Committee on Finance. - Vote 67—Health. – Dáil Éireann (14th Dáil) – Wednesday, 4 Mar 1953

Committee on Finance. - Vote 67—Health.

Minister for Health (Dr. Ryan)

I move:—

That a supplementary sum not exceeding £580,000 be granted to defray the Charges which will come in course of payment during the year ending 31st day of March, 1953, for the Salaries and Expenses of the Office of the Minister for Health, and certain Services administered by that Office, including Grants to Local Authorities, Miscellaneous Grants and a Grant-in-Aid.

The need for this supplementary sum arises mainly from the fact that expenditure of local authorities on health services proved greater than they had anticipated.

Payments of the Exchequer contribution are made on the basis of returns and estimates furnished to my Department by the health authorities. Ninety-five per cent. of the estimated amount of the grant is paid in the year to which the expenditure relates, in two instalments, one at the end of June and the other at the end ofDecember. In the next following year, by which time local authorities have actual, but unaudited, figures of their expenditure, a further 4.5 per cent. of the grant is paid over and the remaining half of 1 per cent. is held over until audited figures are available.

The original Vote for the current year provided for grants amounting to £220,000 in respect of years prior to the current year and £4,960,000 in respect of the current year.

The figure of £220,000 has proved to be entirely inadequate and the latest information I have of the amount payable in respect of balance of grants for previous years is £777,000, so that a further £557,000 is needed in respect of these previous years. A large part of this sum (£200,000) is due to the fact that the cost of the turf cut by local authorities in 1951 under the Government sponsored turf scheme, which had been borne initially on a separate account in the books of each local authority, was transferred in full to the accounts of the services (including the health services) which will use the turf. The additional charges in respect of the health services appeared for the first time in financial statements furnished to my Department after the close of the financial year 1951-52. The remaining increase is due to general increases in expenditure under a number of heads, partly due to increased costs and partly to improved services.

The balance of the supplementary (£23,000) is in respect of expenditure of local authorities on health services in the current year in excess of the amount provided. The excess here is largely due to the fact that after the original Estimate was prepared, it was necessary to increase the capitation grant payable by local authorities to voluntary hospitals in respect of patients sent by them to such hospitals by £1 1s. per week. In addition, approximately half the cost of the temporary bonus of 9/- for men and 6/- for women authorised in December last has to be met from the Vote.

A deficiency of £11,000 in the appropriations sub-head will be met from savings on other sub-heads—Salaries (£5,000) and Publicity (£6,000).

Dr. Esmonde

So far as I could gather from the Minister's statement, the greater portion of this money is needed to meet the increased cost of fuel, principally turf supplied to hospitals. He also stated that some part of it is due to the provision of improved services. I should be glad if the Minister, when replying, would tell me what these improved services are. I take it that what he has in mind is the scheme whereby he is to grant to local bodies a sum of £600 towards the cost of each new dispensary provided. I do not know what the position is in other constituencies, but I certainly can say that in the constituency which I and the Minister represent—Wexford— improvement of the dispensaries is certainly not going ahead with the expedition that one would desire. I think that on two occasions I, and other Deputies, had to ask questions about Foulksmills dispensary. I am glad to say that the lease of it is out, and that we are going to have a new dispensary built there. I think it ought to be stated that, for the best part of two years, there has been no roof whatsoever on that dispensary which was a small house. The lighting was bad— at least before the roof fell off. Now that the roof is not there, there is plenty of light. It is no exaggeration to say that, on wet days, the doctor and the patients attending that dispensary were exposed to the elements. They had the rain pouring down on them. The drugs stored in it had long ceased to function due to the dampness of the place, and to the fact that they were covered with verdigris.

There is another dispensary at Broadway. I ask Deputies to picture it as a very old antiquated cottage with a thatched roof, and not a properly thatched roof at that. The thatch is rotten. The cottage is damp and old-fashioned, with small windows. Even on a bright sunny day, it would be dark inside. In fact, its condition is so bad that on wet days the local people have facilitated patients attending there by admitting them to their homes or business premises. Actually, in some cases, the doctor has used these houses to see his patients.

In citing these cases, I do not meanto throw mud at the Minister, or to do anything like that. I simply want to indicate the unhappy state of affairs that exists in the County Wexford so far as the dispensaries are concerned. I feel certain that conditions are much the same in other constituencies. It is time that we took cognisance of these facts. All of us desire an improvement in the health services. You cannot have that without first having material improvements carried out. The foundation of improved health services must be our dispensaries, and until they are of an up-to-date character there is no use in looking ahead for bigger things.

We have got one or two new dispensaries in the County Wexford. There is a nice one at Bridgetown. It was long overdue. The building which had previously served as a dispensary was what one would describe as a condemned house. It is essential that, in all our new dispensaries, we should have hot and cold water. That is an essential part of the work which should be pushed ahead quickly. Those who service our dispensaries—doctors and others—have had to endure too long the absence of hot and cold water in them. They should also have electric light. Its provision would not cost a lot.

We know that it costs approximately about £1,000 to build a labourer's cottage I think the Minister said the other night that there were 621 dispensaries in Ireland. I imagine it would cost something in the neighbourhood of £300,000 to replace those dispensaries which are in a bad condition. That, I suggest, would not be a large sum to spend in providing our people with dispensaries of an up-to-date character, and in good decent condition. It is true to say that, ultimately, it would lead to a big saving of money. If our dispensaries and our medical services are what they should be, then we are going to have a great improvement in the health of the people generally with, ultimately, a big reductions in expenditure.

