I move that the Bill be now read a Second Time. The proposals in this Bill, together with the motion on the Order Paper dealing with tuberculosis, afford an opportunity, which I welcome, for the fullest discussion on the tuberculosis problem. At the outset let me point out that within recent years there has been a great change in the medical approach to tuberculosis as a result of which I have found it necessary to reorganise the tuberculosis services of local authorities in order to provide, as far as possible, the most up-to-date methods of diagnosis and treatment. It is in relation to this general scheme of reorganisation that the provision of sanatorium accommodation has become a matter of the greatest urgency. In order that we may clearly understand the position as we find it to-day, it is necessary to review the efforts that have been made in the past to deal with this disease. From the year 1901 onwards, local authorities were invited to take steps to counter the exceptionally high death rate from tuberculosis and to guard against the spread of the disease. It was not, however, until 1908 when the Tuberculosis Prevention (Ireland) Act was passed that the basis of the present scheme was laid. The administration of the Act was entrusted to the county councils and the county borough councils. It was, in fact, the first health function with which the county councils were charged. They were empowered to establish and maintain hospitals and dispensaries for the treatment of the tuberculous inhabitants of their areas, or to enter into agreement with the authorities of existing institutions for the provision of such treatment. The power of requiring notification was restricted to the forms of tuberculosis which, on medical grounds, were regarded as dangerous. Owing to the divided state of public opinion at the time notification was only required to be made where the patient, in the opinion of the medical attendant, was liable to communicate the disease to other persons.
A new and more active phase in the struggle against tuberculosis was inaugurated by the National Health Insurance Act, 1911, when specific funds were made available for the treatment of tuberculous patients. Sanatorium benefit was instituted, and insurance committees were established for the administration of such benefit amongst persons who were insured.
In connection with the Insurance Act of 1911 a capital grant of £1,500,000 was appropriated by Parliament in aid of the cost of establishing sanatoria, and other like institutions. Ireland's share of this Sanatorium Grant amounted to £145,623.
Very little had been done by the county and county borough councils towards the treatment of tuberculosis before 1911. There was no provision for making any contribution to the expenditure out of Government funds. In the financial year 1913-14 an annual grant of one-half of the net cost of approved tuberculosis schemes was voted by Parliament. This grant— generally called the National Tuberculosis Grant—has continued ever since.
Tuberculosis schemes drawn up then included (a) dispensary treatment, (b) treatment in sanatoria, and (c) domiciliary treatment. There was in addition a nursing service, a notification scheme, and a laboratory service for diagnosis. A study of the amounts spent under the heading of the National Tuberculosis Grant reveals how the service developed during the years from 1922-23 to 1940-41. The amounts expended from this grant on the basis of one-half of the approved expenditure of local authorities on tuberculosis schemes increased gradually each year from £21,114 in 1922-23 to £174,560 during the year 1943-44.
Prior to the Sanatorium Grant being made available for the provision of institutions for the treatment of tuberculosis, there had been only three public sanatoria established providing about 340 beds, namely, Newcastle, County Wicklow; Heatherside, County Cork; and Crooksling, County Dublin. As a result of the assistance afforded from the sanatorium grant, Peamount Sanatorium, Co. Dublin was opened by the Women's National Health Association in the year 1912. Thirteen county councils contracted with the Association for the reservation of institutional accommodation, in all about 200 beds for patients from their respective counties who were suffering from pulmonary tuberculosis in its earlier stages.
