That a sum not exceeding £7,824,000 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, 1963, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain Services administered by that Office, including Grants to Local Authorities and miscellaneous Grants.
As in previous years, I shall begin my remarks on the Estimate by referring to the more significant vital statistics for the preceding calendar year and to some matters which will arise as the statistics are considered. The figures I shall quote are at this stage provisional, but it need not be anticipated that there will be any major alteration in them when final figures become available.
The number of births registered in 1961 was 59,826 as compared with 60,730 in 1960. The birth rate, at 21.3 per thousand population, was again significantly higher than in England and Wales where it was 17.4 per 1,000, or in Scotland where it was 19.5 per 1,000. Marriages were slightly fewer in 1961 than in 1960, the numbers being 15,140 as against 15,420. The number of deaths, at 34,548, showed an increase of 1,890 over the previous year. The greater part of this increase is attributable to an outbreak of influenza early in the year which accounted for 1,153 deaths compared with 190 in 1960. If we add increases in deaths from pneumonia and bronchitis, frequently associated with influenza, we account for 1,419 of the total of 1,890. Heart disease was responsible for a further 352 of the increase. Therefore under these heads alone the total increase in mortality was 1,771.
Heart disease in the past year, as in previous years, was the greatest single cause of death. It accounted for 10,985 deaths. The increasing toll of deaths under this heading seems to be one of the penalties of civilisation. Advances in science help to lengthen life, and many of our people who in earlier days would have succumbed while still young to pestilences and famine now survive to add to those who develop the diseases and ailments of later years.
Scientific achievements in other fields, as a result of which we now eat more and richer foods and at the same time have less incentive to take physical exercise, also provide a background which is conducive to diseases of the heart and of the cardiovascular system.
In contrast to the disadvantages I have indicated, however, as arising from modern conditions of life, I should mention that in many forms of heart disease, particularly in the case of congenital abnormalities, recently developed techniques permit many more lives to be saved and made more full. Research into the causes of the degenerative diseases of the heart may also be expected in future years to provide us with a means of reducing the very substantial death-rate from this cause.
The next greatest single cause, namely cancer, was responsible for 4,683 deaths compared with 4,759 in the previous year. This slight decrease is too small to be significant. Among the cancer deaths, there were 680 from those forms which are grouped under the title of lung cancer, as against 648 in 1960. This increase is particularly notable. Earlier evidence of the association between heavy cigarette smoking and lung cancer has been fortified by the recently published report of the Royal College of Physicians in Britain and by a report to the Danish authorities.
This fact of the association between cigarette smoking and lung cancer has been prominently published and it is quite unnecessary to labour the point in this speech. The trouble about smoking is that the decision to smoke or not to smoke is a personal one, to be taken by the individual. No nation has yet found an unfailing method of influencing the generality of its people to do what common sense dictates in the interest of personal health. Smoking is not a disease. It does not inevitably give rise to disease, and where it does, the disease is not communicable. It does not endanger the public safety; there is no turpitude attaching to it; and it cannot be held to be contrary to public morality. Consequently there is no justification for making it a crime punishable by law.
Short of this, it is difficult to see what preventive action could be taken to extirpate the habit; and, even if a Government were so ill-advised as to attempt its extirpation, surely the history of what its sponsors describe as the "Noble experiment of Prohibition" should be enough to deter it from such foolishness. In educating the people as to the risks which smoking involves lies our best hope of reducing the incidence of lung cancer. But the educational programme must be framed with judgment and psychological discernment. Nothing would be more likely to evoke an adverse reaction than bellowing propaganda. A calm and frequent reiteration of the facts as they have been ascertained by the research workers is the best strategy; and this is the line which we are pursuing and intend to pursue with parents, teachers and all who have growing boys and girls in their care. By pursuing it, we hope to induce their elders to dissuade the young from starting and to teach them by example as well as precept that smoking is not "the thing".
The fact that cancer is the second greatest single cause of death is, of course, not peculiar to this country, but nevertheless it is obviously a matter which we here must view with the greatest concern. It is to be hoped that as an outcome of the intensive investigations being carried out on a world-wide basis into malignant conditions, advances will be made in due course on this front commensurate with those which have given us such welcome results in the fight against tuberculosis. While this is our hope, it is at present only a hope, and it is clearly necessary for us to ensure that adequate services are fully available on a nation-wide scale for prevention, diagnosis and treatment. With this end in view, I have set up a new Cancer Consultative Council which will advise the Minister for Health by reporting to him on such matters related to the organisation and co-ordination of existing cancer services as he may refer to them. The new Council has had its first meeting and it is my earnest wish, and my belief, that it will contribute in no small measure to our efforts to combat this disease.