I should like to direct the Minister's attention to the need there is for an ambulance service. It is absolutely essential in country districts to have agood, efficient, up-to-date service of that kind. Admittedly, there has been a good deal of improvement in that direction over the past few years. At the same time, I would like to say that there are some ambulances on the road which should not be in service. They are broken-down crocks. So far as North Wexford is concerned, I am glad to say that during the last year or so we have had an ambulance functioning there. But 12 months before that, we had no ambulance in the Gorey area, which has a population of from 15,000 to 16,000 people covering a very large rural area. We had to depend entirely on an ordinary car for the removal to hospital of the necessitous poor and of those entitled to the service of an ambulance. The only other ambulance at our disposal was a Red Cross ambulance which was not very satisfactory as it was not properly sprung and was most unsuitable for the purpose. I would ask the Minister to give his attention to that matter.

The Minister has done good work in initiating the scheme whereby £600 will be made available for the reconstruction of dispensaries. I would ask him to make sure that local authorities go ahead with the scheme. There has been evidence in Wexford of delay, and I am sure the same has existed everywhere else. I would ask the Minister to see that the good scheme he has initiated is put into effect.

There is a great shortage of nurses in this country. It is not that we have not plenty of vocations for the nursing service. We certainly have plenty of vocations and can produce very good nurses. As proof of the success of Irish nurses when they go to England, they can always command employment, not only in the public services there but in the better-class districts, in the better hostels where nurses await cases. They are extremely good at their job, considerate to the patients and well trained.

We have not a great number of nurses in this country. In rural Ireland we have no nurses at all. I would ask the Minister to indicate whether it is the intention of his Department as a whole to service dispensaries with nurses. That is a matter that seemsto me to be a long time overdue. There are a few Jubilee nurses here and there, paid by voluntary contribution and there are some nurses in the West of Ireland but, generaly speaking, there are practically no nurses in rural Ireland.

That brings me to midwives. I do not think we will ever have a decent service of midwives until they are paid a proper salary. For the information of Deputies, midwives start at a salary of between £100 and £120 a year, and rise by increments to £160 a year. Does any Deputy consider that a living wage for a midwife? A midwife has to have a certain standard of education. She has to go to Dublin, Cork or some other centre to train. That involves her in considerable expense. She is then appointed to a district. At one time there was a good deal of private practice in most districts, but private practice is gradually becoming a thing of the past. The paternal State is stepping in and taking over and stifling private enterpise. In some cases midwives have to live on this meagre salary. Does the Minister or his departmental officials think that a sufficient number of midwives will be got to live in the country and to go to the expense of training in order to earn that disgraceful salary? How can anybody live on £120 a year nowadays? In a great many cases the midwife is a stranger in the district to which she is appointed and has to pay for lodgings.

In reply to a parliamentary question that I asked the Minister the other day, he told me that midwives had not very much to do, that in fact some of them never get a case at all. That may be true, but the fact remains that their job is in a certain area; they have to live in that area; they have to live in that area and have to pay for their keep in that area. My point is that they cannot do it on the present salary. It is a matter that should be investigated by the Minister. The Minister should give midwives fair play. They should get a definite increase in salary. The only increase they have had was some sort of allowance for uniform in the last year or so.

Ante-natal clinics seem to me to be one of the most essential things in the matter of health. Ante-natal work asfar as the country districts go, outside the big centres, is non-existent. It should be the aim of the Minister and his Department to set up ante-natal clinics. They should be set up in all the provincial towns. There would be a great saving in health by that means. There would be less trouble at the time of parturition if the women were properly looked after and examined beforehand. The building of these clinics will certainly entail a certain amount of money but it will be money better spent than in building Store Street bus station or something to that effect. I would prefer to see it spent on clinics. The Minister can rest assured that he will not get any opposition from this side of the House if he proposes to build them.

When I was talking on a Health Estimate shortly after coming to this House I advised the Minister that there was a very fine clinic set up and built by voluntary contribution, through the generosity of a local lady, in the town of Arklow which seems to me to be ideal. There is a nurse in residence who examines cases there and ante-natal conditions in that are have improved considerably. The establishment of an ante-natal clinic in practically every town should be the earliest concern of the Minister and he should go straight away with it.

It is fair to say that relations in the health world, dealing with health matters in general over the past four or five years, have not been happy. Matters appertaining to health have been discussed a great deal in the public Press. There has been a good deal of exchange of letters and opinions, which is highly undesirable. A better atmosphere in health is most desirable. The purpose of the Department of Health is to give to the people a decent health service. It is not to spend their time scrapping with everybody else. This business has been going on for several years. There is one way of ending it and it is a simple way. The best way to give the people not only a Health Act but the best health conditions is for the Minister to appoint an advisory council. The Minister will say that he has an advisory council already.

I suggest that the Minister should appoint an advisory council that is notcontrolled or run by the Custom House. In the legal profession we are quite prepared, and I am sure the public are also prepared, to accept the advice of the Custom House on matters appertaining to health but the Custom House should not have the last word in everything. My feeling is that all important matters appertaining to health over the past years have emanted from the Custom House and from the officials in the Custom House.

