That a sum not exceeding £6,799,800 be granted to complete the sum necessary to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1962, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Árd-Chláraitheora), and certain Services administered by that Office, including Grants to Local Authorities and Miscellaneous Grants.
As in previous years I propose to review briefly the more significant vital statistics for the preceding calendar year. The figures I quote are provisional but experience indicates that the final figures will not differ materially from them.
In 1960 there were more births, more marriages and less deaths than in 1959.
The number of births registered was 60,730, an increase of 542 on the previous year. The rate, at 21.4 per 1,000 population, was again appreciably higher than in neighbouring countries. In England and Wales the figure was 17.1 and in Scotland 19.4.
The number of marriages in 1960 was 15,494, an increase of 74 on 1959.
The number of deaths was 32,660, a decrease of 1,585.
There has been a steady downward trend during the past decade in the death rate from tuberculosis. The trend continued in 1960 and the number of deaths from all forms of the disease fell to a record low figure of 468, which was 49 fewer than in the previous year. Equivalent to a rate of 17 per 100,000 of the population, the mortality from the disease in 1960 was in striking contrast with the position in 1950, when the death rate was almost five times as high. The figures for incidence also fell, the number of new and reactivated cases in 1960 being 3,478 compared with 4,344 in 1959. Such progress is encouraging; but the fact that so many new cases occur each year shows that a large pool of infection still exists. This is disquieting, as it indicates that the measures for the prevention and early diagnosis of the disease which are ready to hand are not being availed of as widely as they ought to be. I should emphasise that this is especially the case with B.C.G. vaccination and mass-radiography.
Experience has established that B.C.G vaccination is particularly valuable in the case of young persons who leave rural areas to work in towns and cities as many country-born children eventually do. Yet the latest figures available, though they are an all time record, show that many of them do not yet realise that this easily-acquired protection, which can be the means of preventing grave illness, is there for the asking and should be fully availed of. Mass-radiography is aimed primarily at detecting tuberculosis in the early stages when treatment is likely to be most effective. It offers to all, old as well as young, a necessary check upon lung and other respiratory and chest conditions. Yet in 1960 only about 10 per cent of the population came forward for X-ray. This is far from satisfactory. The ideal would be that everyone should undergo this simple check-up once a year. Perhaps this ideal will never be attained, but if it were, it is certain that probably the vast majority of us would emerge from the check with a clean bill, so far as tuberculosis is concerned. The ascertained fact, however, is that 3 per thousand of those who undergo this check-up are shown to be suffering from the disease in a more or less active from and the question arises—who knows which of us comes within that category? The answer is none of us who has not submitted himself to an X-ray during the year and secured a clean bill on the test. That only 0.3 per cent of those who have themselves X-rayed should be found to be infected indicates that for the vast majority the outcome of an X-ray examination is likely to be highly satisfactory and most re-assuring. And even for the few who are warned that they require immediate medical attention the outlook is not too gloomy; for the community will come to their aid in the most practical way. First of all since T.B. is an infectious disease, medical attention and treatment, whether in the home or a sanatorium, is given free of charge. Secondly, subsistence allowances are granted where necessary in respect of a dependent spouse and children. No person, therefore, need be deterred by financial considerations from availing himself of the mass-radiography service. The service indeed may well save his life, since, if an infective condition should be detected by it, all the health services are available to the individual concerned and will afford him the latest and most effective treatment. Moreover, the X-ray may detect other unsuspected conditions, conditions possibly, which may yield to treatment at an early stage, but which, if neglected may prove intractable. In short, the minutes spent in having an X-ray may purchase many years of life.
But, of course, tuberculosis, though still a significant killer and highly important because it is infective, is by no means the most lethal of the conditions with which modern society has to cope. Last year cardio-vascular diseases and cancer were again the two major killing diseases. The former in fact, was responsible for 10,633 deaths, as against 10,830 in 1959—by no means a notable decline. In the case of cancer, unfortunately the decrease was scarcely apparent, the overall mortality at 4,759 being only 18 deaths lower than in the previous year. While the mortality figures for these diseases are consistent with the prevailing world pattern, the picture, so far as cancer goes, would have been a little brighter, had it not been for the fact that the number of deaths from those forms of it which are grouped under the title of lung cancer, showed a significant increase from 601 in 1959 to 648 in 1960. Since there is abundant evidence of a correlation between heavy cigarette smoking and death from lung cancer, the figures for cancer deaths carry a grave warning to all who smoke.
With maternal and infant mortality, our experience has been much better and the rates have continued to fall. The maternal mortality rate was 0.58 per 1,000 births, as against 0.65 the previous year, while the infant mortality rate was 29 per 1,000 live births as against 32. This continuing improvement is heartening. It is especially so when allowance is made for the pattern of late marriages and large families in this country. Nevertheless, figures for neighbouring states indicate that further improvement is possible. Thus, in 1960, the maternal mortality rate in England and Wales was 0.4; in Scotland it was 0.3; and in Northern Ireland it was 0.4. The infant mortality rates in these areas were: England and Wales, 22; Scotland, 26, Northern Ireland, 27.
The most dangerous period in the life of an infant is what is known as the peri-natal period, extending from the 28th week of gestation to the end of the first seven days of life. This fact was emphasised by a study published some years ago by the World Health Organisation. The study showed that, while infant mortality in general has decreased sharply, mortality at birth has not decreased to anything like the same extent. In addition, the study indicated that almost a third of peri-natal deaths occur on the day of birth; that the death rate is considerably higher for boys than for girls, but that far more girls than boys die of congenital malformations of the nervous system. The reasons for all this are not yet clear, and the fact that a high percentage of peri-natal deaths listed in the study were described as being due to "ill-defined or unspecified causes" went to show that much has yet to be learned about the problem.
