities and the nursing staff in those days.

I am sure that that great tradition of nursing staffs in the various hospitals still persists, but on many occasions I have observed that the arrangements in out-patients' departments are not at all satisfactory. As I understand the position, most people are told to attend at 10 o'clock in the morning and it is virtually certain that quite a large number of the people who attend at ten o'clock cannot be reached before 12 o'clock, 12.30 or 1 o'clock. That is a matter of organisation and it seems to me to be an unnecessary burden on people who are not in good health that they should have to wait around in the out-patients' department for unnecessarily long periods when it is certain they cannot be attended to for quite a long while.

Pending amalgamation and federation, I think hospitals of this kind, and indeed also hospitals which are not covered by this Bill, should give attention to this aspect so that people attending the out-patients' departments will not have to spend unnecessarily prolonged periods awaiting attention.

I have a recollection also of visiting some of these places and I regret to say, and I am sure it is due to lack of finance, that the places in which people have to wait are far from comfortable and far from being the kind of places where we would like our sick relatives to wait. I would urge these hospitals and other hospitals that anything that can be done to improve the heating and other amenities of the out-patients' department should be done.

I noted with particular pleasure that the provisions with regard to compensation of staff whose contracts of service may be disturbed as a result of this amalgamation are fairly adequate and fairly foolproof but subject to those conditions, I notice that it is not indicated whether the appeal to the officer to be designated by the Minister may be an oral appeal or a paper appeal. If the appeal is to be an oral appeal, I do not think we should trouble about it. I am quite satisfied that appeals to the Minister, or to persons designated by the Minister, which are dealt with on paper, as is done in the case of appeals under the Social Welfare Act, are worthless and do not achieve justice or fair play for either side, but particularly for the appellants.

Therefore, I would like the Minister to indicate that it is the intention that appeals under paragraph 6 of the Second Schedule will involve a full hearing before an arbitrator. If that is not to be the position, I think we shall have to provide the same conditions for these people as have been provided for the staffs of other bodies which have been interfered with by enactments of the Oireachtas.

There is just one further matter which occurs to me, a matter which the Minister may be able to clarify. As I understand the position, these seven hospitals will federate and eventually amalgamate and lose their identities. This position will then arise. It has a relation to the Charities Bill passed by this House recently. If a bequest is made in a will drafted, say, in 1957, to—take the first hospital in the list—the Adelaide Hospital, and the person does not die until 1975 when the Adelaide Hospital has ceased to exist as an entity, is there any provision whereby bequests of that kind will be paid to the amalgamated body or will the bequest lapse?

The point I want to stress is that if these institutions which are so well known to so many people and which are the object of people's benevolence and charity are to cease to exist, we should make some provision as to what will happen various bequests to be made in the future. I do not want to have the position where more money will have to be spent in making unnecessary applications to the commissioners of Charitable Donations and Bequests or to the courts to consider such bequests and to decide whether they should be administered cy-près or what should be done with them.

There may be some provision in the Bill in that regard which I have not seen but otherwise it seems to me to be appropriate at this stage to make provision for this kind of contingency because there is a certainty that many people will not know of the amalgamation of these institutions as long as they exist in physical form in various places in Dublin.

We have had strange experiences in recent times in regard to drafting legislation and in view of our recent sad experience in regard to some legislation, I do not think this is a Bill which should be passed through all Stages without a minute examination on Committee Stage.

Professor Stanford

The favourable reception that has been given to this Bill in this and in the other House will, I think, be reassuring to many. It is a regrettable fact, but, I think, true, that there are still some members of the minority who are rather reluctant to face legislation in our Parliament. I have always done what I can to reassure them that was quite unfounded but a certain reluctance or apprehension has prevailed recently. At least what we have heard today and what we read in the debate in the other House can reassure them that wherever citizens are attempting to improve the efficiency of public bodies in this country, they will get the fullest support.

The difficulty that faced these bodies was, of course, the main difficulty of amalgamation or, in this case federation. Some of us have seen the same type of thing in the Council of Europe in Strasbourg. At first, there was an idealistic view that a United Nations of Europe would come very quickly but it soon became apparent that it would come only when the constituent nations were prepared to yield some of their sovereignty, some of their power. In other words, one cannot build up a strong and effective federation without giving something away.