Mr. McQuillan

I am in agreement with what Deputy Esmonde has said in regard to the condition of many of our dispensaries but the remarks in connection with dispensaries would be directed to better purpose to the responsible local authorities in view of the fact that money is now available to the various local authorities for the improvement of existing dispensaries and the erection of new ones. In my constituency at one period there was grave need for the improvement of dispensaries. I am glad to say that that work is going ahead at a reasonably rapid rate all over the county at the moment. Responsibility for dispensaries lies to a great extent with the local authorities and I think many of these bodies are not living up to their responsibility in that regard. I suggest that Deputy Esmonde make his views on this matter known forcibly and emphatically to the local authority of the county that he represents.

I am in complete agreement with Deputy Esmonde as regards the nursing profession. Nurses are anything but well paid apart from the increase in the cost of living at the present time. Their salaries are miserly. It is a miracle that we get any nurses at all to remain at home when one considers the better conditions and the more attractive terms on which they can secure work elsewhere. The Minister should take the advice of the House on the question of salaries in connection with the nursing profession. I am sure I am not the only Deputy who will speak on this matter or plead for improved conditions for our nurses. Even the Minister must admit that this is a matter needing attention. I merely want to remind him of the necessity for such improvement. As far as I am concerned he will have my assistance by way of vote here at any time that he comes in here with proposals for the improvement of conditions in that particular profession.

I am very interested in the fuel supplies of State institutions. I would like the Minister to let us know, in reply, whether local authority institutionsand hospitals utilise turf. I would like him to tell us whether there are local authority hospitals using coal or oil. If they are using such fuel I think it is a disgrace and I think they are setting a very bad example in giving preference to foreign fuel as against home-produced fuel.

Recently in Galway I discovered that in the new health institution there heating and cooking will be done by means of oil-burners. I have been told that oil-burners have been installed for that purpose. If that is true, I think there is something radically wrong in a system that allows such a thing to occur. I need not point out that the greater proportion of our fuel resources lies in the West of Ireland. Apart from the excellent quality of the turf available there the employment content is an important matter. The production of turf is of benefit to many homes in the West of Ireland. Surely we should be patriotic enough now to use native fuel in preference to imported fuel. I do not think there should be any necessity for me to impress on the Minister the importance of utilising our own fuel in our health institutions.

Apart from native fuel being a more economic proposition we have spent enormous sums in recent years in dollar currency on the importation of American coal. Last October we spent £590,000 on American coal. We should only import our minimum fuel requirements. I know that there are certain people who dislike turf. Many engineers in public institutions turn up their noses at the suggestion that turf should be used instead of coal or oil. They make all sorts of excuses for their attitude. They say turf is an inferior product and that it does not give the same economic return as coal or oil. That argument is altogether without foundation, because I have seen for myself that in certain industrial institutions turf has proved to be more economic than and infinitely superior to coal. If it is successful in one industrial concern, I see no reason why that success could not be extended to every institution in the country. It is the duty of the Government and the Minister to ensurethat native fuel is utilised in our institutions. That can be done by requesting these establishments to change their system of heating and cooking. I do not think it is too late yet with regard to the particular institution I have in mind, and I would like if the Minister, when he is concluding, would let us know the position if he has any information.

One of the things we would like to see in this country is a first-class health service. I think all Deputies in this House will agree that the main object of the Minister at the present time it to give improved health services generally, and his anxiety is to ensure that the services that will be given will be the best possible. I have no doubt that they will be planned, not to meet the wishes solely of the Irish Medical Association but with the main purpose in mind of meeting the needs of the people of Ireland, and the wishes and demands of the Medical Association will come only second to the needs of the people. I am sure the Minister is bearing that in mind in connection with this Supplementary Estimate and also in connection with other Estimates and so forth, that he has in view at the present time.

Again, with regard to the nursing profession, a certain amount of dissatisfaction exists among those in the probationer class. On various occasions Deputies in this House have raised grievances on behalf of the probationer groups in the various hospitals and, to my mind, it is time that a little bit of reorganisation took place in this particular matter. Those girls have reached the use of reason and they are out of the kindergarten class but the mentality still exists in many of our hospitals that those girls must, even in the few hours off duty, be in at 10.30 at night and the door is locked on them then. One would imagine these girls had entered a religious order or that they were novices rather than probationers.

An Ceann Comhairle

Is the Minister responsible for these regulations?

Mr. McQuillan

I suggest he is responsible for the conditions of probationers and nurses. I do not want towiden the scope of the debate in this connection, but I do suggest that the time has arrived when, apart altogether from increasing the salaries and allowances of the nursing profession, something should be done to improve conditions with regard to probationers. I am sure the Minister knows what I have in mind in connection with that.

Mr. Sweetman

Deputy Dr. Esmonde, when he was speaking, gave me an unpleaasnt jolt when he mentioned the Health Council. I completely forgot there was a meeting of that council this morning which I should have attended. To be quite honest, I am afraid it went out of my mind. I must convey my apologies to the Minister.

Dr. Ryan

If you were there you would realise that the Consultative Council is not controlled by the Custom House.

Mr. Sweetman

I am sorry I was not there to add to the anti-Custom House atmosphere that apparently was there from what the Minister says. What I want to say will be more strictly relevant to the Estimate. This Estimate arises because of the provisions of the Health (Financial Provisions) Act, 1947, and I want to put it to the Minister very strongly that it is time that the figures for the standard year, which I think was 1947/48, were fixed. County councils do not know where they are in regard to health. They do not know what health grants they will receive until the standard year is fixed. It is certainly our experience in Kildare that the figures for the standard year 1947/48 have not yet been agreed and finally audited. I can speak with positive assertion in respect of Kildare but I am also told that a similar position arises in respect of other councils with the result that it is still a matter very largely of guesswork in any council and local health authority in regard to framing their Estimate as to what will be the grant they will obtain.

