Yesterday evening when we adjourned I was speaking about the development of the health service, of which I regard this Bill as the next stage, and the fact that we had evolved our present situation from the arrangements that obtained up to about 1947 when really the only section of the community for which special provision was made by the State was the medically indigent. Now we have got away from that and the State has recognised that other sections need special help in order to deal with the very heavy expenses of a serious illness. This has led to the arrangement whereby the State has divided the community into the three sections with which we have all become familiar during the past 20 years.
In retaining this particular approach to the health services we have been wise; we could have departed radically in considering this new development and adopted some other method of providing health services, an entirely new method, but if you have tried a system and have had it in operation for 20 years, it is easier to modify it than to try an entirely different one and possibly find that it does not work as well. I have had occasion to talk about our health service in various countries, to lecture on it and to discuss it and I have always been impressed by the favourable views which people took of our arrangements when they were explained to them, of the fact that they were a sort of happy compromise between the arrangements whereby the State makes provision for everything and the other kind of situation in which only the medically indigent are provided for.
In discussing this Bill there are three aspects of it to which I should like to draw particular attention, three important new departures. The first one is the introduction of health boards to look after the general administration of the health services in their areas. The second is the setting-up of the special arrangements for co-ordinating hospitals under the regional hospital boards and the hospital council, and the third is the modification of the present practitioner service with special reference to the free choice of doctor which is now being introduced for the first time for the kind of person who is being looked after by the health services. The health boards have got three special kinds of significance for me. First of all, they do bring into existence larger areas than the former areas looked after by the local authorities. These areas consist of two, three, four or five counties as is projected by the Minister's document which he circulated some time ago. These are very much better units as a basis for planning; they do enable an authority to be created by a health board which will look after all kinds of services in these areas and try to co-ordinate them with each other.
We all remember the difficulty that existed in regard to mental hospitals, where you had not got a mental hospital for every county and sometimes several county councils had to join together to run a particular mental hospital. This, as it were, is almost a forerunner of the situation we will have where health boards will be nominated by several local authorities to run the areas and all aspects of the services in those areas. This will mean we will be able to have more specialised services because they will be able, more economically, to cover this wider area. It is also important in setting up these boards that the Minister has found it feasible to give a considerable amount of responsibility, as representatives on them, to doctors and workers in the ancillary medical profession. This was not possible previously. A doctor might be on a health authority but not necessarily as a doctor. Now doctors will be appointed on the health boards by the Minister on the nomination of the professional bodies concerned and, therefore, they will be on it in their professional capacity. I think this is a very important step we are taking in recognising that a doctor, as well as being a professional man, may also have some competence in helping to run a service and in administering a service.
It is also important that we should recognise that the establishment of these health boards is a step towards taking health services and health problems as far as possible away from politics. It has been a truism for a long time that health services should be above politics, but this is not very easy to arrange in general. Perhaps the countries which have gone furthest in this regard are in Scandinavia where the health services are administered by a national health board appointed by the Government without direct responsibility to any particular Minister. The board have a subvention from the Government and have the continuing responsibility of administering the health services.
If one discusses this with any responsible person from one of these countries one is likely to say that this is an admirable arrangement because the health services are then not in danger of changing with political changes which may take place every few years; they have a stability and the people concerned with them can plan in a forward manner. You will be told on the other hand that the fact that the health services are divorced from politics like this means there is no particular Minister responsible for finding the money for them—there is no Minister for Health to fight his corner in the Cabinet to get the best from the Minister for Finance. Therefore, they are always complaining there that they do not get their proper share of the financial cake.
The system we are evolving here of health boards which will have responsibilities to the health authorities and to the central Department of Health and who will, therefore, receive their financial support from both sources will be a compromise which might work extremely well. At the same time, the majority representation on these boards will be appointed by the local authorities but with considerable representation from the medical and ancillary professions. Therefore, the boards are less likely to be politically orientated or to make decisions on a clear-cut party basis such as the local authorities in the past on these matters.
In regard to the functions of the health boards, one is dealing with something which is an extremely wide subject. Obviously, they will have the responsibility for running the services, and any discussion of their functions is a discussion of the services as a whole, and it is hardly appropriate to embark on that now. There is, however, one point I should like to mention in particular. It is the possible functions these boards might have, or any committee set up under them, in the matter of the dissemination of information about the health services and in organising arrangements for health education.