In the years following, it was found that the most difficult part of the campaign against tuberculosis was the problem of the advanced case and the satisfactory isolation of this type of patient. Every effort was then made to establish local sanatoria to facilitate the hospitalisation of such cases. Before 1922 the only special institution provided to cope with this problem was the Tuberculosis Hospital, Pigeon House Road, Dublin. Since then the number of beds provided for advanced cases increased to 1,975, of which 1,220 were reserved in general institutions approved of by the Department, while in special institutions, including Rialto Hospital, Dublin, and Pigeon House Road Hospital, 755 beds were provided. For early cases, Peamount Sanatorium. Crooksling, Heatherside, County Cork; Newcastle, County Wicklow; and Our Lady of Lourdes Hospital, Dun Laoghaire, were reserved and provided 875 beds. In addition 407 beds were in use for non-pulmonary tuberculosis. They were located principally at St. Mary's Hospital, Cappagh, and St. Joseph's Hospital, Coole. These give a grand total of 2,850 beds for the treatment of pulmonary tuberculosis and 407 beds for the treatment of non-pulmonary forms of the disease—principally of bones and joints. This was the accommodation which had gradually been built up between the years 1914 and 1940. During the last four years a further 253 beds have been provided for the treatment of tuberculosis, in spite of war conditions, of shortage of building materials and essential service supplies.
It is significant that, according as the tuberculosis service has been developed and the yearly cost increased, there has been a concomitant fall in the number of deaths, up to the year 1938. For instance, the total number of deaths from all forms of tuberculosis in the Twenty-Six Counties area in 1904 was 8,798; in 1910 the number had fallen to 7,017; in 1921 to 4,824, and in 1929 to 3,875. In 1938 the figure fell to 3,216—the lowest ever recorded. From 1938 the number increased gradually, so that in 1940 there were 3,685 deaths; in 1942, 4,347, while in 1943 the mortality had decreased again to 4,306.
As a result of the inquiries set on foot by my Department, and from the reports received from the medical superintendent officers of health and county medical officers, many causes have been advanced as being responsible for this rise in the death rate.
Housing conditions, malnutrition, return from outside the State of workers broken down in health, physical strain of training in the Defence Forces, increase in dancing facilities, movement of population from rural to urban areas, have all been cited as causes. Any or all of these factors may have had some influence, but I am not satisfied that they fully explain the rather steep rise in the death rate in the early years of the emergency. After the fullest examination of the position, I have reached the conclusion that some new factor affecting all sections of the people has exercised an influence. A possible increase in the virulence of the disease has to be considered, but, for my part, I look towards changes in our nutritional state as offering the most promising field for investigation. I want to avoid any highly technical dissertation on this subject, but Deputies will understand me when I say that calcium intimately enters into the healing process of tuberculous lesions; that it also has to do with our powers of resistance; and that a deficiency in blood calcium might render us particularly vulnerable. Now, there is substantial evidence that during the emergency we have been, and perhaps we still are, suffering from calcium deficiency, and while I am awaiting the advice of the scientists on this complex question, I have planned to err. on the side of safety and guard against calcium deficiency. As the House is aware, Professor Dillon, of University College, Dublin, and Dr. Murnaghan— a brilliant young graduate working under him—are pursuing this scientific problem for me. It will be some years before they will be in a position to reach firm conclusions, but whatever the outcome, they deserve our gratitude and appreciation for the earnestness with which they have undertaken their scientific labours.
Generally speaking, it has been impossible with the means at our disposal to determine the influence of what is called malnutrition. I may mention that the layman's conception of malnutrition usually conveys a very misleading impression. Malnutrition may be found in the midst of plenty. Powers of assimilating food are not by any means standard. One, human being will thrive on a diet that might not sustain health even in a member of the same family, and food though abundant in quantity may be lacking in essential nutritional elements. An investigation under the direction of the chief medical adviser of the Department into this whole problem of nutrition is being arranged in conjunction with the Medical Research Council.
As regards housing conditions, I have instituted an inquiry which the county and superintendent medical officers of health have carried out with great zeal to determine the extent of overcrowding amongst those persons who are known to suffer from the disease. An analysis of the results obtained as a result of this inquiry is being carried out, and I shall have to consider every possible means by which segregation within the home can be provided for those persons who have undergone institutional treatment, or have returned to their homes and are being looked after by the local tuberculosis service. In this connection I would ask the House to advert to the great improvement in housing conditions since the passing of the 1932 Housing Act.
