With regard to public assistance classes—this, of course, is only an estimate or rather a rule of thumb method, which has been adopted for quite a while back and seems to be correct—it is accepted that one-third of the entire population is covered by the public assistance group. Accordingly, so far as the country generally is concerned, one-third of the population is provided for under the Public Assistance Act. That fraction is not quite true in Dublin. In Dublin, the fraction would perhaps be nearer one-half than one-third so far as insured workers are concerned. The figure of 450,000, covered under the National Health Insurance Acts, is incorporated in the Social Welfare Act.
Having dealt with the present position and before passing to the position projected under the Health Act, 1953, I would like Deputies to understand and appreciate how, generally speaking, these services have worked. First of all, everyone will appreciate that no person who is sick and who requires urgent hospital attention in this country fails to get it and there is, generally speaking, an effort made to ensure that those in danger do obtain immediate attention. That, indeed, is a tribute to all concerned with the care of the sick and needy in this country and everybody interested in the health of the community will appreciate that this country's code of honour in that respect is very high and has always been very high.
Having said that, I pass to a more gloomy side of the picture because, while urgent cases are and have been consistently provided for, existing machinery is and has been for years labouring under very extreme difficulties. The position is that accommodation available now for existing services is far from adequate. I would just like to put it this way: in local authority county hospitals at the moment more than 100 per cent. bed occupancy is experienced. In other words, county hospitals at the moment are taking and accepting more patients than they can satisfactorily provide for. It is done by putting in stretchers and couches and cluttering beds together and generally endeavouring to provide for more patients than the hospital was built to provide for or can provide for satisfactorily.
That is the position throughout the country in the local authority county hospitals. In relation to the voluntary hospitals, each one of them is also working to its fullest capacity, stretched to the very limit to provide urgent medical care for those who need it.
Deputies may say: "Oh well, that means, of course, that both the sick poor and the sick rich are at the moment being provided for in all these hospitals." That, unfortunately, is not so. Under the Public Assistance Act, 1939, which will be repealed on the 1st August, priority must be given in every local authority hospital to the sick poor. They are entitled to the first bed available and if there are only three beds and four applicants the three who qualify as sick poor get the beds.
In addition, insured workers, in accordance with the contract between the Minister for Social Welfare and the local authority hospitals, are also entitled to equal priority so that, generally speaking—and I want to assure the House that I am only talking in generalities in the hope that it may be of assistance to Deputies— at the moment existing facilities are being taxed to their utmost to provide for those who have not the money or the means to fend for themselves and at the moment all the hospitals are being taxed not merely to capacity but beyond capacity to provide necessary services for those to whom the State owes an obligation either in Christian charity or in contract.
That, generally, represents the hospital position so far as ordinary illnesses and surgical cases are concerned. Before I pass on to the proposed or projected position under the Health Act, 1953, I would like to deviate for a moment and deal with the special problem of maternity cases. At the moment every woman of the public assistance class defined in the Public Assistance Act, 1939, is entitled to free maternity treatment in a hospital in accordance with the Public Assistance Act, 1939. In relation to country areas all the maternity facilities are provided in the different county hospitals and they are already included in the percentage figure which I have given to the House. In other words, part of the lack of accommodation and overtaxing of county hospitals is due to the fact that our people continue to have children.
In Dublin, however, the position is quite different. I would like Deputies to consider these figures, because I am not endeavouring to advance any stronger arguments to the House than the facts that are known or should be known to every Deputy. In Dublin, the average birth rate provided for in the maternity hospitals is 16,000 per year. It is reckoned, apart from heart cases and apart from other complications of one kind or another, that each maternity hospital bed can deal with 25 cases a year, so that, to provide hospital accommodation for all the maternity cases dealt with in this city would need a minimum of 640 beds. The situation, of course, need not be approached from that point of view because, as Deputies will be quick to point out, various nursing homes do fill in to absorb quite a number of cases and, generally speaking, the better-off sections of the community have been able to fend for themselves.
We all appreciate that a nursing home may be quite a considerable expense, but just for the moment I do not propose to consider that. Those who are able to afford it and have an obligation of saving for it are generally able to find nursing home accommodation for their wives in maternity, so that, in fact, in Dublin 640 beds probably are not needed unless we had a successful hospital sweepstake every week. Nevertheless, looking for the minimum requirements of the poor people, the position is appalling in the city. I said a while ago that it is usually reckoned that about one-third of the population could be regarded as coming within the framework of the Public Assistance Act, 1939. In fact, in Dublin the position is not exactly the same and the figure is somewhat higher.
It is reckoned that in Dublin 6,000 births a year qualify under the Public Assistance Act for maternity hospital treatment and accordingly something around—I have not worked it out—220 or 240 beds are required for public assistance cases. Those are the requirements—what is the position in this city? There are available in Dublin at the moment as public beds some 220; private beds total 117, so that the total hospital accommodation for maternity cases is 337—far short of what is required even for a reasonably good hospital maternity service.