This was referred to in the Dáil and amendments were suggested to include the function of advising the general public on the availability of the services. These were rejected by the Minister because he thought the possible cost of these information centres, if they became too numerous and too large, might become too great to be justifiable. He reminded the other House that the local authorities already have this function under the 1947 Health Act, and he mentioned there is a centre in Cork that deals with the dissemination of information about the health services. However, as far as I can gather, this is the only such centre outside Dublin.
I think that if an Act of 1947, 22 years ago, gave power to local authorities to do this, and if in the course of these 22 years we have had only one centre developed in one city in this country, it does not indicate to me that this is working well. Therefore, it would do no harm if the Minister took another look at this and put into the provisions dealing with the functions of health boards and their local councils a specific reference to either health education or to the dissemination of information about the health services. In the long run this at least would stimulate local authorities to take public notice of this and it would help in turn to make the services more efficient and possibly more economic to run.
There is a lot of general talk about various diseases that occur and it is a fashionable topic of conversation, but it does not mean there is any deep public understanding of such diseases. There was a discussion, for instance, on the early signs of cancer and the person conducting it discovered that not one of five adults with reasonably educated backgrounds could give one early symptom of cancer. If there was some better means of disseminating information like that, in the ordinary way so that it would not create scares, you might find that people would come forward for treatment in time so that you would not have to bear the massive cost of treatment in the long run.
It is also a fact that a big proportion of people are unaware of the services that are provided and available for them under various health measures. It has been estimated that, perhaps, up to half of the total illnesses in any community is latent; it is beneath the surface like the proportion of the iceberg, though not as big a proportion. This is one of the reasons why the health services in England have increased in cost so enormously. Their cost in 1945-46, when introduced, was based on the then conception of the amount of illness in the population. They have found since that that programme had to provide a service for illnesses which they did not know existed at the beginning. It is necessary that we become aware of these under-the-surface illnesses and the best way of doing this is by way of having centres not distributed too numerously, and, therefore, too expensively and possibly ineffectively, in reasonably large communities. There might be one centre under the aegis of each health board.
The Minister may say the local authorities already have under the Act of 22 years ago a responsibility in this respect, but if that Act has produced only one centre, it might be no harm to remind the health authorities of their responsibility in this respect. Therefore, as I said earlier, the Minister might think again on this matter.
On the question of membership of the boards, I think the agreement that has been reached by the Minister in the other House with the various people who put forward views as to the relative representation of the local authorities and the medical representatives is well founded and I have no quarrel with it. I agree also that ancillary workers should be represented on these boards. They are very important because of their direct responsibility for dealing with their patients, and this applies particularly to nurses.
Special reference has been made to psychiatric nurses. I do not know why they have been taken out of the whole body of the nursing profession for special mention. There are others, as well, with equal importance. There are obstetric nurses and paediatric nurses. In fact, the entire nursing profession is now becoming as split up into specialities as the medical profession. Therefore, I do not know why psychiatric nurses have been picked out and why they should have been given more of a right to representation on the boards than obstetric nurses. There is as much obstetric work these days as psychiatric work and I hope that situation will continue well into the future. That is a matter which presumably has been worked out with the Minister and the nursing authorities.
An amendment that was suggested and pressed with some force in the other House was the desirability of having other workers in employment on the health boards represented on these boards. I do not find myself completely in agreement with that. I agree with the Minister that if you make these boards too large nothing will ever get done. Having served on a number of these boards, I feel that the people who have the direct responsibility for the particular function that the board has to carry out, namely, dealing with sick people and promoting health, are the people who are more likely to give the best service on these boards. This is not to say that I underestimate the valuable work done by everybody connected with an institution like a hospital, but I think the best way of dealing with that is to bring in these other people, the people who run the catering service, the people who run the clerical side of the hospital and the administrative side, everybody, in fact, on various types of committee where these particular functions will be discussed.