In recent years active interest has been aroused in the spread of the disease, and as a result representations on the subject have been made to me by several bodies. The tuberculosis sub-committee appointed by the Council of the Royal Irish Academy of Medicine made a special report in 1942 and submitted a scheme to provide for the detection, treatment, cure and prevention of pulmonary tuberculosis. This scheme envisaged the provision of a central tuberculosis dispensary, a centre or centres for differential diagnosis and early treatment, well-equipped modern sanatoria, and efficient after-care in the patient's home to be the essential elements around which a service ought to be built.
In their second general report the Hospitals Commission dealt specially with tuberculosis. They advanced many attractive suggestions, and in particular recommended the establishment of four sanatoria for the treatment of early cases. They suggested that regional sanatoria be situated in Dublin, Cork, and in the West, with the retention of Peamount as a centre for the eastern counties. On the broad question of additional accommodation for pulmonary cases the Commission were of opinion that the provision of outdoor pavilions on the grounds of existing hospitals is only temporising with the bed shortage position and that the real solution is to concentrate on the earliest possible realisation of the projected sanatoria.
In December, 1943, the Anti-Tuberculosis Section of the Irish Red Cross presented to me the report of their survey committee which had been considering the outlines of a long-term tuberculosis project. As a basis for discussion they adopted two principles. (1) That the standard set up by the National Tuberculosis Association of the U.S.A. of two beds per death should be adopted in Ireland. (2) That the patients should not be classified as early, moderate, and advanced, with a view to the hospitalisation of these three classes of patients in separate self-contained institutions; and that all types of pulmonary tuberculosis should be treated in the same institution with separate accommodation within this institution for sputum positive and sputum negative cases. The society also favoured the establishment of regional sanatoria, and they suggested that it was essential to reduce the number of fully-equipped institutions to a minimum, and advised that not more than five such institutions should be provided to meet total needs.
I take this opportunity of acknowledging the valuable and wholehearted assistance which I have received from the Anti-Tuberculosis Section of the Irish Red Cross Society, and from the other agencies and private persons whom I have not mentioned, but who from time to time have offered useful suggestions, and I assure the House that I have given long and serious consideration to the various proposals submitted to me.
I am convinced that any scheme which might be expected to deal successfully with the threat of tuberculosis to our community must contain the following elements. Firstly, effective and up-to-date methods of detecting the disease, not alone in an early stage in those who contract it, but in unsuspected persons who may be sources of infection. Secondly, satisfactory segregation of those persons with pulmonary tuberculosis who are sputum positive and hence liable to spread the disease. Thirdly, the ability to provide the most efficient and advanced treatment in institutions specially designed and equipped for the purpose. Fourthly, special protection, including medical observation and advice, nutritional and other assistance measures as required, for those groups who, though not at the time suffering from tuberculosis, are most especially in danger, by reason of their exposure to infection; and fifthly, the development of an adequate and comprehensive welfare service which will enable those people who are so unfortunate as to be stricken by this disease to sustain themselves and their families in reasonable comfort, so that by the aid of the community of which they are members they may be enabled to undergo treatment. Lastly, a vigorous campaign of propaganda and education which will counter foolish prejudices in the minds of our people which militate against the efforts of those who strive to combat the evil, and which will also, by the inculcation of a healthy way of life, strengthen and guard our people against this scourge.
I would point out that one of our greatest difficulties arises from the fact that, in the great majority of cases patients first coming to our notice are already in an advanced stage. The insidious onset of the disease is, no doubt, to some extent responsible for this state of affairs. The individual affected does not notice anything out of the ordinary at first, so that generally he is far advanced in the disease before medical advice is sought.