Last year, I referred to the fact that I had authorised a grant from the Hospitals' Trust Fund to provide a cobalt unit for cancer treatment at St. Luke's Hospital, Rathgar. Unfortunately, difficulties outside the control of the hospital have delayed its installation; but I am assured that the work will be completed and the unit available for the provision of treatment within the next few months.
The death rate from tuberculosis continued its downward trend in 1961 when the total number of deaths from all forms of the disease reached the lowest figure on record, 419, which was 49 less than in 1960. The figures for incidence also fell, the number of new and re-activated cases in 1961 being about 200 fewer than in 1960. Nevertheless, it is a sobering thought that the number of new cases is still as high as 3,030. This is a clear indication that a large pool of infection remains, and that we are still a considerable way from the eradication of the disease. It is important therefore that our people should make full use of the facilities for the prevention and diagnosis of the disease which are so readily available to them in all areas.
First in point of time for recourse to it is B.C.G. vaccination. This simple and safe procedure affords great protection and parents should see to it that their children have the benefit of it. It is especially important that young persons leaving a rural environment for the first time to work in towns and cities should take advantage of it.
Another important procedure is, of course, mass-radiography. By it the disease can be detected at an early stage when treatment is likely to yield the quickest and best results. It would appear, unfortunately, that the fall in the death rate has given rise to a high degree of complacency; so that it is becoming increasingly difficult to secure a good response when units of the National Mass Radiography Association visit local areas. This is to be deplored, because, as I have mentioned, the incidence of the disease here is still very high. Moreover, its incidence is increasing among older people. In the interests, therefore, of their own health and the health of their families everyone, old as well as young, should have a regular chest X-ray examination. The service is there for the asking. The process takes only a few minutes. It is painless. It is free from risk. There is not even the trouble or embarrassment of undressing. In face of all this, and in view of the safeguard it affords, it is surprising that the public response continues to be far below what is desirable.
I am glad to be able to report that the downward trend in maternal mortality, which has been evident for some years, continued in 1961. The rate was 0.45 per 1,000 births as against 0.58 the previous year. In the case of infants the mortality rate was 30 compared with 29 in 1960. It is pertinent to these figures to refer to corresponding rates in neighbouring areas. In 1961 the maternal mortality rate in England and Wales was 0.33, in Scotland it was 0.4 and in Northern Ireland it was 0.5. The infant mortality rates were: England and Wales 21.4, Scotland 25.8 and Northern Ireland 27.5. As will be seen, maternal and infant mortality rates here are in general higher than those of our nearest neighbours although they have decreased very considerably in recent years.
As Deputies know, since 31st March, 1956, maternity services under the Health Act of 1953 have been available to mothers in the middle income group and their infants up to six weeks old. The same services are also provided for other persons who, in the opinion of the health authority, are unable without undue hardship to provide them for themselves. The services cover care by a doctor during pregnancy and for six weeks after childbirth, the attendance of a mid-wife and, where necessary, hospital and specialist treatment; and they are free of all direct charge to an eligible patient.
One of the main aims of the new service was to encourage eligible persons to look for early ante-natal care. This is in accordance with medical opinion which stresses the need for competent supervision of the expectant mother's health throughout her pregnancy, so that any complication may be detected in good time. Under our scheme, the doctor, provided he is consulted at a sufficiently early stage, is expected to attend the mother, at least four times ante-natally, and twice post-natally. He is also required to make at least one examination of the baby. The doctor may, of course, see the mother and infant as many other times as he deems necessary.
The great majority of maternity patients under the scheme—87 out of every 100—now have at least four ante-natal attendances by the doctor. One-third of the patients have their first ante-natal examination before the end of the fourth month of pregnancy and slightly more than half of them have their first examination before the end of the fifth month of pregnancy. While this represents a considerable improvement on earlier experience, the position could be still better. Once again, therefore, I would urge expectant mothers, in the interest of their own health and the safety of their unborn children, to consult their doctors early in their pregnancies—the earlier the better.
The provision now being made for ante-natal care has been reflected in the improved figures for maternal and infant mortality; so that in 1961 the number of maternal deaths was 27, as compared with 70 in 1955, before the maternity service was opened to the middle income group. The rate for infant mortality has hovered between 35 and 29 per 1,000 births, during the past five years and, standing at 30 for the year 1961, compares with 68 for 1947.
The present downward trend in mortality among women in childbirth is no doubt gratifying, but let me emphasise it gives no ground for complacency. Everything possible must be done to lessen the risks and reduce mortality still further. And for this we must depend almost as much on the timeliness and good-sense with which expectant mothers place themselves under medical advice, as on doctors, nurses and hospitals. Indeed when we consider that the over-all marital pattern in this country is the quite unusual, if not unique one, of relatively late marriage combined with high fertility, the steady decline in maternal deaths here represents a very meritorious achievement and reflects credit upon our medical and nursing professions.
