I move——
Committee on Finance. - Vote 58—Health
I think the Minister might have a House.
Notice taken that 20 Members were not present; House counted, and 20 Members being present,
I move:—
That a sum not exceeding £6,525,600 be granted to complete the sum necessary to defray the charge which will come in course of payment during the year ending 31st March, 1961, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard Chlaraitheora) and certain services administered by that Office including grants to local authorities and miscellaneous grants.
As in previous years, I shall preface any discussion of the Estimate and of the various problems facing my Department by referring to the more significant vital statistics for the preceding calendar year. The figures which I quote are at this stage provisional, but I do not expect that there will be any serious alteration in them.
The number of births registered in 1959 was 60,188, as compared with 59,510 in 1958. The birth rate, at 21.1 per thousand population was again higher than in England and Wales where it was 16.5 per 1,000, and than in Scotland where it was 19.1 per 1,000. Marriages were more numerous in 1959 than in 1958, there being 15,255 as against 15,061. The general death rate, at 12 per 1,000 population, was the same as in 1958.
There were significant changes in the rates of deaths from particular causes, among them tuberculosis, the death rate from which continued to decline substantially. There were, indeed, only 517 deaths from all forms of the disease in 1959, as compared with 581 in 1958 or, to go back a little further to the time when the disease was still a major scourge, with 2,712 in 1949. The death rate from tuberculosis in 1959 was 18 per 100,000 of the population, which was the lowest ever and compares very strikingly with the rate, five times as high, of 91 per 100,000 which was experienced ten years ago.
Fewer died in 1959 from acute poliomyelitis, the figure being 2 for the year as compared with 9 in 1958. In the case of diphtheria, however, there was a significant increase from 6 to 9 deaths, underlining the need to avoid complacency in the matter if immunisation for diphtheria, or, indeed, for any other infectious disease. Tuberculosis and the other infective and parasitic diseases — which caused a total of 697 deaths in 1959 — have, I am glad to say, become one of the lesser categories of the causes of death.
In 1959, the two major causes were again heart diseases, responsible for 10,821 deaths, and cancer, which caused 4,777. In the present state of medical knowledge the task of combating these conditions is a formidable one.
So far no such advance in pharmacology as has provided most effective therapeutic agents for the treatment of T.B. has been experienced in their case, and now they have become a cause of grave and increasing concern to Ministers and Departments of Health the world over. Among the cancer deaths, there were 601 from the forms of that disease which we group together under the title of lung cancer. It is to be noted that this was 37 more than for 1958. The increase is very significant and should be regarded with serious concern and as a serious warning by all who smoke.
I am glad to be able to report that the maternal mortality rate declined from 103 per 100,000 births in 1958 to 66 per 100,000 in 1959. There was also a fall in the infant mortality rate from 35 to 32 per 1,000 live births. Though the decreases registered in these mortality rates are to be welcomed, nevertheless the position in regard to maternal and infant mortality is capable of very great improvement, as experience in the North of Ireland and in Great Britain shows. Thus in England maternal mortality in 1959 was at the rate of 39 per 100,000 births; in north-eastern Ireland it was 58; and in Scotland 36. The rates for infant mortality were: England and Wales 22 per 1,000 births, north-eastern Ireland 28.4 per 1,000 births, Scotland 28.4 per 1,000 also. That our experience of maternal and infant mortality compares so unfavourably with the position in Great Britain and the rest of Ireland, should be of the greatest concern to us all, even allowing for the unusual pattern of relatively late marriages and large families. I may say that it has been a major factor influencing certain decisions which I have made and to which I shall refer later.
In regard to poliomyelitis, despite vaccination we are still far from the stage where we can afford to treat this disease with unconcern. I have considered it therefore a wise precaution to ensure that the Regional Poliomyelitis Centres in Dublin, Cork, and Galway should be maintained in a constant state of efficiency and readiness to treat cases of the disease and to deal with a serious outbreak if it should occur. Past experience of the disease furnishes no reliable guide as to its likely incidence in the current or future years and if the available protective measures are not used the disease may continue to exact its toll of deaths and disability. Last year, when the number of cases of paralytic poliomyelitis was 39 with 2 deaths, might be described as a year of mild incidence. The corresponding figures to date this year of 69 cases and 8 deaths are already higher than the figures for the whole of 1959.
With the approach of the season when the incidence of poliomyelitis is generally highest, these figures emphasise the need for a high level of vaccination in the community and especially in young people. Vaccination continues to be our only effective weapon against the spread of the more serious forms of the disease and provides a very high degree of protection. It is important therefore that the vaccination service provided by local health authorities should be fully availed of.
Substantially more than one-half of the estimated gross expenditure of my Department is represented by Subhead 1, which provides for a total of £8,800,000 in grants to local health authorities in aid of their expenditure on health services. These grants are authorised by the Health Services (Financial Provisions) Act, 1947, under which the State undertook to meet half of the cost of the local health services.
The total cost of the services in the present year, having allowed for such receipts as charges made on patients, will be about £17.6 million. This compares with £16.8 million in the year to the 31st March, 1960, and £16.5 million in the year previous to that. The increase in the present year is due largely to the cost-of-living increase to officers and employees of health authorities. I should mention here that, in addition to the amount which is paid from central and local taxation, it is probable that a sum of something like £1,250,000 will be paid from the Hospitals Trust Fund to voluntary hospitals by way of deficit grants. The total expenditure from public funds this year on the health services may be taken, therefore, to be about £18.8 millions.
It is relevant at this stage to refer to demands which have been made for the State to accept responsibility for the larger part, or even for the full cost of the health services. To put these demands in their proper perspective, I must tell the House of the position which existed before 1947, when the Health Services (Financial Provisions) Act was passed. Local finances at that time bore by far the greater part of the cost of the local health services and were supplemented only by modest State Grants, grants of which the local authorities were not free to dispose but were obliged to apply to limited specific purposes. Thus, in the year to 31st March, 1948, these limited grants totalled only about £830,000, no more than a mere 16 per cent. of the cost of the services, whilst the local authorities had to meet the remaining 84 per cent.
This position was radically readjusted in favour of the local ratepayers by the Act of 1947. Under that Act the State undertook to meet, for each health authority, the full amount of any increase in the cost of its services until the total cost was twice the amount met by that authority from local taxation in the year ending on 31st March, 1948. When this point had been reached the cost was to be divided equally between the two.
Since 1947-48 the total cost of the local health services has risen from about £5.7 million to the £17.6 million estimated for the current year. In the initial stages of this upward trend, the State bore the entire additional cost. Thus, in the year to 31st March, 1951, the local authorities' contribution, at £4.8 million, was the same as in 1947-48, whereas the State's contribution had risen from the £830,000 which I have mentioned, to £3,700,000. The State's liability borne on this Vote in respect of the present year's estimated expenditure is £8.8 million, which will be matched by an equal expenditure from the revenues of the local authorities.
It will be seen, therefore, that whereas the local contribution has increased by £3.8 million, that is by about 80 per cent. over its 1947-48 figure, the State's contribution under Vote 58 alone has increased in the same period by £7.8 million, and it is now over ten times as great as in 1947-48. I should point out also that these figures relate only to the contribution which the Dáil makes under this Vote directly and specifically towards the cost of the health services. But it is not the sole contribution that is made out of Central Funds in easement of the cost of the health services to a particular category of ratepayers. A further contribution is made through the Agricultural Grant and that this operates to further reduce the cost to the farming community of the health services will be apparent from the following figures.