Another factor that seriously hampers our efforts is the widespread belief that tuberculosis is hereditary. It is evident that a lot more educational work will have to be done before there is a general acceptance of the fact that everyone is born free from this disease; that over 70 per cent. of us contract it in some form; and that, so far from tuberculosis being incurable, 90 per cent. of the people who contract it get well without any special treatment. Thanks mainly to the educational efforts of the Anti-Tuberculosis Section of the Irish Red Cross Society a more enlightened outlook is rapidly becoming evident. There is great scope for further fruitful effort in this direction and I have no doubt the effort will be made. The vital importance of this matter will be understood when it is realised that an inquiry, which I have caused to be made throughout Ireland, has shown that more than 60 per cent. from one end of this country to another, of the cases which were referred to the Tuberculosis Medical Service, were in an advanced condition.
The isolation of known open cases is, undoubtedly, an object to be achieved as a matter of great urgency. It is the most direct method we have for reducing the prevalence of tubercle bacilli in our surroundings. It is the measure which, applied to the smallest number of persons, gives the maximum of protection to the community. Further, it is in the household associates of the open case that the search for additional cases should begin, with almost the certainty of finding persons affected by the disease who were hitherto unsuspected.
As regards the point that a service should provide the most efficient and advanced treatment in institutions which would be of the latest and best design, and furnished with the most up-to-date equipment, I would simply state that the whole purpose of the Bill under consideration is to achieve this end.
The question of after-care, with which I associate propaganda and education, is one meriting serious consideration. In this country there is no doubt that our way of life and many of our habits are particularly conducive to the spread of tuberculosis. It is also true that there are many prejudices which are quite natural and understandable to one who, like myself, claims to have a close knowledge of our people. Therefore, any service which does not include wide provision to combat these two features would be deficient and ineffective, but as I have already indicated, this particular field provides ample scope for such influential and widespread organisations as the Irish Red Cross Society acting in close co-operation with our tuberculosis services under the guidance of the responsible Department of State.
I would point out that the Legislature has vested in the central authority the duty of supervising the measures taken by local authorities under the powers conferred on these authorities under the Tuberculosis Acts, 1908 and 1913. My Department is in constant communication with these authorities in regard to the steps to be taken for the prevention of the spread of tuberculosis, and for the treatment of tuberculous patients. It is not considered necessary to establish another and a new governing body.
With regard to the co-ordination and intensification of the efforts of the various bodies engaged in combating the disease, as suggested by the motion, let me first classify their nature. They are the local authorities through their approved tuberculosis schemes, voluntary organisations operating tuberculosis institutions, voluntary organisations operating institutions not wholly devoted to the treatment of tuberculosis but in which beds are specially reserved for tuberculous patients, district nursing associations and the Anti-Tuberculosis Section of the Irish Red Cross Society.
The efforts of these bodies are, in fact, co-ordinated to a high degree through my Department. It must be conceded that they deal with features of the problem with which, in some respects, it is not possible for the State or any statutory body acting alone to cope satisfactorily. It has always been my policy and the policy of my Department to assist in whatever way lay in our power the various bodies now engaged in combating the disease. We have endeavoured to integrate them into our national service and to utilise their abilities to the greatest possible degree. I can, in fact, say that there is not a bed in a voluntary institution that is not constantly occupied, nor is there any member of the personnel of any voluntary organisation in this country who is not afforded the fullest scope for his activity. I have aided by subsidy, by the granting of facilities, by the smoothing of difficulties, by expert advice and by granting official approval any reputable voluntary organisation who would help me in the fight against tuberculosis. I can, therefore, say that every effort to achieve co-ordination has been made and that there is no waste of effort of which I am aware.