About six years ago, the World Health Organisation invited Ireland, Sweden and the Netherlands to undertake a special survey as an initial step towards determining what action could be taken to reduce this peri-natal mortality. All three countries agreed to accept the invitation; and, on my immediate predecessor's invitation, the Medical Research Council agreed to conduct the survey here. I am glad to say that the work has been proceeding very satisfactorily and that it is anticipated that results will be available for analysis this year. It is impossible to say, of course, what contribution the work will make towards a reduction in the number of deaths in future, but I know that every member of the House will agree with me that participation in pieces of research such as this, well thought out and carried through on an international scale, is worth while and will join with me in thanking the Medical Research Council for its ready co-operation.
Turning to the communicable diseases, we find that deaths from poliomyelitis rose from 2 to 17. The number of cases of this disease noted in 1960 was 183. As the House is aware, a vaccination service which gives a high degree of protection against it has been in operation since April, 1957. Its scope has been widened every year since then, and in the current year is being widened still further.
The service now provided by health authorities is available to persons in the lower and middle income groups between the ages of 6 months and 40 years, to expectant mothers in those income groups and to other special categories. These include hospital staffs, certain practising nurses, medical and dental students, teachers, and other public health staff who might come into contact with poliomyelitis cases, together with the families of persons in these groups. The service is free of charge to persons in the lower income group and the special categories mentioned. For those in the middle income group, outside the special categories for which, as I have stated, it is free, reasonably small charges are made. Provision is also being made for a fourth injection where appropriate. In view of the wide coverage which the service now offers, there is no reason whatever why anyone should take the risk of contracting "polio" rather than be vaccinated against it.
I cannot be too strong in urging everybody to avail of the several vaccination and immunisation services which their local health authority provides, not only against poliomyelitis, but against diphtheria and small-pox. It is true that we have had no case of small-pox for many years and that the incidence of diphtheria has declined considerably and this may be the reason why the number of persons who have taken the precaution of protecting themselves against these diseases is disappointingly small. Prophylactic safeguards against the risk of contracting these diseases are available free of charge to everyone without exception, and yet they are not being generally availed of. Such lethargy is not only disappointing, it increases the risk that, should one or two cases occur and remain for even a relatively short time undetected, a very grave and widespread situation may develop with great rapidity.
To turn now to the Estimate itself, the largest single item is that included under subhead G—which provides for a total of slightly over £9,000,000 in grants to local health authorities in aid of their expenditure on health services. These grants are authorised under the Health Services (Financial Provisions) Act, 1947, the effect of which, nowadays, is broadly to commit the State to meet half the cost of local health services.
The total cost of these services in the present year, having made allowance for such receipts as charges on patients, will be about £18 million. This compares with £17.6 million last year, and £16.8 million in the year to 31st March, 1960. The corresponding totals for 1953/54, the last complete financial year prior to the partial introduction of extended health services under the Health Act, 1953, and for 1956/57, the first complete year after the introduction of the services, were £11.2 million and £15.8 million respectively. While there was thus a definite increase in the cost of the health services in the period immediately following the coming into operation of the 1953 Act, and while the cost has continued to increase more gradually since, the whole of this increase cannot be attributed to the Health Act. Not by any means.
Quite a substantial factor has been the making good of regrettable deficiencies in our health services, deficiencies which common humanity demanded should be remedied, Health Act or no Health Act, as rapidly as possible. The increased facilities which have been provided for the care and treatment of mentally-handicapped children is an example of this. In 1953 there were 1,460 beds for such children. This year we have 2,734 and it is hoped to bring this figure up to 3,000 by 1963-64. Not only has the capital cost of these additional beds been met almost entirely from the Hospitals Trust Fund, but the greater portion of the actual cost of maintaining the children is covered by the capitation grants paid by local health authorities, who are in turn recouped as to one-half of their expenditure from moneys provided under this Vote. Thus the cost of caring for these young patients is borne almost completely by the ratepayers and taxpayers, and is increasing from year to year.
In 1953 the capitation rates payable to these institutions were generally in the region of £2 5s. Od. per week and were payable in respect of about 1,400 children. To-day they vary between £3 10s. Od. and £4 per week, and are payable in respect of about 2,400 children. In 1953 the cost of this service was of the order of £190,000; to-day it is in the neighbourhood of £450,000, perhaps even more. It will almost certainly be more next year and more still as time goes on. But what are we to do about it? Who of our critics will tell us to call a halt in dealing with this problem? Are they not urging us to spend more and more money to solve it?
Expenditure on drugs and medicines used in our mental hospitals during 1953/54 was £25,000. This year it will probably be £122,600, which is quite a considerable increase. But the increase is spent in the main on newly-evolved drugs, most of them drugs the established therapeutic value of which is high, the drugs which give so much relief to the mentally disturbed. Thanks to them the whole approach to mental illness has been altered. There is now hope in most cases, if not always a complete cure, at least a marked alleviation of suffering. Thanks to them also the general atmosphere of our mental hospitals has changed. Their patients are more peaceful, calmer, and less fractious than they used to be. But the drugs which have brought all this about are expensive; they increase the cost of the services, and accordingly they send up the rates. But is there any Deputy who is prepared to urge that for these reasons we should cease to buy them, cease to use them, and turn our now peaceful and curative mental hospitals back again into the bedlams they once were?