The Agricultural Grant for the year 1958-59 was £5,500,000 all of which was appropriated to meet the general cost of the local authority services, including health services. If we divide this total in the ratio of the expenditures from local funds on the health services and the other local services, we can say that about one-third of it, or £1.8 million, is assignable to the health services. The total expenditure in the counties on health services, which, after deducting miscellaneous receipts, was £11.6 million, was therefore met as follows:
|
£. million |
|
|
Health Services Grant |
5.8 |
|
Agricultural Grant |
1.8 |
|
Rates on land and buildings |
4.0 |
Thus to meet the cost of their health services in 1958-59 the Government gave to the county councils not merely £5.8 million from the Health Vote, but £1.8 million through the Agricultural Grant as well. In other words in the case of county health services, the Government actually paid 66 per cent. of the whole cost, while the county authorities paid only 34 per cent.
It might be interesting to consider how the revenues out of which the councils met their share of the cost arose. They were derived from the following sources:—
|
£. million |
|
|
By rates on buildings |
1.5 |
|
,,,,,, agricultural land |
2.5 |
|
From the Agricultural Grant |
1.8 |
|
Total |
5.8 |
We may conclude from these figures-I think the conclusion is unassailable — that owners or occupiers of buildings bore, as such, 50 per cent. of that part of the cost of the health services which could be regarded as specially appropriated to their needs; whereas owners of land, as such, only bore 29 per cent. of their share, the Government bearing the balance, that is to say, 71 per cent. in their case.
In view of what I have said, I do not think that it could reasonably be held that the State has been ungenerous in the provision which it has made for assisting local authorities to finance the health services in rural areas. The figures and percentages which I have given do not apply to urban areas. In such areas the rates do, in fact, meet half the cost of the health services.
Last February, the Dublin City Council requested me to receive a deputation for the purpose of discussing with them ways and means of devising — I quote their resolution —"a more equitable apportionment of the cost of providing our health and social services". I shall, of course, be quite willing to discuss this matter with the deputation from the Corporation. But even if I and the Minister for Finance could be persuaded that the Corporation had a good case, the suggestion that the State should bear a greater proportion of the burden of the cost of the health services raises an issue of fundamental importance.
It may readily be admitted that so long as the local finances bear their present proportion of the cost of the health services, it is reasonable that the local authorities should operate the services with only general direction and supervision from the centre. If the State were to take over the whole, or a substantially greater part, of the burden of the cost, we should have to look anew at the administration of the services and possibly consider whether or not the authority which is the main source of the piper's pay should have more say in the tune being played. To put it more plainly, if the Exchequer's proportionate share of the cost of the health services were to be increased by more than a casual or insignificant amount, then the Minister for Health, because of his responsibility to the general taxpayer, would be bound to take a more active part in the administration of the health services, even perhaps to the extent of taking them over, or entrusting their operation to bodies nominated by him. Personally I would view such a development with the utmost disfavour, and I think so would most people. Nevertheless, if taxation without representations is to be deprecated, so also is local control without local taxation. In short, those who wish to maintain democratic control in the local administration of the health services must be prepared as ratepayers to pay for it.
I should make it clear that no such proposals for a change in the local administration of the health services are being considered by the Government but those who are pressing for a change in the financial basis of the health services should realise that, if their pressure were to be successful, this issue would be bound to arise. The resolution submitted by the Dublin Corporation also referred to the statutory demands which must be met by it as a rating authority. The demands referred to were made hitherto on the Corporation by joint bodies, like the Dublin Board of Assistance and the Grangegorman Mental Hospital Board. They were based on estimates prepared by these joint bodies and Dublin Corporation as the rating authority had no option but to provide for them in striking their rates.
The fact that the statutory demands of joint bodies on rating authorities have become very substantial in recent years has caused some concern to the Minister for Local Government and myself, because the rating authorities as such have had no say as to what should be included in the estimates of the bodies making these demands.
We have, however, taken action by the Health Authorities Act, 1960, to improve the position in respect of certain rating authorities, among them the Dublin Corporation. Under the Act a draft of the estimate which any of the new Health Authorities may propose to make must be sent before final adoption to each of the rating authorities represented thereon. Thus the rating authorities concerned will be in a position to make such representations as they may wish about the size of the proposed demand. The Health Authority in turn will be made up of members of the rating authorities, so that whatever comments any of the latter may make on the estimate should considerably influence its final form.
Except for Subhead I, the subheads of the Estimate are comparatively small and for the most part the sums included do not differ significantly from last year. The increase in what is provided for under Subhead A for the salaries and wages of the staff of my Department is due mainly to the recent cost-of-living award.
Despite all the efforts over the years of my Department and of the local authorities, acting under its instigation, to make the public better informed as to their rights under the Acts, I am forced to the conclusion that ignorance as to the scope and nature of and entitlement to the services available under them is widespread among the public at large. This want of information would appear, moreover, to be most marked in respect of institutional services. Frequently where the General Medical Service is concerned, the hardship occasioned to an eligible individual who fails through ignorance to avail himself of it may not be much. On the other hand, I know, and I am sure every Deputy has similar knowledge, that where lengthy and costly treatment in a hospital is concerned, too many people, who are in fact eligible for such treatment either free or at reduced charges are, through ignorance of their rights, incurring bills which they find it difficult if not impossible to meet.
I propose, therefore, in the coming year to make available to every household in the country a booklet outlining in simple language what the health services are, and how, and by whom they may be availed of. By this means and through other advertising media, I hope to make the public at large fully aware of the extent and character of the health services available to them. I have decided for this purpose, to ask the House to approve an increase of £10,000 in Subhead M over and above the normal requirements for publicising health and the health services.
There is only one other subhead in the Estimate to which I need refer before moving to mention some of the general matters not specifically related to the Estimate itself. This is the new Subhead O which provides £3,000 for technical assistance in respect of which a sum was laid aside in the American Grant Counterpart Fund for obtaining advice and assistance on the establishment of a rehabilitation centre.
As I indicated on this occasion last year, I then had the interim report of the National Organisation for Rehabilitation under consideration. In that report it was recommended, inter alia, that a rehabilitation centre should be set up wherein a programme of physical training and graduated work could be provided for persons who would need such treatment to prepare them to resume their employment or to fit them for training for a new occupation.
Since then, the authorities of Our Lady of Lourdes Hospital, Dún Laoghaire, in conjunction with the National Organisation for Rehabilitation, have put forward a plan for the establishment at that institution of a rehabilitation centre. I have indicated my agreement in principle to this plan and the arrangements for the centre are at present under discussion between the authorities of the Hospital, the National Organisation for Rehabilitation and my Department. The sum of £3,000 provided for in Subhead O will be available for transfer to the Organisation to obtain expert advice in connection with the establishment and development of the centre. Deputies will note that the expenditure from this new subhead will be balanced by an appropriation-in-aid from the Grant Counterpart Fund.
I am glad to be in a position to report that the steps which I took to restore the solvency of the Hospital Trust Fund, strongly reinforced as those steps have been by the ever-increasing success of the Hospitals Sweepstakes, are bearing fruit. A position has been reached when the partial resumption of the Hospitals Building Programme which I initiated last year may be enlarged to enable the planning of certain further urgent works to be begun.
The present position in relation to the Fund is briefly as follows. Shortly before the end of the 1959-60 financial year the major portion of the proceeds of the recent Grand National Sweepstakes, amounting to £1.1 million, was paid into the Fund but of course must be regarded as income appropriate to the present financial year. Therefore, if we ignore that payment, the balance in the Fund on the 31st March last would have amounted to £2.4 million. Against that balance, however, it should be noted that there are inescapable commitments on capital schemes, already in progress or completed but not fully paid for, amounting to £1.1 million, as well as commitments in respect of hospital deficits, which, as I mentioned earlier, may amount to about £1.25 million.