As I have indicated, the principal weapon in the fight against tuberculosis is the approved tuberculosis scheme operated by each local authority. The medical superintendent officer of health or the county medical officer of health, as the case may be, is the authority co-ordinating the various elements of the scheme in each area. He has under his direction one or more assistant county medical officers of health with special experience of tuberculosis work, or whole-time tuberculosis officers. These officers carry out clinical tuberculosis work under the scheme, and in fact most of the county medical officers of health themselves undertake duties in this regard. As anyone can understand, the quality, efficiency, and activity of any public health scheme depend primarily upon the personnel. In order to obtain the best possible officers for the service I have consistently over a number of years insisted on an ever-rising standard of qualification. Through the Local Appointments Commission I have been enabled to obtain better and better trained men. I have also within recent months instituted a system of refresher courses for county and assistant county medical officers of health so that the staffs of the local authority tuberculosis services will be brought to the highest level of knowledge of the most modern methods in use for diagnosis and treatment of the disease. These courses are continuing, and will continue, until I am satisfied that all have benefited. In accordance with developments, either in medical practice or in relation to the schemes, further opportunities for post-graduate work will continually be available. I might add that I am also arranging for post-graduate tours abroad to enable officers to profit by the experience and development of tuberculosis work in other countries. Facilities for private study leave and opportunities for research have been and are availed of by medical officers.
I would also like to refer briefly to the nursing service of the schemes. In each area there is available one or more public health nurses devoting part of their time to tuberculosis work. In the county borough areas, and in some of the county areas, whole-time tuberculosis nurses are employed. In all areas where it has been found useful to do so, the services of nurses employed by local district nursing associations have been utilised for duties under tuberculosis schemes. In passing, I may say that subsidies ranging from £15 to £40 a year are paid to the associations in respect of the services of each nurse. It is my intention to develop further the domiciliary nursing services available in each area. I am considering how best this can be achieved, and I can promise that with the general development of the service there will be a simultaneous improvement in the domiciliary nursing of tuberculosis.
I come now to the tuberculosis centre. The pivot upon which the whole anti-tuberculosis structure is based is the dispensary. In each area there has been established a central tuberculosis dispensary, usually situated at the point of largest population, with branches at places in the county or area offering the greatest convenience for the attendance of patients. It is my intention to develop such centres, both central and branch, to a much greater extent. They will in future come to be the principal diagnostic centres for the disease. They will be equipped so that each centre will be able to provide, as a minimum service, what can only be regarded as the fullest and most comprehensive investigation of the disease. Further, treatment of a specialised nature, such as pneumo-thorax work, hitherto not everywhere available, will be universally provided. In this respect my Department is seeking to secure supplies of apparatus, both X-ray and technical, but reasonable people will appreciate the special difficulties of the present period, and those of them who are able to rise above political considerations will be understanding and helpful.
The intensification of a case-finding programme based upon the efforts of local medical officers, nurses, medical practitioners, voluntary agencies, and local authorities is one of the most important features of my proposed reorganisation of the tuberculosis service. I have inquired recently from the officers of the tuberculosis service with regard to the matter of tuberculin testing. I find that many of them have schemes already in operation for the detection of cases by this method. Many others are actually organising such schemes. In order to enable us to arrive at a common understanding of the results to be obtained from these schemes, my Department, under the direction of Dr. Deeny, our distinguished chief medical adviser, has instituted a research into the relative values of the various forms of the tuberculin tests. This work is at the moment being carried out actively. A great development in the search for the disease amongst contacts is projected. The system of record-keeping is being further examined with a view to the organisation of a better means of approach to the aspect of past relationships to present cases.
On the subject of mass radiography, I may say that the apparatus for this purpose has been ordered and the moment it arrives we will be ready to develop this further method of attack on the tuberculosis problem. Each tuberculosis officer throughout the country is conscious, and has been made more conscious, of the necessity for the detection, not alone of the early case, which will be most likely to yield to treatment, but of the unsuspected and unsuspecting sources of infection. During recent years it has become more and more apparent, and it is now generally recognised, that the diagnosis of the early case of tuberculosis can only be effectively and accurately carried out by means of the X-ray. As a medical man myself, I must admit that the stethoscope is no longer sufficient, nor can it detect the first signs of the disease at a stage sufficiently early. Therefore, I am endeavouring by every means in my power to provide further X-ray apparatus; to increase the facilities for radiological examination; and in spite of war conditions, which make the supply of apparatus so difficult, to overcome any hindrance to development of this diagnostic aid.