Apart from increases of this nature, originating in a fuller recognition of the obligations which the community in general has towards its more hapless members, account must also be taken of the undeniable fact that the rates of remuneration enjoyed by the personnel of the service have been substantially increased. This increase is in no way peculiar to the health services or ascribable to the operation of the Health Acts. To the extent to which the increases are not represented by an actual rise in living standards, they are a reflection of the fact that, throughout the world, there has been a significant fall in the value of money. To obtain a true picture of the increase in expenditure which can be attributed solely to the growth of health services as such, it would be necessary to eliminate these factors. This would entail breaking down an intricate cost complex into its elements. In view of the fact that the final result would be of no practical utility whatsoever, it would be futile to waste time and money on such a task. There is, moreover, a better and more realistic way of approaching the problem available to us.
The relation which the amount expended from public funds on a particular service in any year bears to the gross national product in that year is a measure of the real burden which the service in question imposes on the community. Applying this standard to our expenditure on the health services since 1953, a picture, and it is a true picture, emerges which will confound our critics —that is so far as costs are concerned. The percentage of the gross national product represented by the amount of central and local taxation required to pay for health services in 1953 was 2.14. This proportion has risen to 2.92 in 1956 but by 1958 had declined to 2.77. In 1959 the percentage was 2.70 and it is estimated to be 2.71 for 1960. It would seem therefore, that not only has equilibrium been reached in the proportion of the national product spent through rates and taxes on health services, but that in relation to the capacity of the community to pay for them, the cost of the health services tends to decrease. This is as one would expect in a prospering community.
During the past year there have been statements to the effect that the additional services provided under the Health Act, 1953 are now costing the ratepayers considerably more than had been forecast in 1952 when the Bill was under discussion. Recently in this House, a figure of 8/- in the £ was mentioned as the amount of the increase. I am referring to the Dáil Debates of 14 March, 1961, Column 550. In arriving at this conclusion, Deputy Thaddeus Lynch, who postulated that figure, appears to have overlooked the significance of certain administrative changes brought about by the Health Act, 1953.
Prior to the coming into operation of that Act, local authorities in their capacity as public assistance authorities provided a wide variety of health services and the cost of these was shown in the rate demands, as well as in the rating returns and the accounts, as public assistance expenditure. The services thus scheduled as public assistance services included such major items as the dispensary service, general hospital services and the county home services —all of which are undeniably health services, and nothing else but health services. On the other hand the medical services provided by local authorities, as health authorities, were limited to such services as school health inspection and control of infectious diseases —that is, to a very restricted range of special activities. But prior to the coming into operation of the Health Act, 1953, it was only the expenditure on such services which was classified as health expenditure and defrayed from the "health" rate.
The 1953 Act rationalised this absurd classification so that expenditure on services which were in fact health services, though previously included under the head of public assistance, was thenceforth debited to the health account. Consequently a comparison of the "health" rate for a year prior to 1954 with the "health" rate in later years is invalid. If it is sought to obtain a realistic picture of the rate position in any year it is necessary to bulk the "public assistance" rate with the "health" rate proper. If this is done it will be found that, in the counties, the average increase in the rates between 1953-54 and 1960-61 was just under 3s. in the £. Not all of this increase was due to the improvement and expansion of existing services or the introduction of new ones. I have already shown indeed that a substantial fraction of it has been generated by a wholly adventitious factor, to wit, the decline in the value of money.
In the county boroughs, the average increase corresponding to the figure of just under 3s. for county areas was 5s. in the £, and here again a substantial portion of the increase has been due to the same factor, one which is completely extraneous to the Health Acts. A rough estimation shows that about half of the increase could be ascribed to this and other adventitious factors. When, therefore, allowance is made for such factors, as it must be made, the average real increase in rates which may be attributed to the improvement and expansion of the health services since 1953 is not 3s. in the counties and 5s. in the county boroughs, but only 1s. 6d. and 2s. 6d. respectively.
The figures which I have given are average figures, taken over all the counties in the one case and over all the county boroughs in the other. To bring home the point in concrete terms, however, I shall take as examples, the cases of typical farmers in Limerick, Kildare and Monaghan, assuming that in each case the valuation of the farm is £30 and that one agricultural labourer is employed.
In the year 1953/54, the rate in Limerick County in respect of health charges, including mental hospitals and all public assistance charges, the most of the latter being, as I have pointed out, medical in character, was 8/1d. in the £. The gross amount of rates payable by our Limerick farmer in respect of these services would thus have been £12 2s. 6d.—if account were not taken of the allowances payable by way of Agricultural Grant. In fact, these allowances reduced the impost on this Limerick farmer by £8 17s. 8d., and left the net sum of only £3 4s. 10d. as the amount which he was required to pay in rates in respect of the financial year 1953/54 to meet the cost of all health and public assistance services, including medical services, provided by his local authority.
For the farmer in Kildare with a £30 holding, the corresponding amounts for that same year of 1953/54 were £14 17s. 6d. gross and £3 19s. 4d. net. For the farmer in Monaghan, the figures were £11 10s. 0d. gross and £3 1s. 4d. net.
Now let us turn to the year 1960/61 and see what the increase was in terms of the actual cash payments which would fall to be made by these three farmers. For the farmer in Limerick, the total rate in respect of health and public assistance charges had risen to 11/11d. in the £, that is, by more than the national average and the gross amount of rates payable by him to meet these charges had risen to £17 17s. 6d. Again, however, when account is taken of the allowances payable by way of Agricultural Grant the actual charge falls to be reduced considerably, the amount of the reduction being £13 0s. 5d. This leaves a net amount of £4 17s. 1d. payable. Accordingly, the actual amount of rates which this farmer is called upon to pay for health and public assistance charges in 1960/61 is £4 17s. 1d. as compared with £3 4s. 10d. in 1953/54, representing an increase of only £1 12s. 3d., in return for which he becomes entitled to the benefit of the extended services under the 1953 Act for himself and his family.