There are two other points about health boards that I should like to mention. There does not seem to be any provision for either the health boards or the local committees to have members other than those who are appointed by the health authorities and nominated by the Minister. They have not, so far as I can see, any power to have on them people outside this range of expertise, if you like. On the other hand, in section 40, dealing with the reorganisation of hospitals, both bodies under that section have the power to have on them people who are outside the membership, in other words, to go outside and bring people in, presumably for their special knowledge in particular matters.
I agree with the view put forward that some provision should be made to have members of health boards on local committees. If the local committee are to function properly and bring the health board into close relationship with the conditions in the various areas for which the local committees have responsibility, then there has got to be some very direct communication between them. In the Medical Research Council we have a number of committees and we have a rule that the chairman of each committee is always a member of the council. We find that this gives a member of the council a direct responsibility for seeing that that committee get on with their work and, in turn, he then has to report on the work of the committee at the council meetings. This is an arrangement which works very well and I am sure it obtains in many other institutions. If some sort of bridge like that were to be made between the health boards and their local authorities the whole thing would find itself in a much more unified and satisfactory position.
I should like to mention another point in relation to health boards. In the health board areas where there are medical schools—there are three such areas in this country: Dublin, Cork and Galway—the health board should have a very close relationship with the medical schools. They will have to use, by and large, the graduates of those schools for the purposes of staffing their health services. The younger graduates will be the house officers of the hospitals. The training arrangements and the teaching arrangements will be, or should be, very closely dovetailed with each other. It would be appropriate for the authority that is running the medical school, the university, that is, to have some representation on the health board. I am sure that this can be looked after by the Minister when he is arranging to make his nominations on that section of the health board but I should like him to assure me in that regard. It works very well in England where the university, if it has a medical school, has representation on the regional hospital board and also on the regional practices committees.
That brings me to the next point, that is, hospital reorganisation. One can only welcome what is done in the section in this Bill dealing with hospitals to rationalise and co-ordinate the hospital situation. It has become extremely difficult with the enormous number of small hospitals scattered all over the country and the desire of each hospital to pursue its work at the highest possible level of specialisation and to have this desire supported by adequate funds from the central pool. This leads to a situation which has become completely impossible and not least of all in the city of Dublin.
My particular interest in this regard is in section 40 and in the implications of that section in regard to the question of medical education. Comhairle na nOspidéal which is being set up under that section is being given responsibilities of a very wide nature regarding the staffing of hospitals. It is very right that these responsibilities should be given to a particular body on a national basis so that proper co-ordination can be brought about but, on the other hand, there appears to me, in the first draft of this section, to be a danger that the staffing of the teaching hospitals might become a direct responsibility of this council rather than of the medical schools that are depending on these hospitals for the training of their students.
The Minister's predecessor and the Minister and the officers of the Department have looked at this problem in a very sympathetic way and amendments have been introduced into section 40 which will go a long way to deal with it but there is one still necessary in subsection (1) (b) (i) of section 40. This subsection gives the council the authority to determine the number and types of consultants in hospitals. Later on we find that they also have the authority to approve the qualifications of persons who are candidates for these posts and when they come to do that they have to consult with the teaching body concerned if there is a teaching responsibility. That is fair enough and we are grateful to the Minister for introducing that amendment but even at the level where they are approving the number of these consultants it has a direct implication for the teaching bodies. I just give one instance of this and this is one with which the Minister is very familiar. We wanted to develop cardiology in a particular teaching hospital in this town and it proved extremely difficult because the authorities in this hospital did not recognise that this level of development of cardiology was the kind of thing they wanted to encourage without reservation.
A very bright young man was appointed. He tried to work in those sort of circumstances and he found it impossible, so he left, greatly, I think, to the loss of medicine in Dublin. When we were replacing him we were in a position to insist that the hospital take a more rational view of this responsibility. Grudgingly, we got a certain amount of encouragement but it was not until we got money from an outside source, an American foundation, to support the post in part that we were able to make an appointment in that hospital of a cardiologist. What I am trying to say is that the hospitals concerned should have the obligation to consult with the teaching authorities in the establishment in determining the number of such posts. Not only in determining the qualifications of them but also in establishing new ones, it should be able to listen to the teaching body when such circumstances arise and take note of their requirements.