As regards treatment, a fatalistic attitude towards the disease has been adopted in some parts of the country. The outlook has been that once a person is stricken with consumption nothing can be done for him. I wish to enlist the aid of all intelligent people to correct this frame of mind. There is no case so far advanced that it will not benefit from present-day treatment, and I can definitely state that it is my policy that every case, no matter in what stage of the disease, will be given the best possible treatment for his condition. If it is that symptomatic treatment alone will benefit, then symptomatic treatment will be given. It might appear to some that such a statement is unnecessary, and that under present conditions there is no person who does not receive treatment, but I assure the House, as I would the people as a whole, more particularly those who are so unfortunate as to suffer from tuberculosis, that the most advanced treatment will be available to them as quickly as human effort can overcome the obstacles.
During the course of my speech I have outlined the essentials for an anti-tuberculosis service, and I have discussed its relationship with voluntary bodies, especially with regard to their particular ability to carry out in the attack on tuberculosis useful functions which lie in their sphere. I described the necessity for an adequate educational campaign to overcome the natural prejudice of the people, and to eliminate habits of life likely to bring about the development of tuberculosis in young people.
I have adverted to the problem of the patient who returns to his home surroundings after a period of treatment in an institution, and the even greater problem of the distress occasioned in the home when the bread-winner contracts the disease, and I have indicated how voluntary organisations can be mobilised for the fight under a common leadership. Accordingly, I propose to ask the Irish Red Cross Society particularly to concern itself with education and propaganda, and with after-care and rehabilitation. In the field of education they have already been particularly active, and, as a result of the intensification of their efforts, I look forward to the disappearance of obstacles that stand between us and real achievement.
The first positive measure which is needed is the provision of additional bed accommodation. In present conditions a programme for its provision to the extent that is immediately required will not be realised without a very radical change in existing procedure. After careful study and examination of the problem in all its aspects it is decided to set up a special organisation within my Department to deal with the provision and equipment of sanatoria on a regional basis. While the Bill proposes to confer such power on the Minister for Local Government and Public Health, it does not follow that the powers of local bodies in this respect are being removed, or that their responsibilities for the provision of measures to combat tuberculosis are being in any way lessened. There is no question of superseding local authorities in the administration of schemes for the treatment of tuberculosis. On the contrary, the main object is to provide these bodies with the institutions which are required to enable them, in partnership with the State, to intensify their efforts in the eradication of the disease.
Modern tuberculosis treatment requires team-work; that is, close co-operation between those who diagnose the disease and those who treat it. This means collaboration between surgeons, physicians, radiologists and pathologists, all of whom must have at their disposal the most modern facilities and equipment. In addition, the basis of all successful tuberculosis prevention is the rapid removal of the sputum positive or infectious case from his normal surroundings. The only form of hospital institution in which all these requirements can be fulfilled is a modern sanatorium, which is really a combination of hospital and sanatorium. It may, therefore, be assumed that sanatoria of this type are essential for the treatment of pulmonary tuberculosis.
The number of beds to be provided has been carefully considered and it has been decided that we will require at least 4,300 beds. Consequently, in addition to the number at present available, approximately 2,100 extra beds will be required at once. It has been suggested that as many as 7,000 beds are necessary, but the medical advisers of my Department are satisfied that 4,300 beds should be the immediate target, with the possibility of providing more if necessary.