For the farmer in Kildare, the corresponding increase is £2 1s. 10d., being the difference between the net amount of £3 19s. 4d. payable in 1953/54 and the net amount, £6 1s. 2d., payable in 1960/61. In the case of the Monaghan farmer, the increase in the rates actually payable is £2 1s. Od. which is the difference between £3 1s. 4d. net in 1953/54 and £5 2s. 4d. net in 1960/61.
Incidentally, averaging the increase in the amount which would be payable in 1960/61 as against 1953/54 in these three cases, we find that it represents no more than 38/4d. over the seven year period. This is equivalent to an increase of 15?d. in the £, which is a long way from the 8/- postulated by Deputy Thaddeus Lynch.
Furthermore, all of this 38/4d. is not properly chargeable against the 1953 Health Act. A substantial portion of it, perhaps even half of it, has been engendered by influences, like inflation, which have operated to increase the cost, not merely of the health services, but of every commodity and of every service, whether it be health, transport, education, food, clothing, entertainment or otherwise. Making allowance for the effect of this all-pervading and predominant factor, it cannot be contended by any reasonable person that over the whole seven years the increase in rates payable in respect of a residential holding of £30 valuation, and properly attributable to the operation of the 1953 Health Act, amounted to more than £1 per year.
The remaining subheads of the Estimate show little change compared with last year and, apart from Subhead N on which I will speak later, do not call for any detailed comment. I may say though that the increase under Subhead A is accounted for by an addition to the medical staff of my Department to bring it up to the authorised full strength and by the general salary increases. The increase under Subhead F is due mainly to provision for the cost of the Commission of Inquiry on Mental Handicap, to which I shall refer later.
With regard to Subhead M, I referred last year to the purpose of the provision of £3,000 then made under this subhead, namely for obtaining advice and assistance on the establishment of a rehabilitation centre. Progress with the formulation of the necessary scheme was not as rapid as had been anticipated and consequently the provision was not utilised. It is repeated this year, and with the establishment of the National Medical Rehabilitation Centre at Our Lady of Lourdes Hospital, Dún Laoghaire —a matter to which I will refer later —the expenditure of the allocation in the current financial year may now be anticipated. An allocation of £1,000 was also made under the Grant Counterpart Agreement with the United States for the study of methods for the diagnosis, prevention and cure of pneumoconiosis in mine workers. Provision to spend this is included in this year's Estimate. Expenditure from the subhead will be recouped from the American Grant Counterpart Special Account and provision has been included in the Appropriation-in-Aid Subhead for a receipt of a similar amount to that referred to above, namely, £4,000.
The fact that liquidity has been restored to the Hospitals Trust Fund has enabled me to authorise the resumption of hospital building on a number of projects. Among these is the new Erinville Maternity Hospital in Cork, on which work is now in progress. This hospital will provide accommodation for 54 maternity and gynaecology patients and a neo-natal unit of 14 cots. A new nurses' home is in course of construction at Portiuncula Hospital, Ballinasloe. Special attention is being directed to the improvement of conditions in mental hospitals and among the more important projects commenced is a new 60-bed admission unit at Cork Mental Hospital. Work has also started on a scheme for the improvement of the water supply and the provision of central heating and new sanitary annexes at Clonmel Mental Hospital. Contracts are on the point of being placed for the building of extensions at the Home and School of the Immaculate Conception, Cregg House, Sligo, which caters for female mentally handicapped persons. This project will provide 143 beds.
Planning has almost been completed and it is expected that tenders will be invited in the near future for the building of extensions at St. Mary's Convent, South Hill, Delvin, where mentally handicapped persons are also cared for. This scheme envisages the provision of 120 beds. Work is also well under way on a building to house the cobalt therapy unit at St. Luke's Hospital, Dublin. This form of treatment has not up to now been available here for patients suffering from cancer. A specially equipped and staffed radioisotope unit is also being provided at St. Luke's Hospital which in addition to catering for the needs of the hospital, will also provide a service for other hospitals requiring it. The total cost of the projects which I have mentioned is estimated at £830,000; and all of them, provided nothing extraordinary occurs, will be carried through to completion.
Among the major voluntary hospital schemes to which approval was given in the past year was the resumption of work on the new St. Vincent's Hospital at Elm Park. This will be a teaching hospital and will, therefore, be a most important addition to the hospital services in the Dublin area. A grant of £1,500,000 has been promised for the project and planning work in connection with the superstructure is now in progress.
I am happy to report that good progress is being made in planning the new Coombe Hospital and present indications are that it should be possible to commence building operations next year.
Other works approved in principle at voluntary hospitals include the provision of accommodation for nurses at the North Charitable Infirmary, Cork, improvements in the accommodation at Cork Dental School, a new theatre suite and the renewal of the electrical installations generally at Jervis Street Hospital, and the reconstruction of premises at the National Children's Hospital, Harcourt Street, to provide accommodation for nursing staff. A scheme for the extension of accommodation at St. Vincent's, Lisnagry, County Limerick, will provide additional facilities for the care of female mentally handicapped persons. The carrying out of improvements at St. Teresa's Home for Girls, Blackrock, County Dublin, where similar patients are cared for, has also been approved.
On the local authority side, particular emphasis has been placed on improving the conditions in mental hospitals and county homes. A short list of urgent works at mental hospitals has been drawn up and considerable progress in planning has been achieved. The gross cost of the works involved is estimated at about £1,000,000. I confidently expect that work on a number of these projects will start this year. The decision, to which I referred last year, to press ahead with the planning of comprehensive schemes of improvement in the county homes is being implemented with all possible speed. Due, however, to the complex problems involved, and the very extensive nature of the work required, the planning is taking somewhat longer than I had expected. This programme for the improvement of standards in the county homes is not being assisted by the Hospitals Trust Fund but, in accordance with a decision taken in September, 1951, will be financed from the Local Loans Fund. Half of the loan charges, however, will be recouped to the local authorities concerned from the Vote for my Department.
