The reception which this Bill has received is a tribute to the value of the consideration which the previous Bill got here. The fact that there were so many amendments on the Order Paper for consideration when the last Bill was withdrawn amply demonstrates the useful nature of the discussions which took place here and the advantages which can be derived from discussing, even at length, a measure of this kind. The Minister's introductory speech augurs well for the consideration of this measure and, I may say, augurs well for the schemes that are envisaged in it. Therefore I should like to deal with certain aspects of this Bill rather than anything that preceded it either here or elsewhere.
The most important aspect of the Bill and of the various schemes under it, in so far as it affects people other than the medical profession or patients, will be the cost. So far the Minister has not given any indication of the cost of the particular services which are envisaged in the Bill. I appreciate that it would be difficult at this stage to give anything other than a rough estimate of the total cost but I did hope that the Minister would indicate to the House the personnel and the cost of the particular personnel required for schemes which may be expected to be put into operation in the near future. Many Deputies in considering the Bill have come to the rather rapid conclusion that immediately on its enactment we shall have entirely different health services available. I think anyone who has come to that conclusion takes an optimistic view of the services provided in the Bill or the services which may be provided, but which may not be fully organised for years to come. A few years ago legislation was passed here dealing with regional sanatoria but I think up to the present any work carried out in these sanatoria has been of a very limited character. Some of them have not even been started. I only hope that when this Bill is passed, rapid development will take place on the various schemes.
I should like the Minister to give the House an indication in his reply of the extent to which facilities will be available, assuming that this measure is brought into operation by the end of the year. So far as my information goes, the present supply of medical men in the country—certainly the numbers engaged in local health services or as county medical officers— will be insufficient to cope with the increased services provided under this Bill. I think that some consultation should take place between the Department and these medical practitioners, in regard to the increased work which must fall on them when the new services are in operation. As the Minister is aware the pay and allowances of dispensary doctors are at present on the meagre side and are barely sufficient to enable them to run their cars and furnish them with the smallest amount of necessary equipment. If these men are to operate more extensive schemes, such as mother and child welfare and school medical inspection, they will be called upon to shoulder much heavier responsibilities than they have had to bear in the past. Unless these doctors are suitably provided for by way of increased salaries, it will scarcely be possible to get applicants for these positions as they fall vacant in future.
I think that an indication should be given by the Minister to the profession in general that he has had this matter under consideration, that any views which they may put forward in connection with it will be considered, that a system of consultation will be provided under which the medical officers can make any representations they wish or, alternatively, that some scheme of compensation will be made available for dispensary doctors and other medical officers who suffer as a result of this Bill. So far as I can see, there are two likely results. One is that existing practitioners may find that when these services are instituted, patients they formerly treated will no longer come to them as they will find that their needs may be met by the new services which may be made available. In that way many doctors will lose a considerable portion of their practice. On the other hand, private practitioners who are available at the moment for child welfare and various other services for which this Bill will now cater, will find that their practices have decreased. I think that the Minister must either provide some compensation for these people or make the terms of appointment for new positions so attractive that such doctors will be attracted to them, so that not merely will it not be necessary to compensate any existing practitioners but that they will be able to assist in carrying on the new services under conditions which will take due cognisance of the fact that they had in the past depended on private practice which to a large extent is now being destroyed by the schemes made available under this Bill.
I should like the Minister to indicate what are his proposals concerning the isolation of certain patients. The particular patients I have in mind are those suffering from tuberculosis. As I understand the matter, many of the general hospitals or the voluntary hospitals dealt with all forms of disease but had separate wings or apartments for tuberculosis and other infectious cases. Proper segregation was provided and precautions were taken to ensure that no person suffering from an infectious disease came in contact in any way with other patients. At the same time, in teaching hospitals students were able to carry out a clinical examination of patients in the different stages of particular diseases. They were able to see patients before they were sent to a particular wing or before they were segregated. I understand that it is proposed in this Bill to segregate all cases of infectious disease in separate hospitals. While considerable support may be forthcoming for that particular method of treatment, from the point of view of the teaching hospitals I understand it is undesirable that students should have to be brought into separate hospitals where they know, before they enter these hospitals, that the patients are suffering from a particular disease. If some patients of that type were housed in a general hospital where other patients are also treated, the students could more readily appreciate the difficulties associated with diagnosis. I would suggest to the Minister that permission should be afforded the teaching hospitals to continue the existing system where they think it desirable provided they satisfy the Minister and his medical officers that adequate precautions are being taken to prevent the infection spreading.
