I move the Second Reading of this Bill. The earliest of the Public Charitable Hospitals Acts, all of which it is now proposed to repeal, was passed in June, 1930, and was to remain in force until July, 1934. The object of the original Act, which authorised the holding of sweepstakes to raise money for hospitals, was to help voluntary hospitals. The Act laid down three conditions which these institutions had to satisfy if they desired to participate in sweepstake moneys. These conditions were that the hospital had to be in the Saorstát and in receipt of voluntary subscriptions from the public, and during the year prior to the passing of the Act had used 25 per cent. of its accommodation for free patients or patients paying ten shillings or less per week.
Hospitals that could satisfy these conditions and wished to organise a sweepstake were required to appoint a committee for the submission of a scheme to the Minister for Justice and give particulars of the prizes, the prices of tickets, the amount or maximum amount of expenses in connection with the sale of tickets and the manner in which the money was to be applied. When the scheme was sanctioned, the committee could arrange with others to promote the sweepstake and the Act contained provisions regulating the expenses of holding the sweepstake.
The immediate object of the promoters of the original Act was the relief of a few Dublin hospitals from their financial embarrassments. In the post-war period a high cost of maintenance was not counterbalanced by an increased flow of subscriptions from the charitable public, and some of the hospitals had fallen into a precarious financial condition as they had not then fully developed a system of charging patients for their maintenance. Only six hospitals, all in Dublin City, participated in the first sweepstake on the Manchester November Handicap, 1930. It has been said that the six hospitals hoped to be able to divide £20,000 as a result of that sweepstake. If that were so, we now see that their expectations were not pitched very high. As things turned out, the six hospitals, one of them a dental hospital, received £131,671 from the first sweepstake alone. The tremendous success that attended the sweepstakes falsified all predictions. In June, 1930, when the first temporary Act was passed, no one reckoned that in less than three years the proceeds of sweepstakes available for hospitals would be reckoned not in tens of thousands but in millions of pounds, and that not only would a few Dublin hospitals benefit but almost every hospital in the country, whether voluntary or rate-aided.
It is easy to say now that we have seen what is possible in the way of raising money by sweepstakes, that it would have been more prudent to have taken the long view at the beginning and to have provided in a more deliberate and systematic way for the distribution of sweepstake moneys. It must be conceded that the magnificent success of the sweepstakes could not reasonably have been anticipated. The arrangements embodied in the Acts which this Bill will repeal were of a temporary and somewhat experimental nature and have been signally successful in fulfilling their purpose. The promoters, the Hospitals Committee and the Trustees are to be congratulated. They have laid the governing bodies of the hospitals under a deep debt of gratitude.
We must now address ourselves to the problems of administration and organisation arising out of the rapid and unprecedented financial success which has attended the plan adopted a few years ago. The administrative proposals contained in the Bill are intended as a basis for the rationalisation of expenditure of the moneys placed at our disposal for the care of the sick, and the suffering, and the improvement of the conditions under which they are treated. The extent to which the perfecting of our hospital system can be carried out will eventually depend on the continuance of the success of the sweepstakes, but even within the limits of the funds which have already been obtained, it is obvious that the country has a unique opportunity of tackling the question of hospital organisation in a comprehensive way. The position of the State in the matter is that it simply recognises the existence of a condition of affairs which is making millions of money available for hospital and nursing facilities. It is not intervening in the control or conduct of the methods by which these moneys are being raised, but once the funds are available, the State conceives itself to have a responsibility in seeing that such funds are expended to the best possible advantage, with prudence and foresight and with due knowledge of the condition of the sick and their hospital needs throughout the country as a whole.