Before passing from this particular subject, I might mention that a steady change has taken place in the pattern of confinement here during the past six years. While the overall number of births has remained constant, the number of domiciliary births has dropped from 21,000 in 1955 to 14,000 in 1960. During this time there has been a corresponding increase in the number of institutional births—from 15,000 to 17,000 in voluntary hospitals, from 16,000 to 18,000 in local authority hospitals and from 9,000 to 12,000 in registered maternity homes. These figures, which reflect changes in our social pattern which make births away from home the rule, pose some problems in the provision of more institutional accommodation to meet this trend.
Sixty-four cases of paralytic polio-myelitis were reported in 1961, with seven deaths. The incidence of this disease fluctuates from year to year and there is no way of foretelling whether in a particular year it will increase or diminish. Fortunately, there are vaccines which, for a time at least, afford strong protection, if not indeed virtual immunity, from the disease. Our present public vaccination service is based on the use of an inactivated vaccine and is provided by health authorities for persons aged between six months and forty years, and for expectant mothers, in the lower and middle income groups and for classes who might be at special risk, such as hospital staffs. The service is free of charge for persons in the lower income group and for the "special risk" categories. A charge of 7/6d. for a course of three injections, with an additional charge of 2/6d. for a fourth injection, subject to a maximum contribution from any family of £1, is payable by persons in the middle income group.
Deputies may have read about developments abroad in the use of oral polio vaccine. This type of vaccine, being administered orally, has a number of advantages over the inactivated vaccine which we are now using, and which is injected, and I have been considering whether we should adopt it instead. In that connection, I sought the advice of the Medical Research Council and have received a report which my officers are considering. Meantime, health authorities will continue to provide a vaccination service on the present basis of inactivated vaccine, but financial provision has been included in the Estimate now before the House sufficient to ensure that, if it is decided in principle to change over to oral vaccine, such vaccine will be available in the current year, at least to the extent necessary to deal with a serious outbreak of the disease in any area.
Although, fortunately for us, smallpox does not figure in our mortality statistics, I wish to say something about it. First of all it is a most deadly disease, highly infectious and about 50 per cent. fatal where a high degree immunity has not been secured. Because there has been no case of it in this country for a long time, the public have become largely apathetic about smallpox vaccination. Perhaps we have all tended to lapse into this apathy, lulled by the prevalent opinion that the risk of the disease being brought into this country from those regions abroad where it is endemic was negligible. Whatever may have been the case when ours was a comparatively isolated community, such a view is no longer tenable. Admittedly when only slow surface transport was available the risk that the infection might be imported was relatively very low indeed. But the development of air travel has changed all that and persons incubating the disease may arrive here before its symptoms manifest themselves and may disseminate it among our comparatively unprotected population.
The outbreaks of smallpox which occurred recently not only in various parts of England and Wales but in the Federal Republic of Germany are an emphatic demonstration of the dangers to which I have referred. Fortunately by the special steps which were taken at our main air and sea-ports we were able to reduce the risk that the disease might be introduced into this country. Planes arriving here from the local infected areas in Britain and in West Germany were given special attention and the passengers were screened by the health staff. Passengers on other planes and ships arriving here from the countries in which the disease had appeared, and who had been in the infected areas within the previous 16 days were requested to report to the port Health Authority. Where considered desirable, they were offered vaccination, and their names and destinations were recorded and notified to the Chief Medical Officers of the areas to which they were going so that, if necessary, they might be kept under surveillance.
I do not feel that it is necessary to elaborate to the House the arrangements settled long since to deal quickly and effectively with the situation which would arise should a case, or a suspected case, of smallpox be found here. These arrangements, which cover a wide range, have all been specially reviewed in the light of our recent experience.
Recent vaccination, and I emphasise recent, is, of course, the only sure safeguard against contracting the disease. The numbers seeking to be vaccinated or revaccinated in recent months have increased considerably over previous experience. To achieve a state of optimum protection in the conditions now obtaining here it would be necessary that everyone should accept vaccination or revaccination. The case for the vaccination of infants is particularly strong, as it is an acknowledged fact that a person vaccinated in infancy is least likely to suffer the complications of vaccination and of revaccination later; and in the light of this it appears to me, and there is strong medical support for this view, that it is desirable that we should attempt to ensure that for the future all healthy children should be vaccinated in the first year of life, preferably about the age of four months. If we could secure this, we could achieve a great deal. As to adults, it is desirable that at least those who might find themselves at special risk, such as public health and hospital staffs and persons dealing regularly with travellers coming to this country from abroad, as well as those contemplating visits to areas in which there are current outbreaks of the disease, should take steps to assure to themselves and to their households the protection which recent vaccination or revaccination confers.