It may be thought that the improved financial situation offers an opportunity to embark on a large scale resumption of hospital building activities. This is not my view, at least yet, for with the world as it is, we have no guarantee that the present satisfactory trend of the Sweepstake revenue will continue uninterrupted. Accordingly I have decided to set portion of the fund aside as a reserve to ensure that any commitments that are undertaken can be honoured. In this connection it may surprise many to know that the capital amounts that would be required to finance the completion of the Hospital Building Programme drawn up a decade ago still stand at about £8 million. In addition, to provide badly-needed accommodation for mental defectives and to overcome overcrowding and otherwise improve and modernise mental hospitals would require many additional millions.
Other demands on the Fund, involving considerable expenditure, continue to be made; so that the total requirements far exceed the funds that are likely to accrue for several years to come. It should be clear, I submit, from all this, that our hospital needs cannot be effectively met by precipitate or ill-considered spending; such as is often urged upon me by those who believe that their demands should have priority over the needs of all others.
During the year I approved of the resumption of planning on the new hospital to replace the Coombe Hospital. The Coombe Hospital which has rendered such signal service to the poor of Dublin was founded about 1814. It was established on its present site in 1826 and the main portion of it was built in 1867. The provision of a modern maternity hospital to replace the existing institution was recommended in the First Report of the Hospitals Commission for 1933/34, that is to say almost thirty years ago. The proposal was accepted in principle by the then Minister for Local Government and Public Health. Unfortunately, a major difficulty arose concerning the selection of a suitable site and was not finally resolved until 1949 when a site at Donore Avenue was acquired. Planning of the new hospital was then begun, but once again in the financial crisis of 1956 the project had to be shelved. The fact, however, that our maternal mortality rate is much higher than in comparable societies, as is also the infant mortality rate, indicates how urgent is the need to make good the existing deficiencies in maternity accommodation. Accordingly, I decided that if a suitable arrangement could be arrived at in regard to planning and ultimate cost, the new hospital should be given the highest priority.
I am glad to say that the authorities of the Coombe Hospital have been most co-operative and willing to meet my requirement in the matter of avoiding over-elaboration and lavishness. I am glad to pay this tribute to them. The approach in the case of other new building projects will be on the same lines and difficulties will be avoided if other hospital authorities display willingness to co-operate in the same manner.
For the reasons which moved me in the case of the projected new Coombe Hospital, I have also decided that the project for a new Erinville Maternity Hospital at Cork, the acquisition of a site for which was originally approved of by the Minister for Local Government and Public Health in 1937, should be allowed to proceed, subject, of course, to my requirements as to cost and accommodation being met.
On the local authority side, I have approved of the conversion of the former Tuberculosis Hospital at Lisdarn, County Cavan, to serve as a medical and maternity hospital and the extension of maternity accommodation at the County Hospital, Castlebar.
Among the other major voluntary hospital schemes to which approval has been given over the last year or so were the provision of a new Nurses' Home at Portiuncula Hospital, Ballinasloe; the provision of further accommodation for mental defectives at St. Mary's, Devlin, and at Cregg House, Sligo; the complete renewal of the electrical installations at Jervis Street Hospital; the provision of accommodation for nursing and medical staff and a new out-patients' department at the Adelaide Hospital; and the provision of a new Theatre at St. Mary's Orthopaedic Hospital, Cappagh.
Some alterations and improvements in local authority hospitals have also been authorised. These include the provision of accommodation for student nurses at St. Finbarr's Hospital, Cork; the provision of additional beds at Sligo County Hospital to enable it to serve as a sub-regional centre for paediatric and ear, nose and throat work and the provision of residential accommodation for medical staff at Galway Regional Hospital.
I have not come to any firm decision yet as to when it will be possible to allow the other major projects in the building programme to be undertaken. Much will depend, as I have already stressed, on the continued success of the Sweepstakes and of the efforts to establish a sufficient reserve in the Hospitals Trust Fund.
No significant change can be made in the local authority dental services this year. As Deputies are aware, dental treatment is provided, free of charge, by local health authorities for pupils of national schools in respect of defects discovered at school health examinations and for children under six years in respect of defects at child welfare clinics. Persons in the lower income group are also eligible for free dental services.
As only a limited amount of funds and dental personnel are available to enable local authorities to discharge their obligations to provide dental services for these groups it has been accepted policy for some years past to recommend to local authorities that they should concentrate their available resources mainly on providing dental treatment for children. This unfortunately means that only a limited dental service is available to adults in the lower income group; in particular the supply of dentures is restricted in many areas to special categories of persons such as tuberculosis patients, necessitous expectant and nursing mothers, and persons in receipt of home assistance. The cost of providing an adequate dental service even for persons in the lower income group is simply not within our means at present. Moreover, there are not sufficient dental surgeons available to enable the present service to be noticeably improved. In fact, in some areas there are vacancies for dental surgeons which the local authorities concerned find difficulty in filling.
Deputies may be aware that an important improvement for young workers was made recently in the treatment benefits scheme administered by the Department of Social Welfare.
Formerly three years' insurance was necessary for all workers before they could avail of dental benefit under the social welfare scheme. Now, insured persons under 21 years of age need only six months' insurance to entitle them to this service. This improvement will enable young insured workers to look after their teeth at a very important stage in their lives.
When moving the Second Stage of the Health (Fluoridation of Water Supplies) Bill, on the 5th April I mentioned that the extent of dental decay in this country is so great that it is virtually impossible to cope with it by treatment methods alone. There is every reason to believe that by the operation of the fluoridation scheme provided for in that Bill, there will in future be a very significant improvement in dental health, sufficient to enable us to cope with the problem which will remain.
Before leaving the subject of dental services generally I might inform the House that following discussions which the Department of Education and my Department had with all the interested parties a new Dental Hospital in Dublin is being planned at present. Subject to certain safeguards I have promised a substantial grant from the Hospitals Trust Fund towards the cost.
As many Deputies know, the condition of some of our mental hospitals is deplorable. I was very glad, therefore, that while having due regard to other claims upon it, the improved position of the Hospitals Trust Fund enabled me to permit a limited list of urgently required mental hospital improvements to proceed at an estimated cost of approximately £1 million. Among the works approved in this programme, and now being planned, are new admission units at Ardee, Castlebar and Clonmel Mental Hospitals. I also approved the building, planned some years ago, of an admission unit at Cork Mental Hospital and this is now in course of construction. I am well aware that a much more extensive programme could be justified but the numerous other calls on the resources available left me no option but to restrict the projected works, so as to keep their cost within £1,000,000.
It will be remembered that, in common with other schemes involving major expenditure, the reconstruction and improvement of county homes in accordance with the recommendations of the White Paper of 1951 had to be deferred in 1956. Having regard to the general improvement in the position of the Exchequer, I have, as I indicated last year, given instructions in my Department to get the schemes moving again. While continuous pressure is being maintained on local authorities to bring these schemes to fruition, the planning and execution of major projects for these institutions must inevitably take time. In the meantime, however, I have directed the Department to encourage local authorities to carry out minor improvements, where necessary and practicable, in advance of the main works.
Extending over a year, discussions were held in my Department on proposals for the federation and ultimate integration of seven Dublin voluntary hospitals. The hospitals concerned are the Adelaide, Sir Patrick Dun's, the Meath, Mercers, the National Children's Hospital, the Royal City of Dublin and Dr. Steeven's. Agreement was reached a while ago on the general terms of a Bill to provide for such federation and the Government has authorised me to have it drafted. I hope that the Dáil will have the measure before it soon after the Summer recess. Therefore, I do not propose at this stage to go into the details of the proposed association between the hospitals. But I should say that the move towards closer liaison is welcome to me and has my full support.