As I have already mentioned, the Irish Red Cross Society recommended the provision of regional sanatoria and it is now intended to provide three such institutions as follows:—
(1) An institution containing 1,000 beds to serve the needs of Dublin City and County. (2) An institution containing 680 beds, to be located in Cork, to serve the Counties of Cork, Limerick, Waterford, Clare, Kerry and Tipperary (N.R.) and (S.R.), together with County Boroughs of Cork, Limerick and Waterford. (3) An institution containing 400 beds, to be located in Galway, and to serve the Counties of Galway, Mayo, Roscommon, Sligo, Donegal and Leitrim.
The eastern region, consisting of Counties Carlow, Cavan, Kildare, Kilkenny, Laoighis, Longford, Louth, Meath, Monaghan, Offaly, Westmeath, Wexford and Wicklow, will be served by the institutions at Peamount and Newcastle Sanatoria and Our Lady of Lourdes Hospital, Dun Laoghaire.
In the new regional sanatoria it is not intended to design pavilions of an elaborate kind.
The original idea underlying the first establishment of sanatoria was based on the belief that fresh air, rest and good food alone were all that were necessary to cure tuberculosis. Within the last few years great changes have taken place in the views of the medical profession on the treatment of tuberculosis. As a result of modern advances and discoveries in medicine and surgery, more active treatment of a specialist and surgical nature can be applied with much better results than were formerly obtained by rest and fresh air alone. Consequently sanatoria have changed from being merely homes of rest, to active treatment centres where all forms of the disease are combated with vigour.
If one accepts this approach to the treatment of tuberculosis the advantages of larger regional sanatoria become obvious. For instance, it is not economic to provide the full range of service; or the same high standard of efficiency in medical and nursing services and equipment, in many small local institutions scattered throughout the country, and serving only local needs. Full efficiency can only be achieved and maintained in large institutions.
In relation to the hospitalisation of tuberculosis the advanced case has always presented a serious problem. The disease is always most infectious at this stage, and therefore it is imperative that such cases must be put under institutional care. There are few cases so far advanced that they will not receive benefit from active treatment. With the present accommodation available—that is, mainly in small local institutions — the segregation of such persons inevitably leads to these places being regarded as unsuitable and unfavourable for the treatment of early cases. They have came to bear in the public mind in some instances an unhealthy reputation. In the new institutions, which I have in mind, active treatment of a most advanced nature will be provided for all cases by the best available medical personnel. By reason of the flexible nature of this planning and organisation, accommodation in separate units can be provided for cases in all stages of the disease.
It is clear therefore that the advantages of regional sanatoria, of the latest type, are overwhelming as compared with local institutions.
The provision of regional sanatoria of the size contemplated presents a difficult problem under prevailing conditions, and, it is considered, would be hardly practicable of solution unless there were available the services of a complete team of advisers, and technicians, whose work could be co-ordinated under one direction, and preferably in one organisation.
It has long been established abroad, and is being increasingly recognised here, that the successful carrying out of any large building project speedily, satisfactorily, and economically, depends essentially on the proper direction and co-ordination of the work, from the very earliest planning stage to the actual erection, equipment, and completion of the building. The successful provision of modern buildings, and particularly hospitals with their highly technical equipment, depend not only on the architect, but also on the various branches of engineering, such as civil, structural and mechanical. Quick success will not be obtained even in the planning (quite apart from the carrying out of the project), and direction of the building and subcontractors, unless the architect and engineers work together in close collaboration as a team. Moreover, it is essential that they have available to them throughout the whole course of the work, but particularly in the early planning stages, administrative and medical advisers for consultation in connection with patients' accommodation, staffing, services and equipment.
The local authorities in the three centres where it is intended to provide the sanatoria would not themselves have that complete team which it is considered would be necessary for the satisfactory carrying out of the planning, erection, and equipment, of the projected buildings and their services. Moreover, the local authority's proposals would require to be examined at the various stages of planning and as the work proceeded. Difficulties would probably also arise during the construction period owing to the possible necessity of making decisions on the spot as to substitution of materials, which may have been originally planned for, but which may not be readily obtainable when the actual work is in progress. It would seem, therefore, that no matter how well the local authorities may be able to co-ordinate the work of their own technical advisers and those of private technical advisers whom they may engage, and even with the closest possible liaison with the Department, it would not be practicable to obtain the same co-ordination and speed of work that would be possible with a complete team and organisation working together under a single direction and under the one roof.