So much for the killing, and potentially killing diseases. I shall now turn to some of the disabling, but not killing, diseases.
At the head of that list comes mental illness. To indicate its importance I need only say that we have about 20,000 mental patients, that they occupy about 34% of all our hospital beds, and that the cost of running the district mental hospitals represents over 22% of the net health expenditure of local authorities.
As the House is already aware, I have entrusted to a competent and broadly based Commission of Inquiry the task of examining our mental health services, with particular reference to the very high number of patients, and of making recommendations for improvements. Over the years we have striven to improve the quality of the service. Undoubtedly the patients in our mental hospitals are now less uncomfortable than they were previously and their prospects of recovery are better than was the case some years ago; but except in a few instances no spectacular developments have taken place. Our patient population remains unduly high and it would appear that numbers of patients are still being admitted to hospital when their condition is such that it would be better for them to be treated within the community.
Throughout the year the Commission of Inquiry has been working hard at its allotted task. Nevertheless, some considerable time must elapse before it is in a position to submit its report. Meanwhile, I have continued the policy of making available to the medical personnel of mental hospitals opportunities for study provided by such agencies as the World Health Organisation and the Council of Europe. Similarly I have facilitated psychiatric nurses in attending a special refresher course. Last December, I caused to be held in my Department a meeting, attended by Resident Medical Superintendents and Managers of all district mental hospitals, at which there was a full exchange of views and suggestions for the improvement of the mental health services. I addressed this meeting and stressed my view that if the condition of the patient warranted it, active treatment should be intensified and every effort made, by resort to the newer drugs and other forms of treatment, to restore him to society.
Since 1957 there has been a spectacular increase in the total number of attendances at out-patients mental clinics. Where clinics are well organised and regularly held, patients are naturally more inclined to attend at them at an early stage of their illness and, in many cases, before there is a need for them to be received into hospital as intern patients and thus to obviate the necessity. It is significant that it is in the areas which have a reasonably well-developed out-patient clinic service that there has been the greatest fall in the numbers of patients maintained in the mental institutions. Treatment at a clinic has many advantages over treatment in a hospital.
For instance, the patients do not lose contact with their homes, their relatives and their friends, and consequently are not in the same need of resettlement as if they have spent a relatively long period in hospital. Moreover, the economies in treating patients as out-patients are obvious.
It is now generally realised that the after-care of psychiatric patients is essential, and that if this is not provided patients tend to relapse and have to be re-admitted to hospital. A doubt as to whether mental hospital authorities had the necessary statutory power to organise after-care services was resolved by the enactment of Section 31 of the Mental Treatment Act, 1961.
I am glad to take this opportunity of complimenting those Mental Hospital Authorities and their officers who organised "open days" and similar functions in connection with the World Mental Health Year. In a most effective way they demonstrated to the public that mental hospitals are not primarily places of detention but places of recovery and cure. Some mental hospitals have gone further in demonstrating that the attitude to psychiatric illness should be no different from the attitude towards physical illness.
In one of those which I visited in the course of the year, I found that physical as well as psychological barriers had been broken down and that a long section of the high boundary wall along a busy main road had been removed almost entirely and not replaced even by a railing. I have little doubt that the enlightened attitude thus manifested towards the patients of that hospital will do much to improve their morale and to enhance their prospects of early recovery and reintegration as useful members of the community.
The Commission on Mental Handicap also continued its deliberations throughout the year but, as in the case of the other Commission I have mentioned, it will be some time before we can expect their report and recommendations.
During the year, work commenced on extensions of 143 beds at Cregg House, Sligo, and 120 beds at Delvin, Co. Westmeath. Both places are homes for the care and education of mentally-handicapped children.
Various other possibilities of securing additional institutional accommodation for the mentally handicapped are being considered in my Department. Some of these involve the diversion to this purpose of accommodation at present being used by health authorities for other purposes and in due course may result in approaches by my Department to the health authorities concerned. I hope that Deputies who are members of health authorities will give sympathetic consideration to any such approach made to their health authority. Despite the fact that we have provided more beds for the mentally handicapped in recent years, the shortage is still great, so I would plead that proposals designed to make additional accommodation available should be received most favourably by health authority members.
The House will be glad to learn that in the course of the past twelve months we have happily been able to make a fair degree of progress in tackling the questions of medical and vocational rehabilitation. I have already paid public tribute, both inside and outside the House, to the noble part played by voluntary organisations in getting this important work under way. But I wish to repeat that the work of these bodies not only supplements in a substantial way our activities, but is a source of encouragement to us in what is, as yet, only an early stage in our endeavours in this important field.