What I say can be tested by experience. Yesterday, or the day before, the National Maternity Hospital issued its 60th annual report and it referred to the conditions obtaining at Holles Street Hospital. The report made an appeal to my Department to provide the money and the permission necessary for an urgent extension of Holles Street Hospital in view of the fact that the hospital has become more and more seriously overcrowded in the past five years. I would like Dublin Deputies particularly to test what I am saying against their own experience in their own constituencies. The average safe minimum period in a hospital for maternity cases is ten days. At the moment, in Holles Street Hospital poor women are lucky to have six days in a bed in that hospital. Six days is the average for the poor people of this city at the moment and it is only by an extensive use of antibiotics that serious infection and disease are not caused in the National Maternity Hospital. That is an appalling situation and a situation that would call for very responsible action by any Minister for Health and certainly a situation that affects me very deeply.
I mention these things to the House so that every Deputy on every side of the House may realise that I am not coming in here with this Bill indulging in special pleading or to make a case. I am coming to this House as the Parliament of this country to state a problem and to state facts in the hope that Deputies on all sides of the House will join with me in doing something worth while to provide better services for the people of this country.
I hope Deputies will appreciate from what I have said, speaking in a reasonable way and on the information available to me, that facilities are inadequate to provide even reasonable services for the poor and for the insured.
Let us pass on now. What is going to happen on August 1st, 1954? What situation will then obtain were I prepared to be irresponsible or should this House discard its responsibilities? Under the Health Act, 1953, ordered to come into operation on August 1st next, the Public Assistance Act, 1939, is repealed. In addition, every insured worker in this country is taken from the Department of Social Welfare, his contract going, his agreement, disappearing, and he is added to a new group of citizens for whom health services are provided in Sections 14 and 15 of the Health Act, 1953. Those sections create in this country a new pool of people all with equal rights, all with the same claims to services of a hospital, specialist, nursing and general medical kind.
That new pool consists of the following five categories of people: first of all, the sick poor—the unfortunate people who up to August 1st will have been provided for by the Public Assistance Act, 1939, and who enjoy absolute priority in every local authority county hospital. They are category No. 1—the sick poor. Secondly—insured workers, who at the moment and up to August 1st in accordance with their contract enjoy priority in every voluntary and local authority hospital in the country—they are category No. 2. Those are the existing categories. Now the new groups come in, and thirdly, we have all persons whose income is less than £600 a year. Fourthly, we have all farmers whose valuation does not exceed £50 a year; and fifthly, everyone else who can show that payment of bills in a hospital would cause him hardship. These are three new groups or categories thrown into the pool without a single additional bed being provided, a single additional hospital being built, without facilities being increased in the slightest. Three new groups are thrown into the health pool in this country and it is suggested that it is a wise thing to do nothing about it.
I want Deputies, in a responsible manner, forgetting in this connection past controversies and past differences, to examine with me what is likely to happen on August 1st, should the House have been prepared to do nothing. All of those people in that pool I have mentioned have equal rights, one with the other. Under Part III of the Health Act, each person in Sections 14 and 15 is entitled to demand as of right from every local authority in this country the services set out in Part III. Each of them has equal rights, with one slight exception that I shall have to mention later. So far as the provision of accommodation is concerned, equal rights each of them has. Now this extended pool, as I have indicated, has to be provided for from existing facilities and by whatever machinery may be at present available.
May I digress for a moment in order to help Deputies? Assuming that there were no difficulties of accommodation or anything of that kind, the machinery under which all these different categories are to be provided with the services set out in the Act, has to be defined in accordance with regulations to be made by the Minister for Health. Broadly speaking, the scheme is this: The Act imposes an obligation on the health authority, a statutory obligation, to provide for A, B, C, D and E. in accordance with regulations, the various services set out in the Act. Under the Act, the Minister for Health, in making his regulations, must provide everything for everybody or nothing for anybody. Under Section 22, the regulations must give, not merely to the impoverished, poor, out-of-work man, but to the fine farmer with the £50 valuation, the right to demand accommodation from the local authority. Under Section 22 of the Act, the Minister cannot pick and choose. He cannot provide for the needy in priority to the better-off sections of the community. He cannot do what Christian charity would impel him to do. That is broadly the scheme enshrined in the Health Act of 1953, in legislation. It imposes a statutory obligation which provides health services by words in an Act of Parliament. It provides these things in one of the statutes of this Parliament, but how is it to be carried out in fact?
People do not retain their health because of the enactment of Health Acts and people do not get better because this Dáil orders them to feel better. You have got to provide what the Dáil by its statutes orders. To bring the Act of 1954 into practice, some urgent steps will have to be taken. Many of the steps will have occurred, if not to Deputies here, I am certain to the people outside. First of all to provide adequately for all these people to whom our statute gives equal right of hospital accommodation, the initial step is to provide hospitals. The first thing to do is to increase the existing hospital accommodation so that county hospitals will not be working at more than 100 per cent. of their capacity, so that Holles Street Hospital will not be turning out unfortunate women at 3 or 4 o'clock in the morning. I can see Deputy Briscoe shaking his head. I can assure the Deputy that I have made personal inquiries and I have found that unfortunate women in Holles Street are being shifted out at 4 o'clock in the morning and sent home in ambulances and cars because other urgent cases of women in labour have come in. Surely, the first thing that must be done is to provide facilities in hospitals and elsewhere to deal with the added classes to whom our legislation gives these statutory rights.