When the Minister was answering questions to-day, in respect of one question, as far as I could hear him,he told us that the average rate raised for health services throughout the country was 1/2½. All I can tell the Minister is the demand which the county manager has given us for next year and which the Kildare County Council will be considering next Tuesday, shows the manager's demand for health services at 53.36d. which is 4/5. I would be very interested to know whether the very low figures in the estimates all over the country come to bring down our figure of that amount to the average which apparently prevails throughout the country, if I heard the Minister correctly at Question Time to-day. I do not want to be too dogmatic on that because I found it difficult to follow exactly the reply to the question. Therefore, if that was not what the Minister said at Question Time I hope he will correct it.

The position so far as I can see is that the expenditure by health authorities on health services is now getting to a pitch at which it is fast going to be beyond the realms of the ratepayers to bear, beyond their capacity for existing services without taking into account anything at all in respect of new services that may be introduced under the Health Bill or otherwise and in respect of which I do not think I would be in order in speaking on this Estimate.

On the basis of this Estimate which is brought in under the 1947 Health (Financial Provisions) Act the position is that we in Kildare are reaching 4/5 this coming year for health services alone and so far as we can estimate we are now double the standard year. We are in the position in Kildare that no matter what the members of the county council may wish the rates for health services will jump by leaps and bounds. That is the situation which I am quite sure is reflected equally in other counties and it is a situation that will create a very serious problem indeed for local authorities. Unless the Minister makes up his mind to soften the heart of the Minister for Finance—if indeed Deputy MacEntee, as Minister for Finance, has any heart —and comes to the assistance of health authorities, then the problem will be one that will be far beyond thecapacity of the local health authorities to bear.

I might add that I am also told that part of our problem in Kildare is in respect to delay in the payment of the health grant. I want to be quite fair when I say that I am not quite clear whether this delay is in the payment of ascertained grants or whether it is delay in the payment of the full grant because it has not been fully ascertained, due to the delay in auditing the standard year's accounts. I should like the Minister, if possible when he is replying, to tell the House how many health authorities are in the same position as Kildare in not having their full grants paid and what is the reason. Is it because they too have not got the standard year's accounts audited or has there been a retention of health grants normally payable to local authorities for some other reason? One of the problems that arises in Kildare is that we are estimating that in the coming year we shall receive substantially less by way of health grants than we thought we would receive, and that we are going to receive this year substantially less than our estimated figure.

When we were striking the rate this time last year, we made the best shot we could at the standard year to arrive at the 1952-53 grant, and it was solely as a result of the erroneous figures we had before us, whether due to juggling at the departmental end or at the county council end I do not know, that there is a fall shown in the receipts for that year. All that goes to show that health authorities will not see where they are until this time lag is made up, until more rigid rules are observed in regard to existing payments and unless, in regard to future legislation and future services, an effort is made to put the cost of additional services on the Exchequer rather than on the ratepayers.

I cannot see how we can possibly expect that the new services that are visualised will not mean an increase in cost of between 2/- and 3/- in the £ in the rates in our county. When you add that to the county manager's demand of 4/5 for health services forthis year, it is easy to visualise what the total rate demanded from the ratepayers will be. The situation is one that is causing the ratepayers considerable anxiety. It is a situation which it is in the power of the Minister to remedy. I hope that when he is replying to the debate on this Estimate or when he is introducing his main Estimate he will indicate that he intends to take steps to remedy that situation.

Mr. O'Donnell

I should like to join with Deputy McQuillan in appealing to the Minister to see that local authorities use turf in their institutions where it is possible to procure turf, particularly in the north-western, western and southern counties. The Minister in this Vote is seeking certain funds to recoup local authorities for money expended on turf in the year 1951. I am very anxious to know whether this expense was incurred by local authorities in procuring and burning turf in their institutions or whether the amount involved represents outlay incurred by them in cutting turf by direct labour. We, people who live in turf areas, are aware of the mess made by local authorities in the cutting of turf by direct labour. The cutting and winning of turf, particularly hand-won turf, is a specialised job, and I think that local contractors should be invited to tender for the supply of turf for these institutions. Local authorities would thereby save a considerable amount of money. I am also aware that during the emergency turf was cut in the County of Donegal by local authorities at the expense of the local ratepayer and the taxpayer which has never since been taken out of the bog. I would appeal to the Minister to insist on local authorities procuring hand-won turf from local contractors and not to allow them to become themselves producers and competitors with these local contractors.

I join with Deputy Dr. Esmonde in asking the Minister to do something for rural dispensaries. I was amazed to hear that in the Minister's own constituency dispensaries are in the condition described by Deputy Dr. Esmonde. That description sounded bad, but I wish the Minister couldvisit some of the dispensaries in West Donegal and see what they are like.

Mr. Hickey

And elsewhere.