Among the more important works at local authority general hospitals which I approved during the past year and which are now being planned, are a scheme of improvements at the County Hospital, Wexford, and the provision of additional beds at Sligo County Hospital, including a sub-regional ear, nose and throat unit.
There is an important aspect of hospital building to which, I feel, I should refer—that of the need for proper maintenance. It is a matter which, unfortunately, has not received due attention from health authorities in the past. The seriousness of it has been highlighted for me by recent cases of neglect, extending over many years, on the part of local authorities in relation to their mental hospital buildings. The result of this continued lack of maintenance of the fabric of these buildings is that the unfortunate ratepayers of the areas concerned will now be faced with a heavy bill to remedy the widespread serious structural defects which neglect has allowed to develop. The old adage "a stitch in time saves nine" is surely apposite here.
Many of our health institutions, notably the mental hospitals and county homes, were built in the last century. It should be obvious to the controlling authorities that, in such cases particularly, periodic inspection of the buildings and prompt attention to defects are vitally important for their proper preservation and for the comfort of the patients and staff housed in them. Furthermore, there has been a capital investment during the last thirty years of many millions, mainly from the Hospitals Trust Fund, on new local authority hospitals. It is an obvious and essential part of the obligations of health authorities to see that these new hospitals are kept in a proper state of repair, and thus ensure that no part of these vital capital assets will be lost for the want of necessary maintenance.
I have asked my Department to examine this general problem, so that everything proper will be done to make certain that health authorities regularly and effectively will inspect all their institutions and operate a systematic maintenance procedure whereby structural defects will be remedied without delay. Henceforth an effective check will be kept on the manner in which health authorities are fulfilling their obligations in this matter.
The hospital treatment of tuberculosis does not now make the same demands on our resources as in recent times, so that the available accomodation is substantially in excess of needs. Steps are being taken to use for other health purposes those of the redundant sanatoria which can be adapted economically to such purposes. During the past year, the reallocation of surplus tuberculosis accommodation brought a measure of relief to overcrowding in the mental hospitals. The former sanatorium at Ballyowen, County Dublin, has now been opened for the treatment of acutely ill female mental patients. The former sanatoria at Shaen, County Laois, and at Listowel, County Kerry, were taken over to make room for some of the patients accommodated in overcrowded conditions at the mental hospitals at Portlaoise and Killarney.
Because of certain difficulties in securing trained and experienced personnel, I have not been able to utilise Woodlands, in County Galway, as I had hoped. Portion of it, however, is now being used for the purposes of a new industrial undertaking, pending the erection of its own factory.
In the field of mental health a Commission of Inquiry is now investigating the problem of mental handicap, and I hope in the very near future to announce the establishment of another, which will concern itself with mental illness. These two Commissions are complementary and between them they will cover all aspects of the mental health services. It will give some idea of the magnitude of their task when I say that the mentally ill and mentally handicapped occupy nearly as many places in hospitals as do all those treated for physical ailments.
The main problems associated with the provision of a service for the mentally handicapped were set out in a White Paper which was published in 1960. Very briefly they are: the organisation of services for the ascertainment and assessment of the degree of mental handicap; the establishment of domiciliary and out-patient services; the provision of appropriate institutional accommodation for those needing it; the organisation of an aftercare service; the provision of training and placing in employment of suitable persons; and last but by no means least, the recruitment of adequate trained personnel to provide the necessary services.
These are formidable problems, and, inevitably, an attack upon them will cost a considerable amount of money. As I have previously emphasised, I regard it as essential that our services should be well conceived, well planned and calculated to yield the best results to those for whom they are provided, so that there will be no wastage of time, money or effort on haphazard, ill-considered, or non-productive developments. In drawing up the terms of reference of the Commission free to advise me on every aspect of the care of those thus afflicted, to report objectively on our services as they exist and to recommend such changes as it considers desirable. Pending the report of the Commission all possible steps to supply obvious needs will be taken. At the moment we have accommodation in residential institutions for 2,734 patients, and when the works now about to commence are completed, we shall then have about 3,000 places.
The terms of reference of the Commission on Mental Illness have similarly been drawn to permit the Commission to examines all the problems involved with the utmost objectivity. I wish to assure the House, though, that any improvements in the facilities for mental treatment, which are obviously necessary and which can be made meantime, will be carried out without waiting for the Commission's report.
During the past year a small reduction of 143 in the number of patients in mental hospitals was achieved. Overcrowding in our district mental hospitals and auxiliary institutions is still, however, a major problem.
I have already mentioned two of the ways in which we are seeking to alleviate it—new building within the mental hospitals and the utilisation of redundant sanatoria accommodation. Even in advance of the report of the Commission on Mental Illness, I hope and trust that the ultimate solution will not be found along those lines. Indeed, as a layman, I feel quite certain that, in the future, treatment services will be developed outside the mental hospitals; whereby it will be made possible to discharge patients, under suitable conditions, at an earlier stage than at present.
An interesting proposal made during the year and one to which I was happy to accord approval was the establishment of two day-hospitals, serving the towns of Monaghan and Cavan and the countryside immediately surrounding them. The Monaghan unit should be operating in the near future. The Cavan unit will come later. I am sure that the House will appreciate the importance of these developments. Under them a patient who attends at a day hospital will have the benefit of the full range of therapeutic facilities ordinarily available only to hospital in-patients, but will also remain in contact with his family and his normal environment. In this way he can avoid the sometimes painful process of rehabilitation and readjustment which is the lot of the in-patient on discharge from a residential institution. Moreover from the point of view of expenditure on health services, the day hospital offers considerable advantages. Less accommodation is required, and nursing and other costs are lower. But needless to say I want the House to understand that this is the merest secondary consideration.