In regard to the qualifications that consultants, particularly in teaching hospitals, have on their appointment and in regard to the manner of appointment, the provisions in this section also meet our wishes and we are grateful to the Minister and his Department for this and for being sympathetic to our point of view. In Trinity College we are fortunate in having an agreement with the hospitals where our students go for training, with the federated hospitals, the Rotunda and St. Patrick's Hospital for different types of training that students get and for the appointment of people who have teaching responsibility. By and large, these agreements provide that such persons will be appointed jointly by the university and the hospital. The appointments board set up to deal with vacancies will be constituted from the hospitals central council and partly from the university itself. We have found in a number of instances that this works excellently. There is some difficulty in bringing this into line with the also excellent system of filling vacancies operated by the Local Appointments Commission but I believe that the wording of this section in this regard is sufficiently liberal and unrestricted as to make it possible for some proper arrangement to be worked out. I am sure the Minister and his colleagues in the Department of Education will be able to help us when we get down to dealing with that matter.
I do not think a teaching body should make an appointment to a hospital of somebody who has responsibility for looking after patients. The teaching body are not the kind of organisation who are equipped to make such an appointment, to judge the qualifications and the ability of the person so appointed to fit in with his colleagues, and so on. Nor do I think that a hospital on its own should make appointments of persons who have teaching responsibility without referring to the teaching bodies but together the two can make a very good job of it.
In regard to the functions of this council in relation to staffing hospitals, I would hope that the Minister, when we come to look at these sections in detail on Committee Stage, would take some special step to introduce into this section or some other appropriate place in the Bill some reference to the right of the general practitioner to work in hospitals. He mentioned this in his explanatory memorandum but there is no specific reference to it in the Bill itself. I think the whole arrangement would have a great deal more teeth if this was said in the early subsections of section 40 and if the words "general practitioner" were inserted in that section and the responsibility of Comhairle na nOspidéal for regulating the number and qualifications of other staffs in hospitals were set out. I think they could be given a right to be considered for incorporation in hospitals staffs.
The whole question of the general practitioner, which is the next point I want to take up, has been under very close scrutiny recently by various bodies and it is clear that only recently have we begun to recognise that this section of the profession is at least as important as—possibly even more important than—the consultant specialist group for the purpose of the ordinary running of the health service. In the Todd Report which I have here there are no fewer than 90 sections dealing with general practitioners and in section 31 we find this sentence: "A very substantial proportion of all illness, perhaps 90 per cent, is dealt with entirely within the ambit of general practice". That is a measure of the importance of the work of the general practitioner and it could be even greater with the development which the Minister foreshadowed of a more active investigative function for the hospitals so that patients are taken into hospital and investigated and then sent back with instructions to the practitioner as to what to do rather than having patients kept in bed in hospital to be looked after by the consultants.
Yesterday a Senator referred to the debt we owe to those who initiated the Hospitals Sweepstake scheme. I agree with him wholeheartedly. I mentioned this on the Appropriation Bill but it is not inappropriate to mention it again now. This scheme was introduced on 6th December, 1929, in Dáil Éireann by the then Professor of Medicine in Trinity College who was Sir James Craig. He had nothing to do with the Prime Minister of Northern Ireland at that time although sometimes confused with him. In his Second Reading speech on that occasion he made it quite clear that he did not relish introducing that scheme. He was a Northern Ireland Protestant and one could understand why he did not want to be in the position of putting forward a Bill in support of the health services of the country, including the hospitals, on a gambling basis. But he found this was absolutely necessary because the hospitals then were in a dreadful situation. There was no money for the development of their services, no money even to continue on the very low standard on which they were then being run. We have all seen the development that occurred following the operation of the Sweepstake scheme. This is one of the most important developments that have taken place in the health services of the country. The amount of money that has come in from this scheme has enabled a large number of hospitals to be built throughout the country and others to be developed. Most of us disagree fundamentally with the Government for taking a large share of this money in tax but this is a matter on which we have never been able to get any satisfaction and there is no use in raising it now.