Mr. O'Donnell

And elsewhere. The Minister may be surprised to learn that in certain dispensaries in County Donegal it has been found necessary to throw out milk powders as a result of dampness in the building in which they were stored. Actually more has been lost by the State and the ratepayers because of the destruction of medicine and milk powders than would defray necessary repairs to the buildings in which these commodities were stored. I would appeal to the Minister to see that local authorities do their duty in regard to dispensaries, that they should rebuild those which are beyond repair and carry out repairs where necessary to existing dispensaries.

Finally, I should like to refer to the matter of recoupment to local authorities for outlay incurred in the upkeep of patients in extern hospitals, hospitals not under the control of the local authority. If a local dispensary doctor wishes to have a patient transferred from County Donegal to one of the Dublin hospitals, by the time the means of the applicant are first of all investigated, the ambulance procured to provide transport and some wirepulling done to get a bed in some Dublin hospital, the patient is generally on the way to the graveyard. This is a matter in which, in my opinion, expense could be reduced considerably. In these days, when we are falling over the necks of Ministers in the Six Counties, I think some reciprocal arrangement could be made between our Minister and the Minister for Health in the Six Counties whereby patients from Donegal would receive an allocation of beds in hospitals in Londonderry —that is the official name for it in the Six County Government area, but I think Doire Cholm Cille will remain the name by which it will be known to us—or Belfast. A considerable amount would be saved in transport to Derry or Belfast and we, in turn, possibly could facilitate our opposite number in the Six Countiesby the provision of beds, say, in Monaghan, Dundalk or Dublin for some of the areas along that particular part of the Border.

I would appeal to the Minister to give earnest consideration to that. Remember that in some parts of Donegal we are actually 250 miles from Dublin. If the patient has to travel by ambulance after 9 o'clock at night it means an ambulance travelling a distance of 500 miles to bring a patient to Dublin and go back. This is some of the money which is being expended by the local authorities and which the Minister tried to recoup the local authority for under this vote. I am suggesting that he should ask the local authorities and his counterpart in the North to give serious consideration to this reciprocal arrangement and thereby cut down some of the expense incurred.

Mr. D. Costello

I have very little to say on this Estimate and I rise principally to add my voice to what has already been said in regard to the condition of the dispensaries throughout the country. Not only in the country places are the dispensaries in such a shocking bad state of disrepair but also in the City of Dublin. They are unsuitable for the work they have to do. The Minister himself has given figures which can only be described as appalling in view of the development that has been going on in this country in the health services for the last few years. He has now informed us that in a recent review of the dispensaries it was shown that out of 621 dispensaries 330 were unsuitable. It seems to me that the major part of the effort of the Department in future in regard to hospital reconstruction should be directed towards improving existing dispensaries and building new ones in order to have proper facilities for the people in need of them.

On the question of the improvement of hospital expenditure I should like to point out to the Ministers and the House that the recent most up-to-date figures which cannot, indeed, be very up-to-date, for hospital expenditure show that in the year ending 31st March, 1951, out of a sum of approximately £2,000,000 spent on hospitalreconstruction only £19,125 was spent on dispensary reconstruction. It seems to me that in the overall planning of the Minister's Department he should pay much more attention to the need for improving the dispensaries throughout the country and if necessary put lower down in his priority list the building of other types of hospitals or clinics.

In reference to the expenditure of this sum out of the Hospitals' Trust Funds, I would like to point out to the Minister and the House the dangerous state into which the finances of the Hospitals' Trust Fund have now got themselves. It seems to me that the Minister should endeavour to take an opportunity if not on this Estimate at any rate at a later stage to make some statement to the House as to what is the position in regard to future plans of the Hospitals' Trust Fund. I appreciate that this is not a matter which arises directly on this Supplementary Estimate but I do feel, however, that the expenditure of State funds on dispensaries does arise. Some of the figures are, indeed, very difficult to ascertain. It would appear that on the 31st December, 1947 there were £9.7 millions in the Hospitals' Trust Fund. On the 31st March, 1951, there would have been approximately £5.3 millions spent out of that fund on capital reconstruction. That has been going on at the rate of £2,000,000 a year and it would appear that the capital fund from which money can be spent on dispensaries reconstruction and hospital building out of the Hospitals' Trust Fund is very nearly exhausted. The current income may be sufficient to pay the deficits of the voluntary hospitals. It will not be sufficient in the future, probably at the end of this year, to pay for future reconstruction of a capital nature on dispensaries and hospitals.

That is a matter in respect of which the Ceann Comhairle has been lenient in allowing me to bring it up on this Estimate but I would say that the provision of adequate dispensaries, the provision of proper places for persons to wait and the provision of proper facilities such as running water whichare lacking in some dispensaries are matters which come up on this Estimate. They should be looked after by the Minister in the administration of his Department.

Dr. Browne

Most of the money is to be expended because of the financial provisions of the 1947 Act. There are some general considerations which, I think, will probably soon arise out of this expenditure. It has a certain amount of relevance to the point made by Deputy Declan Costello. The payments to be made under the financial provisions of the 1947 Act will tend to increase because of the fact that the Hospitals' Sweep Funds are almost completely expended or will be completely expended in a very short time. Therefore, the funds to maintain these hospitals in the future will have to come either from the Exchequer or from the rates.

I think now is the time when the Minister will have to give very careful consideration to the degree of autonomy which he is going to permit to these voluntary hospitals in the future if their demands on the Central Exchequer continue to grow as they must necessarily grow in the years to come.