I do not wish to overstress the importance of this development—many conditions of mental illness cannot, for instance, be dealt with in such hospitals—but I think the House will join with me in congratulating the Cavan-Monaghan Mental Health Board and its staff on the initiative they have shown.
A notable step forward in the organisation of rehabilitation services has been taken with the recent opening of the National Medical Rehabilitation Centre at Our Lady of Lourdes Hospital, Dún Laoghaire. This centre will be operated by the Sisters of Mercy, in collaboration with the National Organisation for Rehabilitation. Certain building works will be necessary in order to better adapt the hospital to its new purpose, and I have indicated that a grant from the Hospitals Trust Fund will be made to meet the cost of an approved scheme. I should like to take this opportunity to pay tribute to the combination of effort by these two organisations which is producing a more effective and economical result than could otherwise have been achieved. Another new development in this field is the recent opening by the Irish Sisters of Chairty of an outpatients' clinic planned to provide a range of rehabilitation services at St. Anthony's, Merrion.
In singling out for special mention the work of these bodies, I am not unmindful of the very valuable public service given by other voluntary bodies, great and small, throughout the country which have been operating rehabilitation services, perhaps in narrower fields, for some years past. They have, by their efforts, put the community very greatly in their debt. There is, however, an element of danger in such effort if it is not co-ordinated. Overlapping of activities could lead to waste of effort and money, and to frustration. The prevention of such overlapping and the achievement of co-ordination without regimentation was one of the objects which my immediate predecessor, Deputy T. F. O'Higgins, had in mind when he established the officially-appointed National Organisation for Rehabilitation. I have decided, as a matter of settled policy on my part, that before official support can be given to the establishment or development of any rehabilitation project, the advice of the Organisation will be sought. I have no doubt that such advice from that objective and broadly-based body will be of the greatest value to me, to future Ministers for Health and to the various groups operating in this field.
I should like to mention a few points in connection with the operation of what are known officially as the General Medical Services. Due to the extensive press publicity given to them at the time, Deputies are doubtless aware that in certain cases fees were accepted by dispensary doctors from persons who were entitled to general practitioner services free of charge, and of the action I felt compelled to take.
A district medical officer, that is to say a dispensary doctor, when he accepts one of these much sought after appointments enters into a solemn contract with the health authority, in consideration for the payment of a salary, to provide, to the best of his professional ability and without charge, for every person in his district determined by the health authority by the issue of a medical card to be so entitled, a comprehensive general practitioner medical service at the officially appointed dispensary at the officially appointed time, or at the patient's home if he is unable, because of his illness, to travel to the dispensary. Consequently, deliberate failure to give prompt and adequate attention, the conscious creation by his actions of the feeling that a better or more prompt service would be given if a payment were made, a demand for a fee or the acceptance of a fee or other reward, constitutes a breach of the obligations to the patient and to the health authority into which he entered voluntarily in accepting appointment.
I believe that the attitude of the very large majority of dispensary doctors towards their eligible patients is above reproach, but, if a dispensary doctor is so callous as to exploit the need of a poor person who is without means to engage a private doctor, then I am certain that Dáil Éireann would not expect me or any other Minister for Health to tolerate such exploitation. I feel confident that the House will, accordingly, endorse the warning which I now give that lack of proper attention to eligible patients or the demanding or acceptance of fees from them, will be dealt with most severely. Health authorities have recently granted a liberal increase in salary to district medical officers so that the argument, invalid though it always was, that dispensary doctors were entitled to accept fees because their salary was inadequate has even less substance than it had before.
Experience of the operation of dispensary medical services has shown the need from time to time for the revision of dispensary districts in various areas, but more especially in urban centres, in order to improve the standard of services in those areas, by, for example, affording relief to district medical officers, responsible for the care of an excessive number of eligible persons, or by allowing the attendance of eligible persons at more convenient centres. During the past year certain dispensary districts in the Dublin, Limerick city and Cobh areas were altered in this way. Major revisions are also under consideration in Cork city and suburbs, Galway, Kildare and a number of other health authority areas.
In dealing with such revisions in the larger urban areas I have thought it wise to depart, where possible, from the rather rigid sub-divisions of such areas previously in operation. Instead, it is intended where appropriate to have one dispensary district embracing the whole urban area. Duties can then be allocated to an appropriate number of district medical officers in the dispensary district, each one being assigned a sub-division of the district. This arrangement will be more flexible, as the sub-divisions may be varied administratively by the manager, with the consent of the Minister. It will allow the health authority to deal speedily with problems arising out of shifts of population within the urban area.
Under an Age Limits Declaration made in January, 1960, the retiring age of 70 was fixed for dispensary doctors, to operate from 1st July, 1960. The age limit for other officers in the local authority services is 65. Following representations made to me, by individual dispensary doctors and by groups of such doctors, in which the unusual nature of the position of dispensary doctors was stressed, I took measures to ease the effect of the Declaration in certain respects.
These measures included the postponement of the operation of the Declaration from 1st July, 1960 to 1st January last, the raising of the age limit for dispensary doctors who had reached the age of 67 years on 1st August 1960, to 72 and the fixing of an age limit between 70 and 72 for those between 65 and 67 on 1st August, 1960. In addition, I arranged that dispensary doctors may, when they retire from their permanent posts under the revised age limits as thus fixed, be in some cases retained in a temporary capacity for a while.