I feel that it will put the combined hospitals in a position to continue more effectively the admirable service which they have given to the Dublin public, some of them for over two centuries. Naturally in negotiating the agreement to federate many cherished views had necessarily to be modified or even sacrificed. I should like, therefore, to express to all concerned my appreciation of the manner in which those governing the individual hospitals have submerged their particular interests in order to advance the common good.
Unfortunately, it is not possible for me in present circumstances to contemplate any considerable capital expenditure on the provision of new buildings for the federating group. I am confident, however, that the benefits of large scale organisation which may be expected to accrue from the federation will enable the various specialities, now such a feature of modern medicine, to be fully developed, and thus ultimately ensure that a more comprehensive service will be provided for the public at no greater cost than at present.
Amalgamation in another sense was recently the concern of this House in the discussion of the Health Authorities Bill. Deputies will remember that one of the major objects of this Bill was to establish special new Health Authorities in Dublin, Cork, Limerick and Waterford. The 1st July is a particularly appropriate day for this purpose. It will coincide with the conclusion of the local elections and the new Health Authorities will thus take over when the term of office of the present county and city councils ends.
All the necessary steps for the setting up of new authorities have been taken by my Department and will follow in due course at local levels, and I foresee no difficulties in effecting a smooth transfer of functions to the authorities from the present miscellany of local bodies in these four areas. As I said in the debate on the Health Authorities Bill, I have every expectation that new authorities will be in a much better position to provide a more convenient and more efficient service for the public. I am sure I am speaking on behalf of the whole House, including those who may have had reservations on the Bill, when I wish the newly established authorities success in their work.
The other main proposal of the Health Authorities Act, which is the abolition of the legal distinction between the local administration of the mental health services and that of the other health services will also come into effect on the 1st July. As I indicated in speaking on the Bill, however, this is only a first step in a design to bring the law of the mental health services more up-to-date.
A further step in this direction will be taken with the enactment of another Bill which I hope to bring before the House soon. This will be a fairly short Bill to amend in certain respects the provisions in the Mental Treatment Act, 1945, relating to the admission and care of mental patients. The Act of 1945 is, however, a large and comprehensive measure which introduced what were, at the time, far-reaching and fundamental changes in the law relating to mental health.
There have been further great changes since then, however, in the treatment of mental illness and in the attitude towards mental disease and, after the interim measure which I will introduce soon, it will be necessary to consider a more fundamental measure to replace or considerably amend the Mental Treatment Act of 1945.
As the House will be aware, I recently caused to be published a White Paper dealing with the distressing problem of mental deficiency in this country. The provision of a comprehensive service for mentally handicapped persons is one of the major health problems remaining to be solved.
The problem is not, I may say, wholly one of accommodation. In all over 2,100 new beds for mentally handicapped persons have been made available since 1932 at an expenditure of £1.6 millions from the Hospitals Trust Fund; 1,300 of them, provided in the period since 1947, being in special institutions catering for mentally handicapped persons. To these we may add an additional 600 beds which are in immediate prospect. Nevertheless, institutional accommodation is still far short of requirements, for it has been estimated that there may be as many as 24,000 mentally handicapped persons in this country of whom 7,000 would require institutional care.
It must not be assumed, however, from all this that the question of institutional accommodation resolves itself to the relatively uncomplicated one of providing upwards of 4,000 additional beds for the afflicted, that is, additional to those we have at present and the 600 shortly to be available. Unfortunately, there is much more involved. In the first place there is a marked shortage of personnel with the necessary experience, training and vocation for the staffing of these special institutions. Traditionally, the institutional services in this country for mentally handicapped persons have been administered by religious communities who are themselves finding it difficult at the present time to extend their field of activity.
To relieve that situation, An Bord Altranais have recently made provision for the training and registration of nurses for the mentally handicapped but that arrangement has not been sufficiently long in operation to have relieved the staffing problem to any great extent. The type of accommodation required also falls to be considered — whether it should be for children or for adults, whether it should be residential or day accommodation, whether it should be fully equipped to provide intensive training or of the simple hostel type; these are the questions to which in the light of our present knowledge of the problem there is no ready answer.
A comprehensive service for the mentally handicapped must include the organisation of services for the ascertainment and assessment of the degree of mental handicap; the provision of appropriate institutional accommodation for those requiring it; the establishment of day clinics for the training of persons whom it would be possible to maintain at home; and the organisation of an after-care and placement service which would enable persons following their training in institutions to occupy their particular place in the community. The provision of such a service would require trained staffs of various types and overshadowing all there is the question of cost. With health expenditure running at the yearly rate of over £17 millions it is, in my view, essential that the service to be provided, as well as being effective, should be the most economical possible and that there should be no wastage of public funds on haphazard or ill-conceived developments.
The main problems associated with the provision of a comprehensive service for the mentally handicapped are set out in the White Paper to which I have referred. I propose, as outlined in the White Paper, to set up a Commission of Enquiry to examine the matter fully and to make recommendations as to how we should proceed. Unfortunately I have not yet been able to come to a final conclusion in that regard. In the meantime, developments in this field already in train will go ahead and every effort will be made to supply obvious needs.
In the service for the treatment and alleviation of mental disease-which is, of course, quite distinct from mental deficiency — we also have our problems. This service caters for almost 20,000 patients in 21 district mental hospitals and auxiliary institutions. The mental treatment service suffers mainly from the handicap of insufficient and outdated accommodation, not entirely suited to modern concepts of mental treatment.
Serious overcrowding is undoubtedly one of our greatest single problems and while this exists it will be difficult to bring about a marked improvement in the general standards of the hospitals. However, it is perhaps significant that the year ended 31st December, 1959 saw a fall of 456 in the number of patients in our mental hospitals notwithstanding that total receptions rose from 8,177 for 1958 to 8,559 for 1959.
I have already referred to the programme of extensions and improvements to mental hospitals which has been initiated. It is indeed a very modest one.
On the other hand, I am satisfied that the improvement of facilities in the accommodation which we have and the establishment of adequate outpatient clinics and psychiatric consultant services are at least as important as the provision of new accommodation. Perhaps more important still may be a service which will give much more attention to the preventive and after-care aspect of mental health. This I hope will come in time. Pending the organisation and development of such a service, district medical officers and other medical practitioners can help to lessen our difficulties by spreading knowledge throughout the community as to the nature of mental health and the measures necessary to preserve it.
Finally I should like to say something about the future. There is no reason to expect that the present trends in our vital statistics, which are part of a pattern common to most civilised nations, will not continue. It is reasonable, therefore, to believe that deaths from tuberculosis and other infectious diseases will continue to decline, so as to become almost negligible in their demands on the health services. On the other hand, heart disease and cancerous conditions are showing a marked tendency to increase and are likely to become even more important among the diseases with which the health services will have to deal.
As well as ensuring that the equipment and skills are there to treat and ameliorate these conditions, we shall have to play our part in the extensive research on their causes which is being pursued in many countries to-day. In addition to acute illnesses such as these, we shall have to care increasingly for chronic illness in the aged and greater and greater numbers of old people who, while not actually ill, are unable to fend for themselves.
When it is completed the programme to improve county homes to which I have referred should leave us with proper facilities for the institutional care of these age groups. On the other hand, I think that it is better that old people should be cared for at home, so I am hoping that the development of the contributory old age pensions scheme, of which all sides of the House approved in principle recently will encourage this. I look forward also to great progress in the treatment of mental illness, as more is known of its nature and the factors which give rise to it, as the knowledge grows among the public that in very many cases it is a condition which will yield even to existing drugs and treatments, and as through research the drugs and treatments themselves become more effective.
I look forward to the day when a much larger proportion of the mentally ill will not have to resort to institutions for treatment, but may live with their families and in the community while they are being treated and cured. But this day is not yet at hand and in the meantime much remains to be done to improve the accommodation and facilities for treating mental diseases and for caring for mental defectives. As I have already mentioned, a start has been made on this work and, with more surplus tuberculosis accommodation becoming available in future years, we can expect that it will proceed satisfactorily.