I hope I am not being contentious when, in referring to these improvements, I mention that particular hospital of which Sir James Craig was a senior member of the staff. Sir Patrick Duns, which I attended as a student, has had relatively little benefit from the Hospitals Sweepstake scheme. The hospital is essentially the same as it was in 1929, which was about the time I qualified. There have been improvements but not of any major character.
This also applies to most of the hospitals in that group, hospitals to which students of our medical school go. I know there are reasons for this. I know that the multiplicity of these small hospitals has made it very difficult, in the absence of any agreement between them, for the Minister or his Department to achieve all the developments they would like to see taking place. This restriction has not applied equally to all the small hospitals.
This group has now taken certain steps which I think will help the Minister to help them. About ten years ago they formed a federation and, in the course of the negotiations, some of them extremely difficult, in the development of that federation, they have recently, with the help of the Minister, formed a plan for their future development. We will now look to the Minister to encourage this group of hospitals in this development in a way which I think they deserve.
This federation is made up of seven hospitals. Some of them have been serving the sick poor of Dublin for over 200 years. Most of them were built in the slum areas so as to be easily accessible to the sick poor. They provide about 1,200 beds altogether and they have over half the attendances at out-patient departments in the year. These are figures which are not generally recognised. When the amount of work done is staggered over seven small units like that, it tends to be lost but, when it is all gathered together, it makes a very substantial total. They want to go on doing this and they want to go on doing it in a modern and worthy style. They want a provision in a specific way to allow this to be done to the standards of the 70s, 80s and 90s of this century.
At the same time, they do not want to deny their younger people the opportunity for post-graduate work and specialist training. This is absolutely necessary at this stage of the development of medicine and, if some provision were not made for this, they would not be able to persuade their younger people to stay in the employment of these hospitals. The agreement we are in process of working out with the Minister—I do not want to go into it in detail here—will provide for both of these aspects and I would hope that there would be no suggestion that the aspect which deals with the ordinary day-to-day illnesses of the very large majority of the people of this town is in any way secondary to or a less worthy aspect of our medical effort than, say, the training of specialists and the carrying out of prestige operations in special centres.
We come to the choice of doctor under the section which deals with general practice. This is an excellent innovation but I find myself in a little difficulty in understanding how it will work. I would welcome an explanation from the Minister on this when he is replying to the debate. Will we continue to have dispensary doctors? That is my principal difficulty. If we do, will we be paying twice for the same job of work? Will we be paying a dispensary doctor to look after a sick person, but that sick person does not choose to go to that particular doctor but chooses to go to somebody else? Will we be paying specifically for that act of service? In other words, will we be paying twice for the same job?
Could it happen that a dispensary doctor would make himself so unpopular with the people in the lower income group that they would all opt to go to someone else? Then he would be getting paid but he would not have anything to do for that part of his salary. I am sure there is some way around this. I am quite certain that doctors are not like that and that that would not happen, but that is just an extreme point that comes to my mind and I should like if the Minister would elucidate it.
It is very important that there should be good quality doctors available in the rural areas. One of the things that the Local Appointments Commission have done over the past 30 or 40 years was to recruit good quality doctors for those dispensary posts. I have been on a number of boards constituted to make those appointments and I was always impressed at the way they weighed up the qualifications and experience of the candidates. As a result, in many parts of the country there are highly qualified people running this aspect of the service.
I should like to mention briefly to the Minister that I believe it is very important to stimulate and encourage the provision of good quality general practitioners. I believe quite honestly that there is not any country in the world where the scarcest form of medical care is not quality general practice. In most countries you can get highly qualified surgeons and very well trained specialists. They are to be found in the cities working in hospitals of various degrees of adequacy but, when you go to the rural districts and look for good quality general practitioners, very often there is difficulty in finding them. I know this applies to those countries as well as the less developed countries.
There are several ways in which we can do this. We have to provide better facilities for general practice so that the practitioners can examine their patients properly and have them properly investigated. They should have access to facilities in hospitals for special investigation on their patients. I saw with pleasure recently that University College, Galway, have succeeded in making such a service available. This should be general and should cover the whole range of general practice. I am not talking about putting specimens in a tube and sending them by post to some laboratory and reading the result and possibly not being able to understand it because you have not read that amount about recent developments. I am talking about an opportunity to make as close contact as possible with the people who are involved in these investigations, who understand what they are doing and are in a position to explain to the practitioner the implication of the results so far as the patient is concerned.