These hospitals, with admirable public spirit, have agreed to give away some of their power for the sake of the higher good. One can only hope that this spirit of sharing will go further. One hopes particularly that in the teaching departments these hospitals will move towards more and more cooperation. There is every sign that will be so. I think we should commend it.

There is one thing which I think should be said. Both the Minister and Senator Hayes paid generous tribute to the work done by these voluntary hospitals in the past. Generally nowadays in this country, we hear a good deal of adverse criticism of the Anglo-Irish ascendancy and of past history. Some of that is certainly desirable but I think it is only fair to remember in this House and outside some of the works of lasting benefit for the whole of Ireland for all classes and creeds which that ascendancy produced. Some of the names mentioned in this Bill remind us of it—Dr. Richard Stephens of Steevens' Hospital; Miss Mary Mercer of Mercer's Hospital and one recalls that the Dean of St. Patrick's—Jonathan Swift—in his day founded Swift's Hospital. The best known, perhaps, to the citizens of Dublin is Bartholomew Mosse who founded the Rotunda Hospital over 200 years ago for the sick and poor of Dublin.

I think we should keep these things in mind. We can hardly avoid it. In fact, if we go to Cork, Limerick or any of the other big cities in Ireland, we can see some of the old buildings constructed and financed by members of the old Anglo-Irish ascendancy, and not only hospitals and charitable institutions but public buildings and organisations. We speak at the moment in Leinster House built by the Duke of Leinster and then taken over by one of these organisations founded by that ascendancy, the Royal Dublin Society. For many years, this was its home and now we have taken it as our home.

This in a sense is not strictly relevant to the hospitals but these names in the Bill give an opportunity of looking at the brighter side of our history to some extent and of recognising—it is quite clear the House recognises and the country as a whole recognises— that that often-maligned epoch in our national history had a good side to it. It is good to see the successors of these generous men who founded these hospitals now ready to re-unite for the sake of the common good.

I have nothing to say by way of criticism or emendation of the Bill. It seems to be admirably drafted. I should like to say something in addition to the tributes paid to the Minister already. We do know of his considerateness and constant helpfulness in preparing the way for this Bill. I can assure him that many people are grateful to him for it.

Pádraig Ó Siochfhradha

Maraon leis an gcuid eile a labhair cheana i dtaobh an Bhille so, tá mise den aigne gur fónta an píosa gnótha ag an dTeach so agus ag an Dáil an gnó so a chur chun críche agus an chomhshnadhmadh a dhéanamh ar na hospidéil. Molaim an Bille. Is dóigh liom go ndéanfaidh sé an gnó atá le déanamh go slachtmhar agus go héifeachtúil.

Tá beagán eolais ba mhaith liomsa a fháil i dtaobh na fáthanna atá leis an gcomh-shnadhmadh sin. Cad é an chúis atá lastiar de taobh amuigh de fheabhsú na seirbhíse a thugann sé? An bhfuil cúiseanna eile ann ar nós uireasa airgid chun an gnó a choimeád ar siúl sa tsaol costasúil airgidiúil so? Bhféidir go bhfuil baint ag sin leis an bhfás a tháinig ar an bhfonn chun na hospidéil sin a shnadhmadh le chéile.

Tá ní eile i gceist agam leis. Cad é an toradh maidir leis na hospidéil so a bheidh ar an gcomh-shnadhmadh so? An leanfaidh siad leis an obair atá ar siúl acu anois—cuid acu ag freastal ar leigheas nó galair áirithe agus cuid acu ag freastal ar il-ghalair agus ar il-leigheasanna? An é toradh a bheidh ar an gcomh-shnadhmadh so atá á dhéanamh anois go raghaidh cuid de na hospidéil ar fad le seirbhís éigin speisialtóireachta leighis? An leanfaidh cuid acu de bheith ina ngnáth-ospidéil il-sheirbhíse? Sin cuid des na nithe atá ar aigne roinnt daoine i dtaobh an chomhshnaidhmthe so.