The original Act was amended by several Acts passed in 1931. It was found that certain hospitals could not participate by reason of the conditions laid down with regard to free patients and voluntary subscriptions. A number of such were specifically exempted from complying with the conditions. The Principal Act did not contemplate any of the proceeds of sweepstakes going to county or district hospitals or other rate-supported institutions. But the success of the sweepstakes soon brought forward claims on behalf of these institutions. In 1931 the Oireachtas made a radical amendment in the method of dividing the money available. Theretofore, the Hospitals Committee fixed, with the approval of the Minister for Justice, the proportion of the surplus that each of the participating hospitals would receive. In substitution of this arrangement it was enacted that the surplus was to be divided into two parts, two-thirds to be divided amongst the participating hospitals and one-third to be paid to the Minister for Local Government and Public Health to be applied by him to meeting expenses in or towards the provision, improvement or equipment of institutions for the prevention, treatment or cure of physical or mental disease or injuries to human beings, including institutions wholly or partly maintained by a local authority. It was subsequently provided that 1-25th of the share paid to the Minister was to be applied for the benefit of nursing associations.
The Act of 1931 also made provision for the appointment by the Minister for Justice of a Committee of Reference of three members. This Committee's function was to report to the Minister on the proportions in which the two-thirds part of the surplus should be divided between the governing bodies of the hospitals entitled to participate. The Committee have already presented three reports. In their report on the Manchester November Handicap Sweepstake, 1931, the Committee of Reference cogently illustrate the dangers of a piecemeal and uncontrolled development along those lines. They state:—
"Considered in its national aspect, the Irish hospital system reveals a condition which is open to certain criticisms. Evidence of this was furnished by the manner in which the claims made by the participating hospitals were presented to us. Many of these showed an acute lack of appreciation of the proper lines of hospital development in relation to the social and community needs. The main features of the majority of the claims were variously related to a single anxiety, namely, to obtain the largest possible award from sweepstake funds. In justification to this anxiety, a programme of building was in most cases hastily considered, generally with a view to increasing the existing accommodation without regard either to the needs of the community served or to any scheme which would extend hospital facilities to classes of patients for whom inadequate provision at present exists. In few cases was it attempted to co-ordinate claims with those of other hospitals, or to investigate the advantages which a unified policy of development would ensure."
This kind of reaction on the part of individual institutions to the knowledge that money was available for them if they only pressed their claim is the kind of reaction that we wish to avoid. Wise and delicate administration will be required to secure well-balanced and harmonious development. Too many institutions must not be allowed to specialise along the same lines to the neglect of other less popular branches of curative medicine. The central specialised hospitals must be made available for all, and the poor must get the use of them free. The local hospitals must be developed to afford the maximum of utility without a high degree of specialisation and their geographical organisation must be carefully planned.
It will accordingly be seen that a plan of hospital organisation is not a thing that can be improvised between one sweepstake and another. It involves numerous problems, some of them novel and complex, that demand careful and continuous consideration. Schemes of piecemeal organisation would also defeat their purpose and give rise to anomalies and overlapping. There must be first-hand investigations covering the whole of the State, and the needs of the community must be determined by somebody in a position to determine what is the best form of hospital organisation for the area and what part the different types of hospitals are to play in meeting the needs of the community.
Having regard to the essential unity of the institutional problem as a whole, both as regards the voluntary hospitals and the poor law hospitals, and having regard also to his position in relation to rate-aided institutions, the Minister must accept the responsibility for supervising and controlling the reorganisation scheme as a whole. But there will be no additions to or extensions of the existing statutory powers of the Minister. As regards legal control, the Minister does not propose to invade the domain of voluntary effort. It is, however, expected that the power of affording or withholding financial assistance which the Bill proposes to give him will enable him to get all voluntary institutions to work in harmony with the general aims of the national scheme of reorganisation. I may say here that the chief aim of that scheme will be to secure from the moneys now made available that the sick poor throughout the country shall be given every facility of treatment and nursing that their richer brethren can afford to obtain. I say, moreover, that this aim will be embodied as a condition of every allocation from the funds placed at the Minister's disposal, whether such allocations are made to the poor law bodies over which the Minister already exercises a certain control, or to those in charge of the voluntary institutions with regard to whom the Minister has up to the present suffered from a certain detachment.