The point in which I am particularly interested is one which I raised some years ago in relation to the Meath Hospital Bill. If we believe in the democratic control of institutions generally, we must insist on a certain amount of representation by local authorities or nominees of the Minister in the control of finances allocated to the voluntary hospitals by this House. An important principle is involved, in that moneys voted by the Houses should be expended only under the supervision of nominees of the House or of the Minister or local authorities.

The voluntary hospitals are facing a crisis in their affairs and we are facing this very important change in the relationship of these hospitals to the community. I do not know if there would be much enthusiasm in the House—and there will be very little enthusiasm in the voluntary hospitals— for this evolution towards a more democratic control of these institutions,but if we are to be certain that money raised by the House is properly expended we must insist on its being expended under the control of the nominees I have mentioned.

The nominees of county councils, of the city corporations and of the Minister have shown themselves generally, in relation to public institutions, to be quite competent to handle their affairs, as in the case of sanatoria, mental hospitals, fever hospitals and so on. Consequently, it cannot be argued that they would not be able to provide at least as good a service as is at present provided. I intend to deal with this matter more fully on a Bill which I understand is coming before the House in relation to one of the voluntary hospitals. I hope that by then the Minister will have his views quite clear on this very important point.

A lot of the money in this Estimate will be spent on the so-called free services to be made available under the tuberculosis and other regulations. There is a general point there which I would like to deal with very briefly, namely, the attitude of public officials in the payment of these moneys to those suffering from infectious diseases or their dependents. We are now moving into a phase in Ireland in which the community is taking over greater responsibilities in providing these social services and health services. It is important that the officials administering these services throughout the country should be clearly conscious of the fact that that money they are handing out, whether in payment for hospital services or as allowances for dependents, is the people's money, that it is from the communal purse and is not handed out because of any particular act of self-denial on the part of such officials. I would like the Minister to emphasise the importance of developing this understanding amongst local authorities. For years in the case of many services—particularly social services at labour exchanges, old age pensions and health services—the officials have been dominated by the older poor law atmosphere of condescending charity, giving somethingwhich a person hardly deserved and giving it merely to keep him alive. I would like the Minister to impress on all public officials the important fact that they are administering services paid for out of the community purse and that any man, woman or child availing of them does so as of right, is beholden to nobody and is taking charity from nobody, as these services are there to be claimed whenever they are needed.

Let me quote an example I had recently of a patient in a hospital who was recalcitrant and, because of that, was removed from the hospital. The medical officer acted quite within his rights in removing him. At the same time, he decided to deprive the man of the allowances which he should receive under the infectious diseases regulations. Again he was within his rights, as the man was not receiving treatment according to his instructions. After a short time the man decided to return to the hospital and take treatment. The medical officer continued to withhold the allowance, as far as I can see as a form of reprisal for the man's recalcitrance. The trouble about that was that the man suffered, his three children suffered and his wife suffered, until the whole question was put straight. I know well, and no one knows better, how much good work public officials do, and nobody hopes more than I do that they may be able to do a lot more of such good work. No one knows more than I do how much they will be criticised for it. At the same time, I would be the last to say they are faultless in their behaviour to the public. I have made objections wherever they have been in any way objectionable to people who have a perfect right to good manners. Secondly, by cases such as these, they give opportunities to the opponents of the extension of State service of this kind to criticise these extensions.

There has been a tremendous amount of criticism of dispensaries and all of it perfectly well deserved. I do not know what the Minister's views are on the question of the extension or improvement of dispensary services, but I believe there is no hope at all for the dispensary services. My hope alwayshas been that they would disappear from the public health services altogether and I believe that that, in fact, is what will happen when the extended health services provide opportunities for people to visit the doctor in his private house, because he is getting paid for them as separate cases. I think people will go less and less to the dispensaries and more to the doctor's private house.

I had no real hope that the dispensary services could be improved to any great extent. It is a hopeless service and fundamentally it was unsound. It is because of that that it has fallen into the state of desuetude in which it is at present. It would be very unwise to spend a lot of money on dispensaries if the other ideal, of all patients going to the doctor's private house, could be achieved and I think that can best be achieved by the provision of practical health services without any difference between the paying and non-paying type of patient.

I should like to ask if any further steps have been taken towards the setting up of a post-graduate school in St. Kevin's Hospital. The constructional changes there have reached a very advanced stage and the idea was —it was recommended by the consultative council set up by the Minister some years ago—that a post-graduate educational institution should be established in St. Kevin's. This is an excellent idea for the improvement of the standard of the public health services and the public health service offices, and the Minister might let us know whether the proposal recommended by the consultative council is likely to be proceeded with.

I should like to know also if any steps have been taken by the Dublin Corporation to implement the proposals of the Danish expert on tuberculosis dispensary services which were put forward by him during his visit some years ago. I recall that he was very critical of the dispensary services at the time and made a number of fairly sweeping suggestions, all of which seemed to me, while not knowing very much about that side of the business, to be reasonably sound and very necessary—at least he made avery good case for them. I wonder whether that report has been implemented to any extent at all by the corporation. The reason for bringing the man over at all was that he ran an excellent service in, I think, Copenhagen, one of the best in the world, and the idea was that we should establish in Dublin a pilot dispensary service which would gradually extend to the different cities and larger population areas in Ireland, because it was always felt that one of the weakest parts of our otherwise excellent health services in relation to infectious diseases is the dispensary or diagnostic side.