Níl a fhios agamsa an fiú an t-eolas sin a thúirt don bhobal ar fad. Tá beagán den phobal atá fiosrach ina thaobh. An méadófar cuid de na hospidéil chun seirbhís a dhéanamh d'ilghalair agus il-leigheas nó an raghaidh siad i ndiaidh a chéile chun speisialtachta i gcuid acu chun galair áirithe a fhreastal? Pointí iad sin atá im aigne agam ag breithniú an Bhille dhom agus tar éis é léamh.

Sílim gur maith an rud é go mbeadh eolas le fáil má tá sé in aigne go mbéadh athrú ins na seirbhísí atá le fáil fé láthair ins na n-ospuidéal sin agus go raghfaidh siad le gnothaí níos specialta i gcursaí seirbhís do dhaoine breoite no i gcursaí seirbhísí múinteóireachta do dhaoine ag foghluim an leigheas annseo i gcathair Baile Atha Cliath Sin iad na poinnte atá im aigne.

Is Bille fonta í. Im thuairim, is maith an rud é go mbeidh na seirbhisí sin go léir ag obair ar aontas le chéile agus go mbeidh seirbhís iomlán le fáil ag gach sort duine atá breoite no ag a bhfuil eas-sláinte no galair ins an gcathair seo no taobh amuigh di.

Professor Jessop

I welcome this Bill with perhaps a greater personal interest than I think any other Senator. I have been a patient in one of these hospitals. Members of my family have been patients I think in many of them. I was a medical student in one of these hospitals. I am a member of the staff now on all of them, except one, and I am a Governor of two of them. Therefore I have had a very close interest in the development of this federation from the first time it was mooted. I was interested very closely indeed in the previous Bill for setting up Saint Luke's Hospital and was very disappointed when that never reached the Statute Book.

The primary intention of this federation, as the Minister said, is to improve the facilities available for the treatment of the sick, of the patients who are there either in beds or attending as out-patients. This improvement, we hope, will be brought about by the proper and orderly arrangement of specialist activities in these hospitals, the sharing of them and, more important still, of the specialist personnel, the training of these personnel and, in all matters like that, the improvement, as far as possible, of the clinical facilities of these institutions. That is an object which quite clearly appeals to everyone. We all understand it.

There is another objective which had not been mentioned. It has been mentioned here this afternoon but it had not been discussed so freely when this federation question had been considered. I refer to the improvement of teaching. All of these hospitals are teaching hospitals. Almost 100 per cent. of the students attending these hospitals are from two of the three medical schools in Dublin. I am a member of the staff of one of these schools and I represent that University in this House. It is as Dean of that school that I should now like to discuss this measure somewhat further.

There is some misgiving and some likelihood of misunderstanding on the part of the general public as to the business of teaching in the hospital. Many people are suspicious of being used as guinea pigs when they go into a general hospital. They would rather, if they could afford it, go into some hospital where students were not liable to come along and examine them or where they would not be demonstrated to the students by members of the staff and their illness explained, perhaps sometimes to their embarrassment. It should be understood that while a teaching hospital does perhaps sometimes submit a patient to situations which the patient might regard with some misgiving — usually before, though not after, the event—it is almost certain that the general standard of clinical care in a teaching hospital will be somewhat higher than in a hospital which is not a teaching hospital. That arises from several different reasons.

The staff have to face inquiring students. They have to answer the most awkward questions by these students and by the younger members of the staff. That imposes the duty on the staff always to keep closely in touch with the most recent developments, to make quite sure that nothing has passed their attention, if possible, and to translate the most recent improvements into the day-to-day work of the hospitals. It imposes the duty on the staff to give the patients the full benefit of anything that is reasonable in recent advances.

In a medical school you have, in addition to that, a number of teachers in the laboratory and the medical school departments whose opinions, whose know-how, whose reading are freely available to the staffs of the teaching hospitals. There is constant consultation between the medical school staffs and the clinical staffs and this is greatly to the improvement of the outlook of both sides, particularly to the outlook of the clinical staff.