We have in one hospital in Dublin —that is the one I happen to know about; there may be others—an excellent arrangement whereby a particular practitioner works in the outpatient department of that hospital during certain sessions each week. This is not recognised by the health authority for payment but he does it and this brings him and his viewpoint and his knowledge of the background of the patient into close contact with the hospital. I think this would be an excellent arrangement for the health boards to have.
I also think—and this is getting away from the function of the Department of Health—that if the Department of Health could bring influence to bear on the Department of Education so that the medical schools would be encouraged to establish departments of general practice, this would add greatly to the prestige and status of the practitioners. We could have a professor in charge of lectures on general practice teaching the students the organisation of practice and the responsibilities of the general practitioner, sometimes out of contact with the specialist service of a hospital.
We have in Trinity College during the last five or six years instituted a scheme, which is working very well, whereby medical students go for a few weeks each year to a number of practitioners around the city, who are prepared to co-operate and take these students around their practices, show them what is going on and explain to them the nature of their work. This has two effects: first of all, it gives students an insight into the other side of illness, the side away from the hospital, and the implications of this illness on the family and it also shows them that general practice can be an attractive and stimulating way of life. This, in turn, will enable us to recruit better quality students for this type of practice.
There are only two or three other matters I want to mention briefly. Research was mentioned here. There is provision in the Bill for the Minister to support specialist investigations and to encourage research. We are grateful for this. The desirability of encouraging research in rheumatism in the western parts of the country was mentioned and emphasised. I wholeheartedly agree with this. Rheumatism is, as the Senator said, one of the most important reasons behind absence from work and so forth, but I would not agree with him in his suggestion that this type of research is an inexpensive type of research. It is anything but that. If one wants to do good quality research in rheumatic diseases one needs to have a very complicated laboratory; one wants a couple of electromicroscopes which cost about £10,000 or £12,000 apiece. One wants teams of workers to look after them, people who understand how to use them. One needs very special X-ray equipment which will cost several times as much as a couple of electromicroscopes. That represents a nice little bill for a start. I do not think the Senator should go away with the impression that he can set up very cheaply in Galway a small unit which will discover the cause of rheumatism in a very short time and relieve the incidence of that particular malady in that area. I am not suggesting such a research unit should not be established in Galway, or that the expense is any reason for not establishing it but, if anybody is thinking in terms of establishing a rheumatism research clinic, he should not think in terms of a small amount of money.
I am in agreement with other Senators about the amount of work that the Department and the Minister, and his successors, will have to do in future when this Bill is passed in drafting regulations to try to make the Bill work properly. There are two kinds of regulations. One kind has to be approved by both Houses before they can be put into operation and the other kind has merely to be laid before the House for 21 days. There is nothing in this Bill that states this as a particular requirement, but I take it that is the overall ruling which has been accepted as binding for all sorts of regulations. Then there are orders. There is nothing at all about the orders. The Bill does not say they will be laid before the House, or put before either House of the Oireachtas, so that we will never know about them until they have been made. I wonder are we entirely at the mercy, shall we say, of the Minister and his successors in this regard. Can he just make an order, having consulted with whatever local people the Act asks him to consult with, and we will not know anything about it until the matter is a fait accompli?
There is, then, the use of the words "shall" and "may". I note this over and over again in the Bill. Sometimes it is quite apparent that the one word is appropriate where the other would not be, but it is not so apparent in every instance. For instance, I know that home nursing "shall" be provided, but I also note that home helps "may" be provided. I do not know why there should be a subtle difference between these two because, if one is ill, a help in the home may be just as important as a nurse. Indeed, there are certain kinds of illness which do not need nursing but do need a great deal of home help. Rheumatism is one of these. One might be crippled with rheumatism and unable to cook a meal. A nurse cannot do anything but one does need a home help. Why have we "shall" and "may" as between these two sections?
I conclude by welcoming the introduction of these two sections providing these ancillary helps. They will be an enormous benefit in keeping down the extravagant use we are making of our hospitals at the moment, not merely for medical but very often for social purposes.