It is clear that there is need for a complete survey of the hospital system of the country as a whole. If the distribution of sweepstake moneys proceeded on existing lines until the needs of the voluntary hospitals, which the Committee assess at seven million pounds, are met, it was clear that an unprecedented opportunity of dealing with the question of organisation in a comprehensive way would have been missed. The present position is that we have several systems working side by side. First we have what for convenience is called the voluntary system, though some of these institutions lack what would be regarded as the main characteristics of a voluntary hospital, inasmuch as they are not supported mainly by voluntary gifts or endowments and all contributions from patients are not voluntary offerings. I am using the word "voluntary" in a wide sense to cover public hospitals which are not a direct charge on the rates or mainly supported out of public funds. These voluntary hospitals are supported in varying proportions by endowments, subscriptions, and fees received from patients able to pay. They include the large clinical hospitals which the medical schools recognise as teaching centres and they also include numerous smaller establishments, some of them special hospitals dealing with particular diseases or with particular classes of patients. Then we have the county infirmaries and county fever hospitals. Their purpose is recited in the Act of 1765. They were to be "receptacles for the poor, who are infirm and diseased." When the Poor Relief Act of 1838, which created the workhouse system, was passed it was intended that the Poor Law Commissioners would examine into the state of the "several fever hospitals, dispensaries or institutions for the relief of the sick or convalescent poor."
The Commissioners were instructed by the Statute to set forth the number of hospitals or dispensaries which ought to be provided in addition to the workhouse. In 1841 the Commissioners reported, and in their report suggested that there should be a Medical Charities Board established, and charged with the duty of suggesting and advising the necessary arrangements for the provision of dispensaries and hospitals and infirmaries, and for their regulation. The Board was never established, but to-day, when we are proposing to establish an advisory body of the character then suggested, it is worth recalling that close on a century ago it was seen that an expert body was needed to ensure that provision made should be properly distributed without inadequacy or overlapping. Thirteen years ago, on the break-up of the workhouse system, many of the infirmaries were absorbed into the new county hospitals system. Some of the county schemes provided for the abolition of the committees of management of the county infirmaries, and the handing over of the infirmary to the board of health; others made no change and the committees were allowed to continue as they were. About two-thirds of the county infirmaries had ceased to exist in 1921. Finally we have the hospitals that are under the control of the boards of health—the county, district and fever hospitals. These have mostly developed out of the old workhouse infirmaries. In some counties there is a county hospital only; in others there is a county hospital, supplemented by district or cottage hospitals, and in a few counties there are district hospitals only.
We have these three systems that I have described working side by side. Arrangements exist between some of the hospitals, but generally it may be said that each group carries on its work in isolation. There is no co-ordinating authority. The haphazard development has resulted in some areas being well served, other areas being less well served, and others again not served at all. No one could seriously contemplate this system, or rather want of system, continuing indefinitely. We have no general hospital system in the strict sense. The pressure of circumstances, illustrated in the case of the county infirmaries, has tended to break it down and to compel amalgamations. The Government cannot stand idly by and see millions of money poured into a system obviously unorganised and insufficient. To do that would be to stereotype all the existing defects for generations to come. Like other countries we must work to some plan. Elsewhere amalgamations and working arrangements are the order of the day. The advances in medicine, with its greater specialisation, make it imperative not only that old and small institutions scattered here and there should be extended and enlarged, but that the best means possible should be devised to bring together in convenient centres the expert personnel, equipped with all the means that science has placed at our disposal for combating disease. I am of one mind with the Committee of Reference when they deplore the misguided loyalties which seek to preserve existing interests, to the detriment of reforms that are so obviously called for.
I observed recently that in Stockholm, in drawing up a hospital plan they propose to discard a number of old and out-of-date hospitals, and replace them by three central hospitals, one for each borough; and that one of these central hospitals will accommodate 1,500 patients—a number which is more than three times the bed-accommodation of the largest of our voluntary hospitals. In Copenhagen also the National Hospital, which occupies a special place amongst the hospitals, has close on 1,000 beds, and receives patients from all over the kingdom. I mention these two to illustrate the trend away from the small hospitals. Whatever the resources the sweepstakes place at our disposal we cannot afford to fritter them away on obsolete or unnecessary institutions. The problem requires study by an authority whose business it will be to link up the different systems. A plan of hospital organisation is not a thing that can be improvised between one sweepstake and another. It involves numerous problems, some of them novel and complex, that demand careful consideration. The needs of the community must be determined, the form of hospital organisation best fitted to meet those needs must be clearly visualised, and the adaptation of our existing hospitals with the least avoidable disturbance to fit into a complete scheme must be tackled and dealt with. It is not a question of finding out the needs of this or that institution, and adding a wing here or a new storey there. We must have investigation at first-hand of the needs of the community, and the relative degree of urgency of whatever new measures are necessary must be determined. When grants are made they must be made for some purpose consistent with a complete plan.