Lastly, and by no means to be forgotten, the students and the more recently qualified doctors act as a very valuable pool of semi-skilled or recently skilled labour in these hospitals. In connection with the Commission on Higher Education, which is investigating matters like this, I had to make a calculation of the number of junior posts in hospitals in this country which are filled by recently qualified students. There must be between 200 and 300 of these posts—I reckon about 250. These students are not yet registered. They cannot go out to practise in public. They have to get this hospital experience. The hospitals employ them. They pay them very well for this grade of labour but not nearly as much as they would have to pay them if they were fully qualified doctors whom they would hire in the open market. There is a considerable saving in the hospital economy due to this fact.

For these various reasons, the importance of these teaching hospitals in Dublin and in the country as a whole —because our graduates go all over the country—has to be rated very high. A great deal of the reputation Dublin has had for the past 150 years or so in medical centres has come directly from the progress made in medicine in these teaching hospitals, that is, in the Dublin teaching hospitals.

The contribution made by the seven hospitals we are now proposing to federate has been considerable. Several other hospitals are outside this federated scheme which have made valuable contributions also but, of the total, I think these seven have made quite a considerable percentage of the full contribution, and that extends over about 150 years.

This reputation which these hospitals had, which was so widespread, so notable, say, at the end of last century, has in recent times steadily declined by comparison with the progress being made in other centres. This is due to the fact that less money is available in this country for hospital development. Less money is being spent, shall we say, on the development of these teaching hospitals than is being spent in other centres on the development of corresponding institutions.

I think Senator Hayes mentioned that many of the buildings are old. They are all the original buildings, to which some new buildings have been added. A great deal of the work at present being done in these hospitals is being done in buildings put up perhaps 200 years ago. The equipment is not as plentiful as in similar institutions in other centres. All these handicaps add up to a disadvantage, a very important disadvantage, from which the Dublin hospitals suffer in comparison with those in other centres. I agree that the present federation will give an opportunity to the seven hospitals concerned to try to straighten out some of these disadvantages, particularly in regard to equipment.

There is a second factor which must be remembered, that is, that in other teaching centres there is a very close link between the hospitals and the medical schools. This has never existed in Dublin. One of these hospitals was originally built as a medical school for Trinity College. The personal link between the two is that the Provost of Trinity College is an ex officio member of Sir Patrick Dun's. That is the only formal link between them. It is not a very strong one because one person cannot make a great deal of difference, particularly when he is a very busy person like the head of a university, so that it has happened that whether or not the medical school might have wished to improve facilities in these hospitals for the purpose of teaching students, there is no way in which the school could go to the hospital and say: “We want better laboratories and we are prepared to help,” because they have no ownership and short of giving money away to these institutions, they could not take any active step.

Before I go any further, there is another point. This dichotomy in the educational situation has also been evidenced in the appointment of staff, medical staff, clinical staff and surgical staff. If you want to run any teaching institution on a proper level these days, you must be able to advertise and get the best man for the job and make it apparent that the best man is going to get the job. If you are appointing a clinician, the person appointed must have authority and the clinical care of a certain number of beds in the Hospital where he is teaching students. That is an absolute sine qua non.

In Dublin, the practice has always been that the schools have to appoint people to their staff who have already got beds in one of these hospitals. That restricts their choice. There is no complaint being made now about the qualities of the people who hold these positions. We have been very fortunate in the past in that we have had an excellent group to choose from, but it would be better if when a vacancy occurs, the position can be advertised in the knowledge that no matter who applies, if he is the best man, whether from this country or not, when he comes to take up his teaching position, he will have the right to have clinical facilities in one of these hospitals. I mention these points because they are at the root of the difficulties in running these hospitals at the moment as teaching hospitals. If we cannot get over these difficulties from the teaching point of view, the standard of these hospitals will be very much lower than it would otherwise be.

This Bill makes a certain amount of provision for improving the principle of these matters, namely, the link between the school and the hospital. The federated hospital will have two representatives on its Central Council from any medical school which gets agreement with it in regard to the education of its students. There is no doubt that the medical school of Trinity College will want to make an agreement about the education of students from the university. We hope, therefore, that when this agreement is made, we will have the right to have two representatives on the Central Council of this federated hospital, two representatives in a total Council of 40. Personally, I would have preferred, and my medical school would have preferred, if this proportion were higher, but at any rate it is a great improvement on the present situation.