Even at this early stage the work which is being done in the hospital of Our Lady of Lourdes, Dun Laoghaire, where the Sisters of Mercy and the National Organisation for Rehabilitation have established the National Medical Rehabilitation Centre is very rewarding. A fairly considerable capital outlay has yet to be provided for in order to develop the hospital to the full and to bring it up to the standard necessary. But when fully developed, the work of the centre will include restoration of function in traumatic cases, a centralised limb-fitting service and the rehabilitation of paraplegics.
Particular attention has to be given to the problem of securing a sufficiency of occupational therapists. Questions of training other skilled paramedical personnel also arise. I have sought the best expert advice available on these problems and have under consideration the necessary steps which should be made to deal with them.
Coincident with the opening of the National Medical Rehabilitation Centre, there has been a quickening of interest in the general question of rehabilitation. It is important that our public health personnel and authorities who hitherto have thought so much in terms of active disease and preventive medicine, should have their minds orientated more to rehabilitation as a real function of the health services. The seminar organised by the National Organisation for Rehabilitation at the Dun Laoghaire Centre in September last year will, I hope, prove to be the first of a number of discussions designed to arouse an active interest in this field of curative endeavour.
Vocational rehabilitation, as distinct from medical rehabilitation, has developed apace under voluntary auspices generally. Much of the funds which have financed this development have come from voluntary sources, but the activities of these bodies have so developed that I feel that their resources ought to be supplemented from public funds. The problem when reduced to legal terms will be one of making regulations under subsections (1) and (2) of Section 50 of the Health Act, 1953, dealing with the training of disabled persons. I propose to make regulations accordingly prescribing the conditions under which financial assistance may be given to organisations whose purpose is to provide suitable training facilities for the disabled. In order that disabled persons may derive greatest benefit from the work of the several organisations now concerned with rehabilitation, it is essential to ensure that, so far as may be possible, the aptitudes of those seeking training are matched with the kind of work best suited to them. The National Organisation for Rehabilitation has this question of vocational assessment under consideration and I hope to see their proposals take practical shape in the coming months.
I think it is appropriate at this stage that I should tell the House what has happened in the last year under the more important enactments which were before it in recent times.
Under the Health (Fluoridation of Water Supplies) Act, 1960, I am empowered to make regulations providing for the fluoridation of public piped water supplies in any area, but, before doing so, I must cause to be made a survey of the incidence of dental caries in a representative sample of school children in that area and an analysis or series of analyses, of the fluorine content, etc., of each public piped water supply in the area. Reports on such dental caries surveys and water analyses must be presented to each House of the Oireachtas. Surveys have now been completed in Dublin, Kildare, Wicklow, Cork, Limerick and Waterford and are at present being conducted in a number of other counties, including Louth, Wexford and Laois. During the past year also, arrangements were made for the analysis of public piped water supplies in the areas in which the surveys have been completed or are in progress. A report setting out the results of the surveys in Dublin, Kildare and Wicklow will shortly be presented to the Oireachtas. In the light of the information contained in it, I think that it will be admitted that, in general, the dental health of school children in the areas covered by this particular survey is very unsatisfactory. Moreover, the results of the analyses of the water sources which supply the area covered by the dental survey confirm the findings of the previous water survey that in only a few of them is fluorine present and then only in insignificant quantities.
The procedures I have mentioned will be carried out as quickly as possible in the remaining counties until the entire country has been covered.
The Medical Research Council of Ireland kindly agreed to be responsible for the caries surveys, the cost of which is being met by grants from the Hospitals Trust Fund. I would like to put on record my sincere thanks to the council for undertaking this important public task. I would like also to place on record my appreciation of the willing co-operation afforded to the survey teams by the managers and teachers of all the schools approached.
After the report I have mentioned in relation to Dublin, Kildare, Wicklow has been presented, the next step is to make regulations providing for the fluoridation of specified water supplies in those areas. These will be made shortly and in accordance with the law will be laid before the Oireachtas. Regulations covering supplies in other areas will follow in due course, after compliance with the statutory requirements.
It will be necessary, once fluoridation is introduced, to carry out a continuing and detailed examination of the status as to dental caries in order that the extent of improvement in dental health may be accurately measured. This will involve having recurring scientific surveys made on a representative sample of the child population, of various ages, these surveys being of a much more detailed character than those already carried out. I am advised that it will be sufficient if these surveys are conducted in a single area, and I have under consideration at present the best means of organising and arranging for them. I hope to be able to combine with them an assessment of the benefits to be derived from the topical application of fluorides, that is, the application of a fluoride solution to the surfaces of the children's teeth by trained personnel. A number of studies which have been, and are being, carried out in U.S.A. and Canada give grounds for hope that it may be practicable and rewarding to introduce this procedure for children in parts of the country where public piped water supplies are not available.