The Bill proposes to establish such an authority, to be called the Hospitals Commission. The Commission will have power to survey the existing hospital facilities in each area, and to bring together all the data that throw light on the health of the people—the death rates, the incidence of disease, and so on. Every application made for a grant out of sweepstake funds will be referred to the Commission for report. They will be entitled to inspect any hospital, and to examine all accounts of receipts and expenditure. The existence of the Hospitals Commission will render the continuance of the Committee of Reference unnecessary. The number of ordinary members of the Commission will be not less than three. Provision has been made for temporary additions to the Commission. It will, we think, be found useful that when some particular questions affecting the county, district or mental hospitals are under consideration the Commission should have the advantage of such help as the Department of Local Government can give.
The division of the surplus in two parts—one going to the participating hospitals, and one to the Minister for distribution—it is proposed to bring to an end. There will be no obligation to divide the proceeds of each sweepstake in proportions to be determined afresh each time a sweepstake is held. All sweepstake moneys will go into a single fund, to be called the Hospital Trust Fund, to be held by National Hospital Trustees, who will have power to invest what is not immediately required for making disbursements. There will be three trustees, who will be appointed by the Minister for Local Government and Public Health. All the existing undistributed surpluses, and any money paid over to the Minister that is not required by him in respect of arrangements which he has made, will be payable to the Hospitals Fund.
The establishment of the Hospitals Fund, and the setting up of the Hospitals Commission, are the two main departures from the law as it stands at present. There are one or two minor amendments to which reference must be made. The definition of hospital has been extended. Institutions for carrying on medical research will now be brought in. I do not think anyone will find fault with our proposal under this head. The acquisition of new knowledge through research is very necessary medical work, and those engaged on it in this country cannot, to the same extent as elsewhere, look to the generosity of private benefactors for financial assistance. It is proposed to abolish all the conditions laid down in the original Act as to the percentage of free beds and the receipt of voluntary subscriptions. The Hospital Commission will be in a position to examine the claim of each hospital, and to see to what extent it is serving the poor. The fact that a hospital joins in the organisation of a sweep will not give it a claim to a share in the proceeds. The claim will have to be based on the services the hospital is rendering to the community, and be established to the satisfaction of the Hospitals Commission, and of the Minister. All types of institutions which cater for persons suffering from physical or mental disorder or infirmity will be eligible for grants. These will include the infirmaries of the county homes, in which numbers of the sick are accommodated, and also a new type of home (which usually includes a maternity ward) intended for expectant mothers who would otherwise have to remain in the county home. Nursing organisations will still remain eligible for grants.
The sections of the Bill relating to the initiation of a sweepstake and the conditions under which sweepstakes can be promoted follow substantially the existing Acts. It will still be necessary to appoint a Sweepstake Committee to prepare a scheme for submission to the Minister for Justice, and to make the necessary deposit to secure payment of prizes. It is not proposed to give power to boards of health or the governing bodies of county infirmaries to initiate sweepstakes.
In conclusion, I would like to repeat what was said to a deputation from the Hospitals Committee recently. Our purpose is to help the hospitals, to provide a means by which the public needs will be studied, and to create a body that will be able to bring experience to bear on local problems. Rumours gained currency that caused anxiety to the friends of the hospitals. The Bill shows how baseless many of these rumours were. There is no intention of diverting sweepstakes money from the hospitals to housing and slum clearance and other purposes, many of them excellent in themselves. Very large sums have been raised, and the purpose of the Bill is to ensure they are spent wisely and to the best advantage, and for the purposes for which they were intended.