The Bill provides ample machinery for school medical inspection and sufficient machinery for informing the school manager that inspection is to be carried out but no provision is made in the Bill for informing parents. There is, of course, the fact that the manager may inform the children and, in that way, the children may inform their parents. The Minister appreciates, as the House must also appreciate, that very often children to not tell their parents, and, if they do tell them, their parents do not heed them. Frequently, although not as frequently now as in the past, parents object to a general medical inspection, and some provision should be inserted with regard to giving adequate notice to parents and with regard to allowing parents who are prepared to have their children inspected or treated separately, the option of doing so, with the proviso that they produce satisfactory evidence that the child has been or will be inspected at intervals as frequent as the normal routine medical inspection in the schools.
The most welcome feature of the Bill is the provision in Section 39 for a maintenance allowance to a patient and the dependents of a patient, in the event of that patient being unable, because of infectious disease, to provide for his or her family. The House is aware that in the past one of the greatest worries of tuberculosis sufferers has been the fact that, while they are ill, their families or dependents were unable to provide adequately for themselves, and in many cases a patient's recovery has been delayed because of worry and anxiety in that connection. In Section 39, provision is being made whereby a local authority can pay either a particular sum, a salary, to a patient or defray the cost of the employment of another person who will carry on the patient's work while he is sick.
I do not know what consideration the Minister has given to the rate of benefits which will be allowed. As I understand from a body which has had close association with tuberculosis sufferers, one of the worries was the fact that up to this no indication was given that there would be a general level standard throughout the country, that the standard might be set by each local authority, and that each local authority would decide for itself the particular rate of benefit. I think it is advisable that a uniform rate of benefit should be payable, with possible provision for the difference in the cost of living in urban and rural areas. Apart from that, there is no case for having one rate payable by one local authority and another rate by a different local authority.
I know that the Minister has altered the original Bill to provide that half the cost may be borne by the State. That is desirable, because under the schemes which will be put into operation, it is obvious that the cost to the local authorities will be quite considerable. I do not know whether the Minister can give any indication on the basis of the number of patients at present suffering from tuberculosis, but in Sweden, for the first six months, the patient suffering from an infectious disease is allowed two-thirds of his salary and, after that, half his salary while incapacitated. I do not know whether these allowances were arrived at after consideration of the cost of living there, but that scheme has been operated in Sweden successfully for quite a number of years, and the Minister might well consider the advisability of adopting a similar scheme or a similar standard here.
One matter on which the Minister dwelt briefly is the necessity for a very large increase in the number of nurses available. I do not think the Minister has any idea as to how sufficient nurses can be provided if this Bill is operated fully and all the schemes envisaged put into operation. Last year certain discussions took place between nursing associations and the Minister's Department. Some of these associations were very perturbed by the possibility that, once the scheme was put into operation, the voluntary nurses or the nursing associations which receive small State grants and which depend mainly on voluntary contributions might find themselves in difficulties. The Minister will realise that, for many years to come, there will be work for these voluntary nursing associations and the Minister should reassure the members of these associations, and in particular the nurses who work under them, that not merely will they be required, but that every assistance will be given to provide them with the necessary equipment and with sufficient salaries to enable them to continue their work.