A number of practical considerations still remain. The medical schools will still have to send their students to these hospitals in their present buildings. No amount of adjustment and no amount of money which could justifiably be spent on these buildings can ever make them modern institutions. They will always be at a disadvantage as long as they are in this state. Therefore, I appeal to the Minister that as soon as possible after the federation scheme has become law, we should have a move to produce new buildings for this group of hospitals.

I thoroughly agree with Senator Hayes that a single hospital of 1,200 beds for this group would not only be unwise but would be unwelcome. On the other hand, when he mentioned that it would be nice if these hospitals continued more or less as they are, I do not think he meant to be taken literally. While he felt that some degree of identity should be preserved, I am sure he did not want these hospitals to remain in their relatively isolated and ineffective state. One of these hospitals has 120 beds; another has 100; and the biggest has 250 beds. No single one of these units is economic. It is nice if you are in a small hospital to know the name and family connections of nearly every one of your patients and it makes for a helpful, intimate atmosphere, but it is not in the best interests of efficiency, either in administration or in medical treatment.

Therefore, we hope that some degree of amalgamation will be encouraged by the provision at an early date of one or two buildings for a small number of these hospitals, in a convenient place where the population still has to be served. It must not be forgotten that the primary purpose of hospitals is to serve a local population. With the transport facilities of the present day, patients can be taken from any part of the country to another in a very short time. As far as the bed patients in a hospital are concerned, they can come from almost anywhere, even in a state of serious illness. Therefore, the real urgency of siting a hospital is in relation to its outpatient activities where you have people in an overcrowded area. These people have probably no means of transport but they ought to be able to get to the hospital conveniently in the case of serious illness.

All these hospitals are situated strategically from that point of view. It does not need any great knowledge of Dublin to pick out the places where you have concentrations of poor people who need that kind of attention urgently and who want outpatient facilities. One could imagine a much smaller number than the present seven hospitals placed amongst this population so that the tradition of service could be preserved. I am sure that what Senator Hayes is thinking about is the preservation of that local service and of having easy access by the poor people to these institutions.

I am speaking for my colleagues on the lay boards and on the medical boards when I say that we have all been impressed by the helpfulness and consideration given to this measure by the Minister and by the officials in his Department. I have sat at the table in his Department working out the provisions of this Bill and I have experienced an atmosphere without which this matter would never have reached its present stage. I should like on behalf of all of us in these hospitals to say that and have it put on record.

I am not going to say anything now that would be likely to interfere with or delay the passage of this measure. I feel bound to express personally, on behalf of my own school and on behalf of the Royal College of Physicians, some disappointment that there is not a better representation of these schools on the Central Council. The schools have been interested in this measure from the very beginning. The Minister mentioned the delicacies of the situation in the Dáil. It has been continuously before the minds of all of us. It came to his notice because of the extremely delicate character of the negotiations from time to time but the Minister cannot know more than a small fraction of the difficulties we ran into. The schools—and certainly my school—although deeply interested in this measure refrained from pressing this in case the additional complications would endanger the whole issue.

That did not mean that we were not interested. Unless the federated hospital can serve the schools properly, it will be stultified in its development and the schools can hardly continue to exist and you may easily be in the position of having a fairly good teaching hospital and no students to teach. I think that is a very serious situation for us to contemplate. It is not at all impossible. Some ten years ago, we had a series of visits from America and England. Our schools were reviewed and were rejected or given a very qualified approval. This situation cannot persist and if it is allowed to go on much longer it will have a disastrous effect. The principal difficulty lies with the clinical teaching. As far as we can control our affairs in our medical schools, we do the best we can. We have never been really seriously criticised. We have been seriously criticised on many occasions for the untidiness and lack of control in our clinical affairs. We must have that put right or we cannot persist in our teaching programme. I very warmly approve of this measure and I thank the Minister for all his trouble.