Improvements in accommodation and the provision of the equipment and skilled staff necessary for modern treatment of illness and disease will not completely serve their purpose unless there is an efficient organisation of the health services under which those entitled to them can obtain them when they are needed. The re-defining and extension of the classes eligible for the services which was made under the Health Act of 1953 have only been in full effect for a little over four years. That period is too short to assess whether or not the change will provide a completely satisfactory basis for the development of health services in the years to come.
I would not be so imprudent as to suggest that the future may not see further changes and developments in the scope of the services, but for the present, the Government do not contemplate any substantial change. Having regard, moreover, to the raising in 1958 of the income level for eligibility for hospital services and the very good value available at comparatively moderate rates from the Voluntary Health Insurance Board for those outside the classes eligible under the Health Acts, I think that in present circumstances what is provided under the Acts is reasonable.
As things are our total expenditure of almost £19 million from public funds on health is so very considerable having regard to our resources that we cannot contemplate spending much more in the immediate future. Our endeavours over the next few years must therefore be in the direction of ensuring that full value is obtained for what we are spending and I propose that the activities of my Department and of the local health authorities should be directed towards that end.
The Minister is an old and esteemed member of this House and he is an old stager in the political game. I have little doubt that it is not pure coincidence that the debate on this Estimate takes place this evening, and not last week, and that it takes place after the events in, Carlow-Kilkenny which gave us Deputy Teehan, and after the people voted for the different local bodies throughout the country. I have little doubt that the House feels that a discussion on the Estimate for the Department of Health would involve much public interest and much public speculation.
In the course of what I have to say on this Estimate, I am happy to think that because of the Minister's decision to introduce it to-night, my contribution will be more objective, and perhaps more constructive, than events might otherwise have permitted it to be. Before discussing the Minister's speech, which is a report by him of the working of his Department over the past 12 months, I should like to avail of this opportunity to pay tribute to the officer of the Minister's Department who this time last year, and for many years prior to that, sat on the Minister's right to advise him. I refer to the former Secretary of the Department of Health, Mr. Patrick Kennedy.
Mr. Kennedy was, I think, the first Secretary of that Department. He retired from that office since this Estimate was discussed last year. I think it is true to say that he crowned a long and distinguished career in the Irish Civil Service by helping the new Department of State to function. He was the official head of the new Department which was set up following the 1947 Act, and he was the official head from then until 1959, and as such, he had to face many crises. It seems to have been the unhappy experience of one of the newest Departments of State to have met many contretemps and crises in a decade. I imagine that many of the things Mr. Kennedy had to face as Secretary of the Department of Health might have quenched the spirit and damped the ardour of a lesser man. Nevertheless, in the face of many of these happenings, he ensured that the Department for which he had responsibility continued to grow in stature and prestige.
I am happy that I personally had the benefit of his advice, and, at times, his sympathy, as Minister. I always found the one helpful and the other, at times, soothing. I should like to wish Mr. Kennedy in retirement many long years, and to extend greetings to his successor. I hope he will continue to see the Department function and grow as it did under the aegis of his predecessor.
In his speech this evening, the Minister referred to many of the activities of his Department over the past 12 months, and to many of the problems which concern the health authorities and persons interested in health matters generally. I note that he has left for discussion, presumably wisely, the many criticisms that continue to be made of the administration of our health services.
The debate on this Estimate is the occasion on which questions of administration and matters of that kind can be ventilated. I should like to say that the health services themselves, as they are provided under our Health Acts, continue to be a most prolific source of criticism of various kinds, once the subject of health arises for discussion. In my time, I tried to understand the critics and to meet their point of view, and I have little doubt that the Minister is continuing to do so also.
The fact is, and remains, that the Health Act, as our health services are commonly known, has not been popular and has not won any popularity in the past 12 months. The services provided under the Health Act continue to be regarded as something less than people expected. In his concluding remarks this evening, the Minister said that the period from the coming into operation of the services under the Health Act was far too short to assess whether or not a change in the nature of the services is likely to come. He went on to say he would not be so imprudent as to suggest that the future may not see further changes and developments in the scope of services but for the present the Government do not contemplate any substantial change. That is putting things a little bit too far. I suggest the time has come, and the stage has now been reached, when there should be a full inquiry into the best manner of providing the type of health services which are suitable to our people.
We have put behind us the controversies that existed prior to the enactment of the Health Act, 1953. We have seen the services under that Act almost fully in operation since 1956. Now, some four years later and some seven years after the Act itself was enacted, we are still faced with the fact that most people resent the manner in which our present services are rendered.
If there is to be a continuance of an orderly, proper development in health services, the situation calls for some dramatic step by the Minister to establish a body to advise him and the Government on defects in the present services, defects in their administration, defects in the criticism that is levelled and, further and more important, to advise on how best we should organise, in accordance with our tradition, our outlook and our heritage, the health services for our people.
I am not biassed or a partisan in this matter. I do not think it would be right for the Minister or anyone else to shrug off the continuance of criticism of the present health services as being something without foundation. The fact is that they leave much to be desired. The Health Act of 1953 is a very makeshift measure. It was an act of expediency, rather rushed into by the Government of the day, not thought-out or planned properly. It discloses now the defects of the situation which led to its creation.
Take the most important services in so far as the general public is concerned. The service which meets them closest and which I would regard as the general medical service under the Health Act is the dispensary system. That applies to close on 900,000 people, old and young, boys and girls — close on 30 per cent. of our people. That general medical service is the service which this State regards as the means whereby the abject poor are to get urgent, necessary, medical relief when they are sick, when they are aged, when a woman is having a baby, if they are in need of hospitalisation, whatever it may be
This is the fundamental service provided for the poor in this country. This general medical service now has statutory authority under the Health Act of 1953. That service was there for over one hundred years before the Health Act was passed by this House. The system of providing medical services for the poor was introduced and came into effect under one of the Relief Acts, commonly called, I think the Medical Charities Act, 1851.
Under the Medical Charities Act, 1851, the British Government decided, in relation to the poor of Ireland, that they would provide medical relief through medical officers appointed by the different boards at the time and that these medical officers would be paid by the Crown. They would look after not those who had difficulty in paying but the very poor, the distressed, the paupers, those who were unable by their own industry or other lawful means to provide for themselves. That was the level at which the State, leaving aside the political changes, over one hundred years ago regarded its duty as beginning.
The State recognised then no duty to anyone except to the pauper, to the unfortunate impoverished person who had not a means of livelihood or of providing for himself. For that person, under the Medical Charities Act, as an act of charity the State provided a doctor if he were sick and in danger of dying. The dispensary system bom in 1851 functioned in Ireland throughout the last century and into the present century. It was carried over when this State was formed. It was not changed in the slightest. It was not altered in any part.
When the Health Act of 1953 came before this House it is notable that into it went the dispensary system unchanged, without alteration. Today, medical services are being provided for the same type and class of person under the same type and class of administration as was envisaged over one hundred years ago.
The dispensary system has long outlived its usefulness. It is absurd that in 1960 we should operate general medical services for our poor in the same way as was thought proper over one hundred years ago. When I was Minister for Health I announced it to be my policy to alter the dispensary system in such a way that for every poor person there would be provided, where possible, a free choice of doctor; that in the cities and towns and centres of population the State should not grudgingly provide for the poor the services they need but should do it generously and properly and provide for every poor person who was sick and in need of medical treatment the right to which his means entitle him — to select the doctor of his choice. That was my view as Minister and had I the opportunity it would certainly be now in operation.