It is proposed, therefore, that the planning of the buildings, their services, and supervision of the work during the construction period, will be carried out under the direction of the chief engineering adviser of the Department and his staff, who will have the Department's administrative and medical advisers available to them for consultation.
It is considered that this proposal will achieve that co-ordination and direction of effort which it is desirable to have, in order to provide at as early a date as possible the accommodation required. I am not going now to set down in black and white what our aims are, but I am hopeful that within a year and a half some of the buildings proposed to be erected will be in full use. The institutions which will be built will be of a very much simpler character than the hospitals already built out of Hospitals Trust funds. At the same time they will provide all the essentials for the modern treatment and comfort of the patients who will be accommodated in them. Owing to the difficulty of obtaining materials —particularly those required for the engineering services — there will of necessity be many departures from what may be regarded as standard practice, and while the institutions will be designed so as to have all the normal amenities, should it happen that any of these amenities cannot be included during the building period owing to lack of materials, they will subsequently be provided according as the necessary materials become available.
The cost of establishing the sanatoria which provisionally is estimated at approximately £1,500,000, will be borne by the Hospitals Trust Fund. When the establishment of the sanatoria has been completed they will be transferred to and will vest in the local authority, and the Minister may call upon the local authorities concerned to repay to the Hospitals Trust Board such amount as he considers reasonable, but not more than one-third of the total cost.
As to the other main provisions of the Bill, Section 5 empowers the Minister to direct the Hospitals Trust Board to make payments out of the Hospitals Trust Fund for the purpose of defraying the expenses of the establishment and equipment of a sanatorium, and Section 6 authorises the transfer to a county or county borough council or councils of a sanatorium when established and equipped. The local authority or authorities to which the sanatorium is transferred will be responsible for the upkeep and management of the sanatorium.
Part III of the Bill sets out the procedure to be followed where land is to be acquired compulsorily. The various steps to be taken, firstly, by preliminary order, and, secondly, by vesting order, are defined in Sections 9 and 10. The remaining sections are concerned with procedure in relation to registration, compensation and deducing of title.
I would ask the House to face up to this problem in a realistic way. It would be foolish to ignore the fact that apart from the capital expenditure envisaged in the provision of the proposed sanatoria, the development of the plans I have outlined will involve a very substantial increase in the financial provisions to be made by the local authorities and by the State. It would be safe to predict an increase in the cost of our tuberculosis services of £300,000 per annum within the next five years. In this debate I may be encouraged by the House to spend lavishly, but if the Deputies who so advise me are as earnest in this matter as I believe they are, I would ask them to exercise their full influence, through the Press and otherwise, to create a public opinion that will reflect intelligent understanding. If rising rates and taxes have to be criticised for legitimate political ends, it is not too much to ask in present circumstances that expenditure on public health services be excluded from the calculations. If we stand together and work in harmony we can defeat this menace. I feel confident that a 50 per cent. reduction on the 1942 death rate from tuberculosis could be achieved within a period of ten years. There is no mystery about the manner of spread of this disease. It is an infectious disease, and the day that we succeed in eliminating the sources of infection we shall have solved what is called the tuberculosis problem. Within the framework of the plans I have outlined success can be achieved. I fully realise the special difficulties of the present times. I know I am undertaking a formidable task. I can only assure the House that I mean to succeed, if success can be achieved under present conditions, and I ask the House for the powers sought in this Bill, because I believe that the provision of institutional accommodation is a most urgent pre-requisite to a rational attack on the menace of tuberculosis.