Mr. MacEntee

I should like to thank very sincerely the Senators who referred to the small part which I have played in producing this measure. I said in opening that this Bill could not have been before the Oireachtas, had it not been for the spirit of co-operation and self-sacrifice in many cases of the members of the hospital boards and, perhaps, particularly the visiting medical staff. In trying to smooth out these differences and to evolve a workable scheme, I did not do anything more than my duty which I first addressed myself to many years ago when I was Minister for Local Government and Public Health. I then sponsored before the Cabinet a proposal for the establishment of St. Luke's Hospital. Unfortunately, that first endeavour was abortive. Due to the dissolution of Dáil Éireann, the project of the new hospital fell by the wayside. It is, therefore, a source of particular gratification to me to find myself in charge of a proposal which will in due course reach the Statute Book and which I hope will fulfil all the hopes that have been reposed in it.

I do not think there is very much I have to say because criticism has been light. The measure is an agreed measure. The text of it has been before the representatives of the hospitals concerned. It has been approved by them and it would be very difficult for us to amend it in substance. Indeed, I would suggest to the Seanad that it would be very unwise and, perhaps, presumptuous for us to endeavour to do so. Many hospitals, by sacrificing a substantial part of their autonomy, have contributed to make the measure possible and any amendment in principle which the Seanad might consider desirable would have to be made in agreement with these hospitals. I think it might, perhaps, have the effect of throwing the whole thing back into the melting pot. I suggest that is a result we could not contemplate with any equanimity.

Senator Jessop made the one substantial point in this debate. He expressed some disappointment about the representation which had been accorded to the medical schools. Again, such representation was settled by agreement. It was necessary that the medical schools should be content with the representation which is to be given to them on the Central Council in order that this measure might see the light of day. I do not think that the Senator need be too despondent. After all, sub-section (12) of Section 7 does provide that by agreement with all the hospitals on the Central Council, the Minister may make an order revising, perhaps, always upwards, the representation which is to be accorded to any particular interest, so that the battle is not over. It can be fought out, I think, if necessary, in the proper place, that is, on the Central Council.

Senator Hayes and some other Senators hoped that the passage of this Bill would not lead to the establishment of one huge institution. What the view of these seven hospitals may be, whether they are going to be amalgamated in one large institution or into a number of other institutions of more moderate size, is a matter for the Central Council. The future of the component parts, so to speak, of this new federation is in the hands of the federation itself. How they will develop the various specialties, how they will provide for accommodation, is a matter now for themselves. They are in that respect, I think, completely autonomous. I am sure—speaking for myself, and I think I may speak for my successors—there is not any of them who would not deprecate the establishment of one very large hospital.

Most of us feel that, while we must have institutions which are economic to operate and maintain, nevertheless we might pay too dearly for such economies as might be anticipated if, by making the institution large, patients would become merely statistical units within the building and the sort of humane contact between doctor and patient and all those attending to his physical and medical care would become so tenuous as to render him no more than a cipher in a very large system. I think, therefore, that, having regard to the general tradition of the hospital services in Dublin, we need not anticipate that this Bill will result in the formation of one large institution which will swallow up all the existing seven separate hospitals.

I do not think there is very much more to be said than that. I would ask the Seanad, if necessary, to give me the remaining Stages of the Bill today except that a small matter has been brought to my notice which we will, perhaps, have to check up with the Central Council. Accordingly, on this occasion, I shall have to accede to the viewpoint of Senator O'Quigley——

Professor Hayes

Why on this occasion? Is the Minister not normally a nice man?

Mr. MacEntee

I am normally a nice man, yes, but do not ask me to agree that Senator O'Quigley is always a reasonable man.

Mr. Donegan

He is a very pleasant man, like the Minister.

Mr. MacEntee

Yes, a very pleasant man. I did not intend to do more than to say that, in deference to the considerations which have been put before me, not only by Senator O'Quigley but by some other Senators, I do not propose to ask the Seanad to give me all the Stages of this Bill to-day, but I do hope we shall get them by next sitting day.

Mr. O'Quigley

We are all in agreement.

Question put and agreed to.

Committee Stage ordered for next sitting day.

Professor Quinlan

Will it be possible to have the report of to-day's Second Reading before the next sitting day? It is very undesirable that a Committee Stage should proceed until a report of the Second Reading of the Bill is available.

An Leas-Chathaoirleach

I am hopeing that it will be available before next Wednesday.