The Mental Treatment Act, 1961, has been brought into operation. As a result, unnecessary procedures have been cut out, resulting in smoother administration of the mental treatment code. Staffs employed in district mental hospitals, unless they decided to "opt out", have had applied to them, with modifications, the general local government superannuation code—incidentally, my information is that very few have opted out. Since 1st March last the power to make a recommendation or sign a certificate for the reception of a patient as a chargeable patient has been extended to medical practitioners generally so that the family doctor may now give the necessary recommendation or certificate, a power which previously was reserved to the district medical officer. In that connection, the booklet, a draft of which I circulated to Deputies to facilitate them in considering the Bill when it was before the House, has been revised and put on sale and should be of great help to persons concerned with the administration of any aspects of the Mental Treatment Acts.
The Poisons Act, 1961, provided for the establishment of an expert Advisory Council on poisons, whose function it will be to advise the Minister for Health and the Minister for Agriculture on up-to-date controls on the sale and use of poisons. The council has now been set up and will begin its deliberations shortly. The making of regulations based on the advice of this council should, in due course, ensure that an up-to-date, comprehensive and flexible poisons code will be in operation in this country.
The Hospitals Federation and Amalgamation Act, 1961, which provides for the federation and ultimately, by consent, the amalgamation of seven distinct Dublin voluntary hospitals, was also brought into operation during the year to the extent that the hospitals are now federated. The object of the measure was to secure a degree of co-ordination and co-operation between the hospitals concerned in the interest not so much of saving money, desirable as that may be, as of providing a better service for the patients whom they serve. I have previously paid tribute, in this House and elsewhere, to the readiness with which the boards of the several hospitals agreed to sink their individuality and surrender some of their autonomy for the common good. My only regret is that they could not, at this stage, agree to go all the way and decide on amalgamation; but I hope the day is not too far distant when they will see their way to take that decision.
The past year has witnessed accelerated progress in hospital building activity. The amount expended by way of grants and loans on capital works in the year was about £860,000 as compared with £770,000 in 1960/ 61. If present indications should prove to be reasonably near the mark, the comparable annual rate of capital expenditure in the years 1962/63, 1963/64 and 1964/65 will be £1,500,000, £1,900,000 and £2 millions respectively.
One of the main reasons why I am able to envisage this accelerated rate of spending is that the improved position of the Hospitals Trust Fund has enabled me to authorise a significant resumption of hospital building activity. Planning is now being actively pursued on schemes estimated to cost some £6½ millions. Works at voluntary hospitals account for about £3½ millions of this programme and the approved health authority hospital building programme is estimated to cost almost £3 millions, about half of which will be met by way of grants from the Hospitals Trust Fund. I might also mention that works at mental hospitals account for about two-thirds of the cost of the health authority programme.
Apart from the foregoing, I have also under consideration further works proposed by hospital authorities involving an estimated total expenditure of a further £6½ millions. It is also probable that arising out of the reports of the Commissions on Mental Illness and on the Mentally Handicapped it will be necessary to incur further considerable expenditure on buildings and equipment. The need for improved accommodation for nursing and domestic staffs must also be dealt with, and, of course, there is always pressure from existing hospitals for improved facilities for the treatment of their patients. The total expenditure to be faced under all the heads I have enumerated will amount to very many millions, all of which will be necessary, not merely to keep our more modern hospitals abreast of the times, but to make good the sad deficiencies which still exist under many heads. We have a mighty programme before us, and I am sorry to say that, as I shall show later, we are not getting from certain quarters the co-operation which is necessary to enable it to be completed in an expeditious and orderly way.
The financial position, in so far as the Hospitals Trust Fund is concerned and so far as can be foreseen, is that the moneys necessary to finance all the works which have actually been approved or proposed, or which are likely to be called for over the next few years, will not be available to the extent sought. Nor is there any prospect of an early improvement in that regard. Furthermore, health authorities will be competing with other borrowers from the Local Loans Fund for a share in the resources available for capital works. It is therefore imperative that all hospital building projects should be carefully pruned so as to avoid lavishness in either the nature or the extent of the works proposed. A thorough reassessment must be made of the existing resources in the way of hospital accommodation of the extent to which existing deficiencies in any particular type may be made good by prospective reductions in demands for accommodation of another kind; it is essential to ensure that accommodation likely to become surplus to requirements will be utilised as far as possible, so that new building may be obviated where that is feasible.