I mention the question of the dispensary system but this is not the first time I have mentioned it. I think I mentioned it in Opposition before and each time this Estimate has come up for discussion since. It is difficult to understand the complacent attitude that seems to be adopted in regard to the manner and form of providing these services for the people — that because it has been there for many years, 100 years or so, it is to be continued. The dispensary system is bad and, in my view, it costs the State a considerable sum of money. I have little doubt that any person taking a short-term view of costings, or perhaps getting a little too concerned with figures, might well say that one good reason for retaining the present dispensary system is that it does not cost too much. I concede that point straight away. On figures it is a very cheap form of medicine and a very cheap type of health service. I have not studied recent, figures but I have figures for 12 months ago. Covered are 850,000 people at a total cost of £879,000. I am quoting figures for 1957-58; the cost may be slightly more now that salaries have gone up. For 1957-58 the cost was £879,000, in other words, £1 per head per year. That is what we are spending on medical services for the poor. I concede that it is a cheap service.
It is interesting to see how that £1 is spent. Of the £879,000, £570,000 was spent on salaries for the doctors; £125,000 was spent on other salaries, presumably salaries associated with the investigation of the claims of those seeking to get medical cards and get on the medical register and perhaps on associated salaries in relation to the local authority personnel; £184,000 only was spent on medicines.
I want to translate that into £1 per head because that is roughly what it works out at. Of the £1 we spend under this system of providing a medical service for a poor person, 16/- actually goes on salaries and 4/- per head goes on medicine to alleviate the condition of the poor person and make him better. I should like the House to consider what that means. It means that in relation to the provision of medicines, drugs and things of that kind for the poor of the country under the general medical service we are spending almost nothing. It is a cheap service; it is easily controlled, but what is the result? If you are going to spend only a token amount on a domiciliary service for a sick, poor person in his home what will happen? Of course that sick person moves to hospital, and the result of this type of cheeseparing has been, as the Minister complained, that our hospitals are full of poor, sick people, many of them people who could be treated and attended in their homes by a doctor. But the doctor cannot do it.
The hard working dispensary doctor in, Crumlin or in any areas near the city with an enormous number of people on his register has neither the time nor the means of continually visiting an old person who is entitled to avail of his assistance and who, because of his age, requires constant visits. What the doctor does is to make the necessary arrangements to have the old person brought into St. Kevin's Hospital. It is the same with any other sick, poor person whom a dispensary doctor may have to attend; if it involves continuous visits, the simplest and easiest thing is to get the person into hospital.
We spend per head on the poor of the country in the provision of medicines something around 4/- per head per year and apparently we take pride in the fact that we have avoided the cascade of medicines that was the problem in England under the British scheme some years ago. We may have avoided the cascade of medicines but we have increased substantially the cost of running our hospitals, particularly local authority hospitals. That system requires investigation; it requires full inquiry. It is a source of criticism which has always been there and will continue to be there until such time — I think this matter should be removed from the realm of Party politics — as a body of trained and specialised persons devise a method or advise on a method of providing for our people the kind of domiciliary medical service which will function properly.
The present system has operated under a British Act since 1851; that is its only title to be in the Health Act of 1953. There is no other reason. There is nothing Irish, nothing traditional about it. It was a measure of British public duty disclosed in one of their Acts in the last century and it is for that reason that it was continued.
When I was Minister, when it was possible to implement the maternity service for poor people, in 1954, when it was possible to get the agreement of the medical profession in providing for the wife of a person entitled to the general medical services a maternity service under the Health Act 1953, I felt that this was the beginning of the end of the dispensary system. Under the maternity service provided in the Health Act the wife of a poor person on the medical register is entitled in relation to her motherhood to a free choice of doctor — a very good provision and a very notable progressive measure in the Act. It was not easy to secure the necessary agreement in getting it implemented but it was done and under the arrangements made any medical practitioner can sign an agreement with any of the local authorities, in effect, holding himself out as being a person willing to take part in the scheme. Indeed, most of the doctors in general practice have signed such agreements and are participating in the scheme.
Under the maternity provisions in the Health Act, if the wife of the holder of a medical card or the holder of a medical card herself is about to have a baby she can say: "I will not go to the dispensary doctor. I do not like him. He is not a sympathetic kind of doctor. I will select his rival, the other doctor or one of the other doctors practising in the district." She has the right to do so and possibly many such persons do so.
There is the absurd situation now that if such a person goes to a doctor, who is not a dispensary doctor, in relation to the child she is about to have, he will attend her of course and look after her. Possibly, the dispensary doctor may be a little bit annoyed that she had not gone to him but there is nothing he can do about it. If this woman, having gone for an examination by the doctor she selects, leaves his surgery and goes out on the street, trips, falls and twists her ankle, she cannot go back to the doctor whom she has just left. She must now go to the dispensary doctor. She cannot go anywhere else. She then has no choice of doctor because her swollen ankle is not due to her motherhood. She then is entirely confined to the dispensary doctor under the present mode of administering the general medical services.
That is, in my view, a reductio ad absurdum. In my opinion, once it has been possible to achieve for women in the lower income group, as it is called —although that phrase is not in the Health Act — a choice of doctor in relation to maternity it is illogical not to provide a full choice of doctor for general medical services. I think it can be done and it should be done. It does not require anything other than a change in administration and in administrative policy.
I have little doubt that for large centres of population — this city, Cork and some of our large towns— the doctors in general practice should be invited to do generally for the poor what they have already agreed to do for women in respect of motherhood. I can see that in sparsely populated areas where there is probably a living only for one doctor as it is, the present system would probably have to be continued. There are parts of the country where, probably, it will always be necessary to pay a doctor to live there. In parts of the west, parts of the north-west and probably also parts of the south-west such a system will have to continue but that is a regrettable necessity. Perhaps if some Government implements its election policies and emigration ceases even that necessity will no longer exist. But, apart from areas such as I have mentioned, it should be possible, as an experiment, at least in the city or some other centre of population, to provide these services through doctors in general practice.
Frankly, I had intended to do it in the city. I have already mentioned it in the House. I had intended to do it in part of the city where there were temporary holders of dispensary posts. Unfortunately, that is not possible now because these posts have been filled but I have little doubt that it could be done and if it were done the quality of the service being provided for those whom we recognise as being distressed and needy people would be very much better. That is not intended as a criticism of present holders of dispensary posts. The present dispensary doctors, I have little doubt, do their best under a system which cannot produce the best in them. Most dispensary doctors are overworked. I shall not say that they are underpaid because I do not know enough about their pay situation. They are certainly overworked and they operate under a system which does not permit them to give of their best to their patients.
If all that were removed and if a poor person could go to the doctor of his or her choice and if the engagement of that doctor meant for him, as it should, the possibility of an increase in his practice, I have little doubt that the quality of the services would be very much improved.
Involved in such a change would be a change in the provision of medicines and again this should be faced. In relation to the quality of the service, I see no reason why the ordinary chemist should not fill the doctor's prescription for such poor people. They do it already for the poor person who is having a baby. A poor person who is having a baby can get whatever things are required for such a condition on the doctor's prescription from the chemist. It was carefully screened and examined in the Department some years ago and what at first appeared to be impossible was found to be possible because a careful pricing was made out and the understanding and cooperation of the chemists were obtained. The same thing could be done in relation to ordinary medical services and it would be a good thing.
Such a change as I envisage would cost more than the present system which works out at £1 a head per year, but I do not think it would cost such a great deal more. We are spending on medicines here 4/- per head per poor person. In England they spend something around 28/- per head; in Northern Ireland, they are spending something around 22/- per head. I should imagine that if a change took place here and we modified the dispensary system, our expenditure on drugs and medicines would go up. I cannot imagine its going up any further than it has gone in the north and even if it did, I have little doubt it is expenditure which would be wise because it is bound to have an effect on the hospital intake. The more people who are properly treated in their homes by the doctor of their choice who will find time to look after them, the better it will be for them particularly and also for the general health services.