These concessions ensured that no dispensary doctor would have to retire without having a reasonable period in which to prepare for retirement. However, it was also represented to me that, these doctors being part-time officers, their pension compensates only for the loss of official emoluments and makes no provision for loss of private practice or disturbance of residence following upon retirement. This could constitute a hardship on officers who could previously expect that they might continue in office until death or voluntary retirement. To alleviate such hardship it is proposed, under Subhead N of the Vote, to make special compensatory payments to dispensary doctors retiring under the age-limit order within seven years of its commencement. The payments will take the form of a supplement to the pension payable by the health authority, varying in amount from 50 per cent. of the pension for those retiring this year down to 10 per cent. for those retiring in 1967. In all cases payment of the supplement will cease to be paid six years after the doctor's retirement.
In addition, to compensate for loss of the use of official dispensary residences, it is intended to make lump sum payments varying from £500 for those retiring in the year ending on before 1st July next, down to £100 for those retiring in the year ending on 30th June, 1965. This part of the scheme of compensation will cease to operate on that date. The estimated cost in the present year of supplements to pensions is £7,100 and that of the lump sum payments is £3,900.
These supplements and lump sums will fall finally on the Exchequer; health authorities will not be required to meet any portion of them. Any necessary statutory provision will be included in a forthcoming superannuation Bill; but in the meantime, I am anxious that the doctors concerned should not remain out of their money and consequently, if the House agrees, I propose to authorise payment as soon as possible after the Estimate has been taken. For that purpose, I am asking that the Estimate should be reported immediately after it has been passed in Committee. I should be grateful for the co-operation of Deputies in this matter.
There have been references from time to time to the desirability of providing a choice of doctor for persons eligible for the general medical service, by substituting for the dispensary service a panel scheme for persons in the lower income group. This question was examined in my Department as far back as 1953, when Deputy Dr. Ryan was Minister for Health. It also received the close attention of Deputy T. F. O'Higgins when he was Minister. I also have considered it very carefully. Apart, however, from the important question of extra cost, and the burden which this would impose, particularly on the rates, there are practical difficulties and disadvantages in this proposal which cannot be ignored.
The establishment of a panel scheme pre-supposes the abolition of the dispensary system in its present form and the remuneration of participating doctors on a capitation basis. This, of course, would constitute something of a major revolution. Apart from this, a highly practical consideration is the fact that in many of the rural areas—indeed in substantially more than one-half of the total number of dispensary districts—the dispensary doctor is the only doctor available within a reasonable distance. Consequently, in actual practice there cannot be a true choice of doctor in such areas. Indeed, one can go further and say that, were it not for the inducement of the regular salary attaching to the post of dispensary medical officer, there would be little to attract private practitioners to set up practice in remote districts with small scattered populations. It will be appreciated, therefore, that if it were not for the present system, there probably would not be the services of even one general practitioner available for the lower income group in these districts and, incidentally, for persons in other income groups who can afford to pay.
This objection does not, of course, apply to urban areas nor to all rural areas and we could consider a selective panel scheme for suitable districts. On the face of it, this seems feasible but I doubt if it would secure universal acceptance. The provision of a panel scheme in any area would be considerably more expensive than the present arrangement. In the typical county which includes both urban and rural areas, and in the areas of the Dublin, Cork, Limerick and Waterford health authorities, this would mean that the local authority would be asked to provide, and finance to the extent of one-half, a more expensive service for the town dwellers than for the remainder of their ratepayers. Now, it is true that urban authorities already provide services and amenities—water supply, sanitation, lighting and so on—which it cannot or at least does not provide for most of the rural dwellers, and this often gives rise to bitter complaints from the rural ratepayers. It is only rational to anticipate that county health authorities will be reluctant to concede a further expensive service to the urban areas, and to do this largely at the expense of the rural dweller.
Even if we could surmount this hurdle and bring in the panel scheme in selected areas, I can foresee at least one other big disadvantage in its operation. As Deputies will be aware, eligibility for the General Medical Service is governed by inclusion in the General Medical Services Register. The local authority decides the cases which are deserving of inclusion in the register and the standards which they apply are not infrequently a vexed local issue, some echoes of which we hear occasionally in this House. In saying this, I do not wish to infer that I believe that there is any general cause for complaint, but if any Deputy does believe that there are grounds for complaint, let him consider what the effect of introducing a panel scheme would be.
At present, it does not cost the local authority very much to add another name to the Register. The dispensary doctor's salary must be paid in any event and, apart from maternity cash grants, the only extra liability in respect of an additional individual would arise from the supply of drugs and medicines. This easy position would not obtain under a panel scheme. Every name added to the Register would mean that the local authority would pay to a doctor on the panel aper capita payment for that person (and, if he had dependants, for each of them) and would also have to budget for the medicines which might be prescribed for them by that doctor. A definite and immediate liability to expend a sum of, perhaps, £10, might be incurred by the inclusion of an additional name in the Register. This being the position it is likely that there would be much greater reluctance to allow an individual's name to go on a panel than there is now to grant him a medical card.
It will be clear from this that such a change cannot be readily made. It is, of course, a possible improvement which must fall for consideration in the future development of the health services; therefore I have arranged for my Department to assemble all the relevant facts and estimates of costs, and in due course the Minister for Health will be in a position to study the matter again in the light of experience.
It may be that some Minister for Health will be able to devise a scheme which will give a choice of doctor to everybody who is entitled to have general practitioner services free of cost to himself and his family. In all realism we must recognise that this is not likely to be feasible in this country, having regard to the pattern of distribution of the population. I think, however, it is essential that it should be accepted that it would be inequitable to provide such a service for urban dwellers only while requiring the rural ratepayers to contribute in proportion to their valuations to the actual cost. It seems to me, therefore, that if the right to choose their own doctor is to be afforded to these members of the lower income group who are resident in our cities and towns, the urban ratepayers must be asked to foot the bill. Indeed, there is a strong case in equity for permitting each urban area itself to decide whether it will allow those of its citizens who are within the lower income group to have a general practitioner of their own choice.