In recent years the implementation of our construction programme has been greatly retarded by a shortage of money. Our situation today in that regard is easier and more liquid than it used to be, inasmuch as we have overtaken and discharged outstanding commitments to contractors and have built up a cash reserve to ensure that once works have been begun they will be carried through to completion—or at least will not be held up for lack of cash. But, while building and other costs have been rising rapidly, the income out of which these costs are defrayed has risen very much more slowly, indeed is tending to find a constant level.
This adverse situation has been greatly aggravated by recent developments in the building industry. By reason of the eighth round increases, wages in the building industry have advanced by about 7 per cent. over the past year, and this factor, intensified by increases in the prices of materials and reduced working hours in the Dublin area, has been reflected in tenders. Moreover, due to the high level of building activity which now obtains there is only limited competition for building projects generally. Hence tenders and prices are much less satisfactory than they were a year or two ago. This not only reduces our financial capacity to give effect to our building programme, but highlights the unnecessary difficulties caused for everyone by the tardiness of certain clients and their professional consultants to bring their plans to tender stage.
The dilatory way in which some important institutional projects have been handled by those who have been commissioned to plan them has become not only a source of embarrassment and grave inconvenience, but calls for special action. The works in question are an essential part of the over-all hospital programme. They were approved in principle and their main features and functions settled many years ago and since then frequent consultations in regard to their details have taken place between the officers of my Department and the architects, quantity surveyors, and other consultants concerned. The difficult financial position which developed in 1956 slowed down, perhaps even led to the suspension of, the active planning of these projects; but in 1959 and 1960 the financial situation was so much easier that I felt justified in allowing those concerned to press forward with the proposed works, albeit with very definite restrictions as to their over-all cost.
The House will be as disappointed as I am that some of these major projects are not yet ready to go to tender on the basis of complete contract documents. Such explanations as I have received have not, in at least one case, satisfied me that the delays in planning, in taking out quantities and in proceeding to tender have been warranted. My dissatisfaction in this instance has been aggravated by the fact that other commissions entrusted at a later date to the consultants concerned appear to have been executed with much greater expedition. This is not good enough. In view of the urgent need to make good the deficiencies of several generations, in view of the humanitarian considerations which are involved, projects included in the Hospital Construction Programme must in future be accorded the highest priority by those concerned, whether as sponsors, technical consultants, or in any other way with the project.
I am well aware that the planning of a major hospital scheme is a complex affair, and that certain staffing problems have arisen over the past year or two which may have impeded consultants in their efforts to make progress, but when it has become evident that it is taking far longer than two years to arrive at a stage when the clients would be in a position to seek tenders, then I am driven to the conclusion that the consultants concerned have not recognised the pressing urgency of these hospital works, have taken their responsibilities in regard to them too easily and under the pressure of other business have put the planning of them aside and only resumed it as other demands for their services slackened off.
It is very frustrating to have achieved a liquid financial position and yet to find that certain hospital authorities who a few years ago were on my door-step importuning me for funds have been slow in taking up the money which they have been told is available to them. The money in the Hospitals Trust Fund has been accumulated for the financing of the hospital construction programme, and not for other purposes, no matter how meritorious they may be. All the works in that programme are urgently required. Mainly on the practical ground that everything could not be undertaken at once, some items have been accorded priority over others, perhaps in themselves just as urgent. They have been given that priority on the assumption that the authorities putting them forward would see to it that the designated works were executed as expeditiously as possible. As I have said, I am far from satisfied in one or two instances that the need for expedition in planning and construction has been realised. But I do not intend to wait indefinitely on the convenience of hospital authorities, or the consultants employed by them, whoever may be responsible. I intend to keep this position under review, and within the next three months I propose, in any case in which it is clear that there has been needless delay in preparing the documents necessary for the obtaining of firm tenders, to give the most serious consideration to the question of withdrawing any assurance of a grant, thereby releasing the funds hypothecated so as to finance other projects. Any projects in respect of which grants might be withdrawn under this policy will lose their priority, and will be placed at the end of the queue.
The approved procedure to be followed by the authorities of participating voluntary hospitals who required assistance from the Hospitals Trust Fund for works which it was desired to undertake was laid down in a circular letter to all voluntary hospital authorities which issued from the Hospitals Commission in 1954. This letter gave clear warning of what would happen if the procedure were not followed. In 1957, in a further circular letter, this time from my Department, the warning was repeated. In 1959, speaking here on the Health Estimate for that year I said, as reported in Volume 175, Columns 191 and 192 of the Dáil Debates:
"... it will be worse than that to look for grants in respect of projects or commitments entered upon without my prior sanction. Let there be no doubt about it: I shall refuse to be coerced by any fait accompli; and those who think otherwise are likely to find themselves shouldering not merely the capital cost of their new venture but every other expense arising out of it as well.