There are people in this city at the moment who, when old age forces them to complain of sickness and they go to their bed, cannot be looked after at home. The service is just not there. The doctor will be called in. He will examine the patient and he will realise straight away if he is to try to treat that person at home, it will involve probably two, three or four visits a day. The demands of other patients, and the number he has to look after do not permit that. The result is that that poor old person, possibly in his or her last illness, is taken away from home and into this strange and unfamiliar situation of being in hospital. We call that the provision of a proper service for the poor. There is nothing more callous, nothing more brutal than such an outlook. If we concede, as we must, that a section of our population are unable to fend for themselves, we must not be grudging in the way we provide for them. We should do it generously and possibly lavishly in order to put them at least in the same position as those better off.
When I suggest that there are grounds for criticisms of our present services and that the Minister or anybody else should not be surprised at the continuance of criticism, I have in mind the fact that our general medical services are obviously inadequate. When the administrative scheme for our present services was proposed in 1953, it was a tragedy that somebody did not take the dispensary system and have a fresh look at it before putting it in as a foundation stone for the new services envisaged in the Health Act. That was a pity, but merely because it was in the Health Act of 1953, it would be a mistake if we said, as the Minister appears to say in the conclusion of his remarks: "It is there only since 1953 and that is too short a time to enable us to examine it." It was there for a hundred years before 1953 and it has been there far too long. The whole system should now be examined and new thinking done upon it.
That is perhaps one of the reasons for the continuance of criticisms in relation to health services and that is not something that can be overcome, unless there is a change in the method of administering these services. But even under the existing dispensary system, there is a continuance of complaints about medical cards and so on, how they are got, how some people have them and other people have not got them, and matters of that kind. That is probably due to the fact that there is no set standard envisaged under our present services and each health authority has the right, a right which it exercises, of deciding who is and who is not an entitled person.
I am inclined to the view that the clamour for medical cards is due to two causes. First of all, it is due to the general and rather widespread misunderstanding — a misunderstanding that may have been born some years back — that one is only entitled to hospital services if one holds a medical card, and many people have, therefore, sought to obtain medical cards. Up to recently certainly it was the general view that in order to get Health Act services in hospital one had to have a medical card. Perhaps publications such as that of Mr. Hennessy, and others, will redress that misunderstanding.
The second cause which leads to the anxiety to obtain medical cards is the fear — I think it is a very real one— that people have in relation to the cost of medicines and drugs. Many people when they seek to obtain medical cards are concerned primarily with obtaining them because of the cost of medicines and drugs in the chemist's shop. We subsidise a great many things here and I have often wondered if it would not be a good idea to subsidise medicines. It is the cost of medicines which makes people seek to get on the medical register. Perhaps it is because of that concern that there was so much anxiety in the last twelve months — I shall only make a passing reference to this — because of the tariff on imported drugs and medicines. I hope that, if there is to be a pharmaceutical industry encouraged here, the Minister will see to it that there will be established as quickly as possible a bureau of standards. There is, I know, some thinking along that line. Certainly such a bureau is necessary.
I have mentioned at some length criticism of the Health Acts and the services under them, that is, in relation to the manner in which they operate under the dispensary system and in relation to the provision of medical cards. But there is yet another aspect. I refer to the present hospital system. When a poor person in the City of Dublin falls sick and has to go to hospital, he or she goes in all probability into one of the teaching hospitals. In the country, the patient goes to one of the local authority hospitals. The teaching hospitals were in existence long before the Health Act. Many of them were charitable institutions and they are availed of by the Dublin Health Authority to provide what elsewhere is provided through the local authority hospitals.
Over the years there has been a feeling in the Department that, while the Minister has to meet the deficits and so on of the teaching hospitals, he really has responsibility only to the local authority hospitals. Over the past few years successive Ministers have concentrated on raising the standards in local authority hospitals. They have aimed at, and they have succeeded in getting, first-class surgeons appointed. Generally, they have raised the level of both surgery and medicine in local authority hospitals.
Probably the Minister — I can speak only about the present Minister — feels that, since he has no right of control over and no right to dictate to the teaching hospitals, he must stand back from them. The result is that, while we are using two different types of hospital for the implementation of the health services, no effort has been made to co-ordinate the system of working as between the two types.
Consider the position of a county surgeon. A first-class surgeon is appointed to a local authority hospital. He goes there full of zeal, enthusiam and determination. He finds himself, somewhat to his surprise, the only man in the show. He has no team available to him. He has no assistance. His shift begins at one minute past twelve and continues right round the clock. Such a man inevitably must become a bit frustrated and disillusioned. The position is that these first-rate specialists appointed to our local authority hospitals find themselves suddenly cut off from any sort of reasonable discussion or communion with their colleagues.
A great deal could be done and should be done to try to marry the two hospital systems. If the Minister sought the co-operation and understanding of the staffs of our teaching hospitals, in this city and elsewhere, he would find it possible to reach a situation in which the teaching hospitals themselves would help in the staffing of minor posts in our local authority hospitals. This could create a ladder which to some extent would join the teaching and local authority hospitals.
I should not like to offer anything more than the general headings of my view in that regard, because perhaps I would not be entitled to do so, but I feel in relation to marrying, or getting the two hospital systems to work together, there is quite an opportunity there, and if it is done, I believe it will be a success. If it is not done, I believe there will be a very poor service provided in local authority hospitals, again not due to the fault of any county surgeon, but because of the system and conditions under which he is expected to work.
To my mind, it is absolutely scandalous to think of a county surgeon in any county hospital, working far removed from any medical centre, and expected to do many operations each day without the benefit of any assistance whatsoever and expected, as in the case of one man in the south of Ireland, to operate with an anaesthetic service provided by a general practitioner. Those conditions add up to tragedy and unfortunately tragedies have occurred. No matter who the person may be, or how strong his physique and nervous strength, a life of that kind is bound to have its effect. There is no one who can continue to give of his best if he never gets time off, if he never gets a helping hand, and if he never has the opportunity of fully relaxing without feeling that if he does so he is likely to be called back to duty at any moment.
I would regard this question of providing properly qualified assistants in our local authority hospitals as a matter of the utmost importance. I know that financial considerations are involved but we must have regard to the effect which the continuance of the present system is bound to have. I know of a case that occurred not 12 months ago, of a man being found on the roadside who was examined by a doctor on the spot and found to be dying. The doctor phoned the county hospital to have the man brought there by ambulance and to inform them of his condition. The unfortunate man was brought to the hospital — not in fact by ambulance, but that does not matter — and the only person to receive him was the hall porter. Again that was no one's fault, because there was no way of providing anyone else as the house surgeon in the hospital happened to be the doctor responsible for a dispensary some distance away.
It is most disturbing to think that in relation to that hospital at that time —for that day—there was no doctor living in, and when an emergency arose, the hall porter had to phone a doctor who was "on tap", who came immediately, who did all that was necessary and did it extremely well. A situation which permits that to happen is a situation which is bad. I think a great deal of that is due to the fact that sufficient attention has not been paid — in recent years certainly — to trying to get these two hospital systems working together. There was some talk about that some years ago and I believe it should be followed up.
I should like to refer now to the charges which the Minister imposed some 18 months or two years ago, for specialist services and X-rays. Last year, I believe the revenue for these charges in the entire country amounted to £28,750—call it £29,000. That was for the half-crown charge for specialist services and the 7/6 charge for X-rays, and all the rest of it, and I want to suggest to the Minister that for the sake of £29,000 it just was not worth all the pother, excitement and difficulty involved in relation to the issue of stamps in this city.