As Deputies are aware, it is my policy, as it was my predecessor's, because of the limited amount of funds and dental personnel available, to urge local authorities to concentrate mainly on providing dental treatment for those who will benefit most from such treatment, namely children. This means, of course, that only a limited dental service can be made available for eligible adults, those in the lower income group. Such improvements in the situation as we can achieve by the recruitment of wholetime dental officers in areas where they are urgently needed, and, in a number of the larger areas, by the appointment of senior dental surgeons who will organise and co-ordinate the services as well as carry out dental treatment themselves will still be inadequate for the provision of a comprehensive service for all those eligible.
There has been a certain amount of public disquiet from time to time here as in other countries, as to the possibility of "fall-out" from tests of nuclear weapons giving rise to a dangerous level of radioactivity in our food. I have answered various Parliamentary Questions in connection with it. During the past twelve months this matter has been the subject of a special study by officers from all the interested Departments. The results of the study, and of the tests which were undertaken in the course of it, will shortly be published. I can say, however, at this stage that the conclusions are reassuring and indicate, as we had anticipated by extrapolation of the results of similar tests in Britain, that no danger exists from radioactive fall-out in this country.
In speaking of last year's Estimates I referred to the Health Authorities Act, 1960. Since that time the transition to the new health authorities for the Dublin, Cork, Limerick and Waterford areas has been effected smoothly and with the minimum of disruption. The division of the expenses of the new Health Authorities as between the bodies which appoint them is an important feature of the Act and in this connection it is gratifying to record that agreement has been reached in the Dublin and Waterford areas in regard to the basis of contribution. Temporary arrangements, as provided for in the Act, are in operation in the Cork and Limerick areas and discussions in regard to the permanent basis for dividing the costs in these areas are in progress.
Many of the more important provisions of the Mental Treatment Act, 1961, were brought into operation on 1st April last. These included those relating to superannuation. The remainder of the Act will be brought into operation very soon. The relevant Regulations have been drafted and the necessary consultations are almost at an end. When the Bill was before the House I announced that I hoped to translate the complex superannuation provisions into more simple language and to issue this paraphrase as a memorandum to the staffs of district mental hospitals so that they could appreciate the effect of the options provided for. I am afraid that when the memorandum is issued in the near future it will be found not to be as easily understood as had been originally hoped but I know that interested Deputies and staff organisations will understand the difficulties involved.
Arising out of the decision of the Supreme Court in regard to the Solicitors Bill, 1954, it has been found necessary to consider the provisions in the various Acts relating to the registration of medical practitioners, dentists, nurses, pharmacists and opticians, dealing with disciplinary control in cases of serious misdemeanours which would lead to the persons concerned being struck off the appropriate register.
When we speak of broad developments under various aspects of health legislation or mention improvements which have taken place in the health services, it is sometimes easy to overlook the fact that these developments and improvements could not have been achieved without the aid of the necessary professional, technical and ancillary personnel. It is important that, in order to secure and retain staff of the required calibre and to ensure that the services will be of the highest quality, the remuneration offered to them does not lag behind that in comparable employments elsewhere.
During the past year I was glad to be in a position to accord unqualified approval to the implementation by health authorities of increased salaries for certain grades of medical and dental personnel. The increases were the outcome of negotiations between representatives of the various staffs concerned and their health authorities. I hope that the improvements granted will have the effect of attracting into the local services an adequate supply of suitable personnel and that they will help to overcome the difficulties which have been experienced in the recruitment of certain grades, especially junior medical staffs and dental surgeons.
In the case of nursing staff, proposals for increased remuneration are at present under consideration locally, following the submission of claims affecting all grades of nursing personnel employed in the local service. When proposals are received in my Department, I shall be glad to consider them as sympathetically as circumstances will permit.
It has been contended that the 1953 Health Act has been responsible for an unwarranted increase in the cost of our health services. I have already shown
(1) that much the greater part of any increase which has occurred has been due to the fall in the purchasing power of money and that this influence has been world-wide in its operation and
(2) that a substantial fraction of the increase has been occasioned by our efforts to make good certain acknowledged but deplorable deficiencies in our existing services, as, for example, the provision made for the treatment of mental illness and for the care of persons labouring under mental handicap in various forms.
Our efforts to deal with these and other problems, like the problem of rehabilitation, have resulted in increased charges on the community. But these have been largely offset by economies in the longer-established services, so that the net effect, as I have shown, has been to stabilise and, indeed, to slightly reduce, the over-all cost of the services in its relation to the gross national product.
We must all recognise, however, that, in its attitude towards the maintenance of the health of its individual members, the community must conform to the spirit of the times. It cannot be indifferent to the sufferings of even its least worthy citizen. Indeed, in charity, it is bound to succour him and, if he should be ill, to do its utmost to ensure that all therapeutic facilities available to it will be afforded to him. Equally such facilities must be available to all others who may require to have recourse to them.
With the increased development of medical knowledge and skill, the scope of all such services must expand. Unfortunately, it would appear that a concomitant increase in the cost of them cannot be avoided. So the natural trend is for the cost of health services everywhere to increase. I submit that I have demonstrated that in our case the increase, if any, has been nominal, though the improvement in our services has been striking. Taking everything into account, the amount which Dáil Éireann is now being asked to vote for the maintenance and improvement of the health services is reasonable, and I recommend the motion accordingly.