I refer in particular to the Jubilee Nursing Association. That association was founded many years ago, and, in the western areas, in Donegal and some of the other congested districts, has done very valuable work. There are at present about 260 nurses working. Some of these are members of the Queen's Institute of District Nursing and others of the Jubilee Nursing Association. These titles may at present seem rather out of date, but nevertheless the nurses give the service, and I think their services are appreciated by the people of these districts. Every effort should be made to facilitate these associations in future, and not merely should they be facilitated, but there should be the fullest co-operation between them and the Department. If co-operation can be secured between these associations and the Department, I feel that not only will the future of the nursing associations be assured but the working of the proposed schemes may well be simplified, and the difficulties in many districts of securing nurses lessened by taking into consideration the existing services and, if necessary, extending them, or working these existing services into the new services envisaged in the Bill.
With regard to institutions which may be taken over or set up by local authorities after a local inquiry, the Minister referred to the fact that a local authority could set up an institution, and, on his direction, must set up an institution after the holding of a local inquiry. Many of these old institutions, set up under former régimes in entirely different circumstances from those which exist at present, have far outlived their usefulness. Many of them have been modified, extended and improved, but nearly all have attaching to them the stigma which attached to the old workhouse, and I suggest that every effort should be made to provide new buildings. Some Deputies express surprise that an institution like St. Kevin's should not be acceptable to many people, but anyone with any experience of the old St. Kevin's Institution, with its severe drab buildings and its historical background, cannot fail to realise that there is good reason for that dislike. While rapid strides and great development have taken place there under the commissioner, nevertheless the institution is unsuited to present-day needs. The buildings are depressing and do not lend themselves to easy adaptation and in general the institution has the flavour of the institutions so well described by Dickens. I suggest to the Minister that no effort should be spared to urge on local authorities the necessity for providing modern, up-to-date institutions. It is true to say that some of these institutions can be adapted, at any rate for particular patients or particular types of patients, but, in general, the gathering together of acute and chronic cases, which has been the system at St. Kevin's in the past, is objectionable. Anybody with experience of it must look forward to the day when those patients will be segregated either by providing one institution for acute and another for chronic cases or by providing an entirely new institution.
I should like the Minister to give the House some information as to the personnel of the health council. As I understand, a temporary council is operating at present. Will the Minister continue that council on a permanent basis or will he provide branch councils or an entirely new council? Can the Minister say what arrangements are contemplated for the calling together of members of the council? How frequently will the council meet? Will the calling of it depend on the Minister and will it just consider matters referred to it by the Minister? Or will the council exercise its own discretion so far as general matters of health are concerned and the number of occasions on which it will meet?
The provision concerning food and drink in Part V is welcome. In many cases that provision is, I think, necessary. Part VI, which deals with proprietary and standard medicines, is also welcome. Doctors consider that many of these medicines confer considerable benefit. Some of them are useless but some of them are effective in minor ailments—if only psychologically. The Minister should make regulations under the section providing that the ingredients of these medicines be shown on the container and that those ingredients be available to purchasers. It is desirable to have such a safeguard. Many of these medicines do give on the bottle particulars of the ingredients but many others do not. It should be compulsory on all proprietary medicine manufacturers to indicate to the public the nature and quality of the substance which they produce and sell.
The only other matter to which I should like to refer goes to the root of the public health services. Has the Minister carried out a nutritional survey? While Deputies praise the provision which is being made in the Bill for health services and the provision which was available in the past, I think that much of our trouble from tuberculosis is attributable to lack of proper nutrition. Many of our people are obliged to live to a standard lower than that which would afford them proper food, with the necessary health-building properties. If people are obliged to live to a standard beneath that on which they can properly maintain themselves, it is inevitable that a disease such as tuberculosis will occur. The Minister should, as a prerequisite to consideration of any schemes in the future, hold a nutritional survey and, on the strength of that survey, adopt certain standards. Unless that be done, we are bound to have recurring tuberculosis. While we may provide for that in Bills, we are failing in our first duty—to provide a sufficient standard for the wage-earning families of the country.