Finally, I should like to know what progress has been made with regard to the extension of the B.C.G. campaign and what success the Minister is having with regard to this service, which could do so much good and which has done a fair amount of good up to the present.

Mr. Dillon

It is not customary on a Supplementary Estimate for matters of principle to arise, but I think the query raised by Deputy Browne with regard to voluntary hospitals is one on which most Deputies will wish to hear from the Minister a clear decision in principle. If I correctly interpret Deputy Browne, his view is that the voluntary hospitals should cease to be voluntary hospitals and should come, at least in some measure, under public supervision. I think that probably most Deputies will agree that, if that suggestion is acted upon, we are putting our foot on the road which leads directly to the British system of the conversion of all voluntary hospitals into public health institutions.

That is a matter on which we have to make our choice here and now—let those who believe in the voluntary hospitals and their continued service to the community say so and let those in favour of the abolition of the entire system of voluntary hospitals in this country elect for that, in the full knowledge of what they are doing. There is no half-way house and there is no use in pretending that a voluntary hospital continues to be a voluntary hospital, once the State claims the right to put on its board a certainnumber of nominess who shall have, in the last analysis, a veto over the administration of the hospital by their power to threaten the withdrawal of whatever State grants the hospital has been brought to depend upon for its continued existence.

Let us not lose sight of the fact that the voluntary hospitals in this country carried on for a century without receiving one penny piece from the State. They carried on on the charitable contributions of those who so highly valued their services to the community that they put their hands into their own pockets and annually gave to these hospitals the funds wherewith to carry them on. I believe that the first breach of that system was the contributions under the Hospitals' Sweeps. That was followed by a general practice which has grown up of the local authorities, when referring a patient from their own municipal hospital to a voluntary hospital, undertaking to pay a weekly sum out of the rates for the maintenance of the patient referred to the voluntary hospital. But the voluntary hospitals, particularly in the City of Dublin, which have catered for the poor of this city on a voluntary basis, providing them with an infinitely better dispensary service than the State has ever succeeded in providing in their own out-patients department and providing for the acutely sick free of charge are, in my judgment, a very precious asset to our society.

In Great Britain, the Government have turned their back on the voluntary principle, have wiped these hospitals out and have insisted on their becoming State institutions. Does this Oireachtas intend or desire to do that here? If we do, we ought to do it with our eyes open, and we ought to do it honestly and above board, and not by moving in under cover of claiming that we are doing no more than our minimum duty in supervising the expenditure of public funds. Far from agreeing with Deputy Browne that it is an essential consequence of making available public funds to a voluntary body that you should put in Governmentnominees to interfere in its internal management, I strongly urge on the Minister that one of the prime aims of any Government should be to identify in the State the voluntary bodies doing good work to whom Grants-in-Aid may safely be made, without any claim on the part of the State to supervise their outlay.

It is quite illusory to imagine that there is anything foreign in this or that it is a new departure. We give Grants-in-Aid to an authority. When I was a Minister of State in this country my advice to the Government and my injunction to the Department over which I was in charge was that we should seek out voluntary bodies doing useful work and seek an opportunity to come to their aid, on the clear understanding that the aid we gave them carried with it no implication whatever that we claimed to interfere with the administration of the work to which they put their hands. I remember sending for the Irish Agricultural Organisation Society and saying to them that I had got approval from the Government to tell them that hereafter their annual Grant-in-Aid was made to them on the clear understanding that they had no duty to the Government in respect of it except that, at the end of the 12 months, they must certify that it had been spent for the purpose of the Irish Agricultural Organisation Society. I remember, without naming a variety of other bodies, both the then Minister for Education and myself determining certain voluntary associations throughout the country with whom a similar course of action might with propriety be pursued because we valued the fact that they were prepared to do a useful public service on a voluntary basis, and that on that basis, they could perform that public service infinitely better than any bureaucratic machine, however good, could do it.

I think that a defect that tends to make the desire to serve of many well-intentioned persons fated to futility in this country is the obsession that the eminently desirable thing to do is to put every activity in this community under the supervision and in charge of the State. I think a great many peopleare orientated in that connection by the fact that their heads are as soft as their hearts and that, moved by human suffering, they cannot hold back from the desire to rush in and seek to right what is wrong, regardless of the fact that they are quite liable to leave a trail of disaster behind them infinitely worse than the evil that moved them to move precipitately.

I never heard anybody say, until 1952, that there was not money available to provide decent dispensaries for the people. I suggest to the House that we ought to do first things first. Can we, first of all, make up our minds as to whether we want dispensaries or not? Let us make up our minds on that fundamental question. I am prepared to say that, in my opinion, the first step to take is to provide a decent dispensary building with adequate staffing, and if that requires more than one doctor, then get more than one to attend the patients we want to go there and have their sickness investigated.

Deputy Dr. Browne wants everyoneto go to the doctor's residence and to do away with the dispensaries. Are we to spend £2,000,000 on building dispensaries and then discover that we do not want them? I think that the Minister for Health ought to tell us what are the intentions of the Government in that regard. Does the Minister share the view of Deputy Dr. Browne that all dispensaries are to be abolished, or does he share my view that far from abolishing them we ought to improve them and bring them up to date?