If the total revenue from Cork, Dublin, Limerick, and throughout the country amounts merely to something around £29,000 or £30,000. I suggest it might be wiser to go back to the original provision in the Health Act under which these specialist services were provided without any charge. The result of these charges has not been to reduce the cost of the provision of the services in any way. I assume that the imposition of the charge was not intended and could not have been intended to discourage people availing of the services. I have little doubt that it has not discouraged them.
I was interested to see also that the revenue collected from the 10/- per day charge from different people in the hospitals throughout the country amounted in 1958-59 to £245,000. Again, with regard to that, it is I think worth saying that when the Health Act of 1953 was introduced in this House it was urged on behalf of the measure —and certainly urged when I was being asked to implement the Act subsequently — that one of the benefits of the measure was that no longer would county councillors, members of corporations and public representatives be asked to try to use their influence to get bills reduced. We were supposed to have the position where from this on a person entitled to Health Act services could go into hospital, there would not be any charge made and all this business about approaching public representatives to get hospital bills reduced would disappear.
Of course, that has not been the position. Particularly since the charge went up to 10/- per day, I think most Deputies and most county councillors find the position to be precisely what it was before the Health Act of 1953. We get the same approaches on the same grounds as was the case prior to the Act. Often the bill is sent out by the local authorities in faith, hope and confidence and without any idea that they are going to be paid the amount of the bill. I find in my own experience that frequently, as a result of directing the attention of the local authority to the obvious facts of the case, an account is waived and disregarded. I do not know whether or not the Health Act was really intended to be an advance, but certainly if you reenact in relation to hospital services the same kind of system, only calling it another name, you are not doing anything except trying to fool yourself.
The total revenue from the 10/- per day charge amounted to almost £250,000. That is not much related to the entire cost of our health services. If you take the charges for specialist services and the charges for all the hospital beds throughout the country, the total amount is £300,000. Again, I think it might be wiser to forget about these charges altogether.
The matters I have mentioned in relation to the present services, as I said at the beginning, give colour to the criticism which has continued unabated in relation to the Health Act and the Health Act services. Many people feel quite genuinely that we adopted the present form of our services some years ago not because it was felt here it was the just and proper thing to do but rather because they were doing it elsewhere. We adopted here a pale copy of the British system rather because the British had done it and, therefore, we should do something along the same lines. I think the experience since has shown that the system of providing these services has not been perfect. It may be that any system will have its defects, of course, but it is very essential for the proper functioning of the health services that they should have the confidence and support of the people.
No one can say of us on this side of the House—particularly of us in the Fine Gael Party who were strongly opposed to the Health Bill of 1953— that we have not made a very full contribution towards the implementation of the services in an effort to make them work. Nevertheless the confusion continues and the criticism has not abated in the slightest. Therefore, I would urge on the Minister, in the interests of a future orderly development, that the time has surely come to have a full, unbiased, unprejudiced, non-political examination of this entire problem so that sociologists and persons experienced in and concerned with these matters and who are divorced from the arena which concerns us in this House, would be in a position to advise fully on defects, if defects exist, in the present services and on a proper development for the future. I would urge the Minister to consider that suggestion in the coming year.
Before referring to other matters, I must say I was frankly surprised that the Minister's statement to-night gave the House no information about health insurance and the work of the Voluntary Health Insurance Board. It is frankly quite disturbing to me to find in an hour's speech by the Minister not one single reference to the work of the Voluntary Health Insurance Board.
It is not for want of appreciation of it.
It was to enable the Minister to say that that I made the reference. I have not got the figures but I hope the Minister, when concluding the debate, will give us the present position so far as the Board's activities are concerned. I saw from one of its statements in April of this year that the membership of the Board now extends to 83,000 people and has increased by some 57 per cent. over the previous year. That is a very notable increase and I hope that the work of the Board and its attraction will continue to develop in that way.
When the legislation which led to the formation of the Voluntary Health Insurance Board was brought before this House some years ago, provision was made for an initial loan to the Board by the State to enable it to go into business. I think provision was made for loans by the Minister for Health not exceeding £50,000. It appears from the last report of the Board that it asked for and obtained a loan of something over £13,000. It also appears that that loan has since been repaid in full, with interest, to the State. It surely is noteworthy that a Board of that type should have so quickly discharged an initial loan of that kind and that, in fact, what was claimed for the Board, when the legislation was introduced, should come to pass that, in fact, this measure of social legislation has not to date and I hope it will continue— cost the taxpayer one penny. I hope that is understood and appreciated by the public generally.
Health insurance is a new measure in this country. It is an effort to encourage a person to stand on his own two feet. It is an effort to teach people, where they can afford it and where they are not distressed, not to have their hands out always seeking State assistance, to teach them to join with others to help themselves. I am happy to think that the measure of success achieved by the Board since it started operations in October, 1957 has been an extremely satisfactory one. The Board now covers over 80,000 persons and I hope that in the next year it will continue to increase its membership because the more people realise that they have a duty to fend for themselves and a particular duty to safeguard their own health and the health of their families the better for the country as a whole.
In that regard might I say something further to the Minister? I understand from a discussion we had earlier this evening on the Finance Bill that the Health Insurance Board continues to be taxed, to be liable for income tax at the hands of the Minister for Finance. I shall not blame the Minister for Health for what the Minister for Finance may decide but I should like to urge this on the Minister because I gather from what the Minister for Finance said that, perhaps, the Minister for Health may not have placed the full story before the Minister for Finance. I would urge on the Minister to do all he can to ensure that this income tax liability should be dispensed with. The fact is that in the Voluntary Health Insurance Bill a section was contemplated—certainly it was in the draft—providing that the Board, since it was non-profit making, would not be liable for income tax.
When the Department of Finance learned of the inclusion of this measure in the Bill, they informed the Department of Health that the Department of Finance was still the Department of Finance and that a measure of this kind was proper only for a Finance Bill and not for a Bill dealing with health insurance. In the light of that information which was also conveyed at Ministerial level, it was agreed that the Section would be taken out of the Bill and that it would be considered at the time of the Finance Bill which was contemplated shortly after that. In fact, it was not included in the Finance Bill of 1957. It certainly was a measure which should have been included.
To-day the Minister for Finance said that he was not completely aware of that background. Perhaps, the Minister might check what I said and acquaint himself with it. It is true to say that income tax relief is already provided under the policy of the State for co-operative concerns of different kinds—co-operative concerns that, in fact, engage in commerce and that, in fact, make a profit. Here is a measure of social co-operative insurance and no profit can be made under the Statute; any surplus of revenue over expenditure must be utilised either for the reduction of premiums or an increase in benefits. It does seem a bit absurd that the mere process of collecting premiums should in itself be taxed as income moving from one person to another. I would be out of order if I said anything more about it but I would ask the Minister to take up the matter again with the Minister for Finance.
The Minister also referred in his statement here this evening to rehabilitation. I am glad to learn from the Minister that progress is being made on this matter. It was not an easy one. It was a difficult examination and I hope that the centre which the Minister envisages will be successful.
The Minister also referred in his speech this evening to the hospitals building programme and he reported that the steps which he had taken to deal with the position of the Hospitals Trust Fund were now bearing fruit. I just do not know what steps the Minister took.
We are not spending anything.
The Minister just did nothing.
That was not so easy, mind you.
Very easy. It might have been more difficult if the Minister had continued to mount and provide for the programme which I left behind. It would have been a difficult job in financing, I have no doubt, but with faith in the continuance of the Hospitals Sweepstakes and of the accretion to the Trust Fund the programme could have been carried out.
Progress reported; Committee to sit again.
The Dáil adjourned at 10.30 p.m. until 10.30 a.m. on Thursday, 30th June, 1960.