Need I say that, with regard to the provision of extra accommodation, nothing has been done? On August 1st we shall not have available any extra beds in this country. On August 1st Holles Street Hospital will still be overcrowded. On August 1st every county hospital in the country will still be catering for more than it reasonably should. Consequently, in order to make this Act work on August 1st, as the House would have liked it to work, it would be necessary that discussions should take place and agreements be reached with the different voluntary and teaching hospitals in this country. If the voluntary and teaching hospitals were not available to provide for and care for all the people set out in Sections 14 and 15, then indeed an appalling situation would arise in this country. Accordingly any Minister sincerely desiring to see these services provided for the people of this country, should regard it as incumbent upon him to discuss the position with each voluntary and teaching hospital and to meet whatever reasonable proposals they may put forward in the desire to reach agreement—not in the desire to reach disagreement.
Since this Act was passed by Dáil Éireann, no effort, good, bad or indifferent, has been made to have such discussions with the voluntary hospitals and the teaching hospitals in this city or elsewhere. No agreement even of the scantiest kind has even been contemplated or hoped for. Nothing has been done.
Thirdly, anyone who sincerely desires to see this Act come into operation should contemplate that some discussions with a view to agreement should be carried out with the different other interested bodies in the country, with the medical profession, with the nursing profession, with the chemists, with the dentists, with the different people who have to provide the services enshrined in the Act under discussion. Again, I regret to have to inform the House that no effort, good, bad or indifferent, has been made to enter into such discussions, to ascertain the views of the nursing profession, to meet the dentists, to see what the chemists have to say; nothing again has been done.
Fourthly, an Act of this kind imposing as it does and must a substantial added burden on the county hospitals throughout the country must require very definite arrangements by all the local authorities. What is the position in regard to that? When I went into the Department of Health, concerned as I was sincerely to see that we would have in this country better health services, I caused inquiries to be made throughout the country to see what steps had been taken by local authorities to provide the services set out in the Act. The Dublin Corporation told me that if a series of conferences could not be arranged at a very early date the operation of the Act from 1st August would lead to most unsatisfactory consequences and that the operating date should be put back. From Kildare it was stated that it would be impossible to implement the regulations from 1st August because arrangements for hospital, specialist, general practitioner and midwifery services or for the provision of drugs, obstetrical outfits, etc., had not been made because the local authority did not know what fees to pay and because neither the staff nor the council had had time to familiarise themselves with the regulations.
Wexford County Council said it would be difficult to guarantee the additional bed requirements for the maternity and child health services which they thought would be necessary immediately the regulations became effective. Carlow County Council said they had deferred the making of detailed arrangements for the operation of the services until they had got instructions about how they were to work them. Waterford Corporation also spoke of their difficulty in implementing the regulations by the date suggested. There is a further complication here which I may have to explain later. Clare County Council reported that no child welfare service could be established at present, nor could the existing school medical service be expanded.
Donegal County Council, while stating that the general institutional and specialist services would be implemented as far as their existing facilities would allow, said that as they had not got a county hospital with its allied services, it was not feasible to provide the services of a county surgeon, a county physician, etc. Certain difficulties were expected also in operating the free milk scheme, particularly in getting milk supplies. The Dublin Board of Assistance said it had not been possible to make complete and detailed arrangements for the operation of any one of the services because they did not know what they would be required to operate.
The position in Dublin, Cork and Waterford is complicated considerably because, while the corporation and county council of these areas deal with health services, the entire medical assistance service that is given by the dispensary doctors and by the local authority hospitals is operated by local boards of assistance. Before the health services can be implemented in those areas Statutory Orders must be made setting out what services under the Health Acts will be administered by the boards of assistance and what financial arrangements will be made for meeting expenses. The health authorities in Cork and Waterford are not finding it easy to agree locally on the financial basis of the new service which the local boards of assistance will operate. In default of agreement, the matter must be settled by the Minister for Health, and that is not a matter which can be settled easily.
These are some of the results of inquiries which I have made with regard to the local authorities generally. Many other replies that I have received show that the extent to which arrangements have been made is the filling of forms to deal with the services set out in the Act. I have shown to the House, and I am sure it will appeal to the good sense of the Deputies, some of the steps that should necessarily have been taken to provide that the services in the Health Act of 1953 would not only become law—that is an easy thing to do—but be enjoyed by the people of this country. I hope I have shown that the necessary steps in fact have not been taken.
Let us consider for a moment what has been done. My predecessor, from time to time in this House and outside it, after the passing of the Health Act, 1953, expressed his intention to have the services in operation on April 1st. I would have thought that he would have utilised the time from the passing of the Health Act in October, 1953, to the 1st April to carry out these essential steps, but he did not. Not an extra bed was provided; no discussions were held with the voluntary hospitals; nurses were not seen; dentists were not talked to; the chemists were not consulted—no one was consulted and, accordingly, time went on and April 1st drew nearer and nearer and nearer, but still nothing was done until a by-election was held in Cork and another one was held in Louth.