I wonder would I be doing Deputy Dr. Browne an injustice if I were to say that what he really wants is a complete socialisation of medicine, and that every suggestion he makes in this House is really designed to get his foot in the door and gradually to force on all of us a complete system of socialised medicine such as operates at present in Great Britain? He nods his head in agreement. I think, in view of that, that it is time that this House made up its mind quite definitely on the question—is that what the rest of us want? Do we want the whole system of medicine in this country socialised on the model of Great Britain and New Zealand? It is a legitimate view for those who want to hold it. I do not. I am against it. Who is for it?

An Leas-Cheann Comhairle

I think that is a question which it would be much more relevant to debate on the main Vote.

Mr. Dillon

Deputy Dr. Browne thinks this a suitable time in which to give notice of that. Deputies, therefore, are getting the opportunity of making up their minds as to the side of the fence on which they want to come down. The voluntary hospitals are being assailed, and the foot is being put in the door for the purpose of wiping them out. I am against it. What says the Minister for Health? The dispensaries are being assailed. It is sought to put a foot in the door and away with them. I am against that. I want good dispensaries, properly staffed for the people, which they can attend. Will the Minister tell us on which side he comes down? On the larger question, will he start excogitatingso that he can give us a full and coherent explanation of his mind on the subject, with special reference to that significant new feature in the public health charter of Ireland, the £1 contribution which represents, I assume, Fianna Fáil's external relations with Catholic morality or the purchase of orthodoxy with 20 pieces of silver?

Mr. O'Higgins

I should like, fair being fair, to congratulate Deputy Dr. Browne on his recovery from his recent violent attack of laryngitis, which prevented him from giving his views in this House on last Thursday on the important matters of health. Having recovered from this attack, the Deputy has come into the House again, the hatchet man charged with the duty of finishing the voluntary hospitals and of adding his voice to the effort to socialise medicine. I am sure that the Minister for Health—he is responsible for the maintenance and administration of the law in relation to the voluntary hospitals and, I have no doubt, recognises his complete responsibility—will resist any attacks on the medical profession, and will deal with Deputy Dr. Browne.

On behalf of the Counties of Laois and Offaly, which I represent, I should like to know certain things from the Minister. During the past 12 or 18 months we have heard, in both counties, rumours to the effect that the Minister proposes, shortly, by an Act of this House, to impose an obligation on the county councils of Laois and Offaly to provide institutional treatment for a lot of people for whom such treatment is not being provided now. If that is so, I would like to know what steps the Minister has taken to assist the Laois or the Offaly County Council in improving the dispensary facilities and increasing the number of maternity beds available in both counties.

I assume that, before the Minister for Health sought by legislation to increase the responsibilities of either of these health authorities, he would have taken steps to ensure that the machinery was already created for the purpose of providing better dispensary facilities and more maternity beds and, as a Deputy representing theconstituency of Laois-Offaly, I would like to know from the Minister what concrete steps he has taken in the last 12 months to ensure that these highfalutin health schemes, when passed by this House, will have some chance of going into operation.

I know that before the Estimate is passed my colleague, Deputy Peadar Maher, will join me in asking the Minister what assistance has been given to both these county councils in this important task. I do think that from time to time we in this House are inclined in these matters to put the cart very much in front of the horse's nose and are inclined to legislate de bene esse,without considering what we can do by departmental action to provide something worth while for the people. Accordingly, I would like to know from the Minister in relation to both the counties I represent what action his Department has taken to provide better health services for the people in the last 12 months.

Mr. MacBride

I take it that the Supplementary Estimate largely arises from increased costs which local authorities have had to bear in the course of the year, costs which were probably the inevitable result of the Budget and of the Government's economic policy. However, that is a fait accompli.I do not suppose there is anything we can do about it beyond paying the bill which arises from the folly of the Government's economic policy.

I would like the Minister to feel, however, that in so far as money is required by the Government in order to assist local authorities or to recoup local authorities in the provision of proper dispensary facilities, the House would be unanimous on that question. I am sure, from indications that have been given from time to time from different sides of the House, that the Minister can consider himself as being pressed by everybody in the House to encourage local authorities to provide better dispensary facilities.

There is one matter that I would like to refer to in regard to dispensary facilities in Dublin. A new problem arises in the newly-built areas of Dublin. These areas have now reached theproportions of small towns or even large towns in themselves. Housing development in these areas has not taken into account—of necessity, I suppose—the need for providing dispensaries. A very good step was taken in the Crumlin area in the provision of a clinic. That is certainly a step along the right lines but, if at all possible, the Dublin Corporation and the Dublin County Council should be encouraged to provide special buildings even in these newly-built areas to serve as dispensaries and clinics.

There is also the necessity for the provision of round the clock dispensary facilities in those areas. Where there is a large population, such as there is, for instance, in the Crumlin-Drimnagh area or in the Cabra area, where there are close on 80,000 people living in a fairly restricted area, inevitably, emergency cases will arise 24 hours round-the-clock, emergency cases that may not require hospital treatment but that may require immediate treatment of one kind or another. I would ask the Minister, therefore, to consider the possibility of asking the Dublin health authorities to provide, not merely buildings for use as dispensaries, but also a round-the-clock casualty service in these areas.

I do not propose to touch on the other matters that have been raised in the course of this discussion. Any suggestion that the voluntary hospitals, which are in the main run by religious Orders which have rendered valuable service to the country for a long time, should be nationalised would not be received with favour by the Minister or, indeed, by anybody else in the country. I, therefore, do not take the suggestion made by Deputy Dr. Browne as being very serious in that respect but I would urge the Minister to do everything he can to encourage local authorities to improve dispensary facilities.