I am forced to speak bluntly in this matter because in some quarters there is a disposition to think that hospital authorities can spend first and then turn to the Minister for Health for recoupment."
I think it will be agreed that I could hardly put the point more strongly. Moreover, in a further letter issued in June 1959 I drew the attention of the authorities of all participating hospitals to the statement and warned them that it would be strictly adhered to. I have now to repeat the warning as strongly and as emphatically as before. It may seem extraordinary that I should have to do so, but a number of glaring examples of complete disregard for its most explicit terms have come to my notice over the past year. These will be dealt with as foreshadowed in the statement which I have quoted and in the circular letters of 1954, 1957 and 1959. And to make certain that the position is again made clear to all concerned, I repeat once more that, so long as I am Minister for Health, no assistance will be forthcoming from the Hospitals Trust Fund for any works undertaken or commitments entered into without the prior approval of the Minister signified in writing, stating the amount of the grant and specifying the works in respect of which it will be given.
Some years ago it was often difficult for a patient to obtain admittance to a public hospital at short notice; but in latter years pressure in this regard has considerably eased. The fact indeed is that in respect of hospital beds, we appear to be better off than many other European countries. The ten year hospital building plan recently published in Great Britain enables us to compare our position and progress with theirs. The most striking feature of the comparison is that in England and Wales, there are at present about 3.9 acute beds per 1,000 of the population, against 6.8 here. Inherent differences —population densities and so forth— which exist make direct comparison of figures open to qualification but, even allowing for these, it is true to say that our acute bed ratio is proportionately much in excess of the British figure.
The British authorities have fixed on a ratio of 3.3 acute hospital beds per 1,000 population as being the figure to be aimed at in their 10 year plan. They consider that this reduced ratio for acute hospital beds can be secured by the development of home and communtiy services; by increased efficiency in the hospitals; by the development of out-patient facilities; and by substituting for existing small general purpose or special hospitals large general-purpose establishments, so as to obtain a more efficient and effective bed user. These are the lines on which we ourselves have been moving, even if our progress has been retarded by lack of resources, and by the difficulty, in some cases, of reconciling divergent interests.
In point of scale, it might be said that our biggest task now is not the further expansion of our acute hospital bed complement but the modernisation or replacement of existing obsolescent accommodation. Considerable work has already been done in this sphere and it has been facilitated by the fact that we have been able to divert redundant institutional accommodation to other purposes. A gratifying example of this is well known to the House. It is the extent to which we have been able to apply to other uses beds which originally were provided for patients suffering from pulmonary tuberculosis. Over two-thirds of such beds have been thus diverted and there are indications that still more will become available. In the case of other infectious diseases a similar decline in incidence has been manifested, so that a number of fever hospitals have been utilised for other purposes or where, for various reasons, this would not be justifiable have been closed down altogether with consequent savings to public funds. However, we must bear in mind that a substantial margin of fever beds is necessary to ensure that adequate isolation facilities are available at all times as insurance against possible epidemics, and a levelling-off in this trend is likely.
Last year I stressed the duty of local health authorities to maintain in good condition the fabric of their health institutions. I have since requested these authorities to make proper provision for regular and effective inspection of their institutions and for the prompt and systematic reinstatement of structural defects. As part of a general examination of the problem, comprehensive information has been obtained from the authorities regarding the arrangements which they are making under this head. In addition, a number of institutions have been specially inspected by technical officers of the Department who have reported specially on the manner in which the buildings have been maintained. All the information thus obtained is being studied and will form the basis of a draft programme for effective buildings maintenance which it is hoped to issue this year.
The House will be glad to learn that the schemes of voluntary health insurance operated under the Voluntary Health Insurance Act, 1957, continue to develop very satisfactorily.
The financial year of the Voluntary Health Insurance Board ended on 28th February last, and during it the number of persons insured increased by 28,000 to 133,000. This represents steady progress and I am sure that increasing awareness of the value of the service will result in continued expansion in the years to come.
The Legislature, in laying down the mode of administration of the voluntary health insurance system, made the provision that the subscriptions provided for the different schemes adopted by the Board should be fixed so that, taking one year with another, the total revenue should be sufficient, but only sufficient, after the Board has made such allowance as it thinks proper for reserves, depreciation and other like purposes, to meet the charges properly chargeable to revenue. During this period when the number of subscribers is growing rapidly, the question of the reserves to be made for future heavier liabilities will be crucial to the continued success and stability of the Board's operations. I am glad to say that in my opinion the Board, while pursuing an imaginative and progressive policy in the matter of benefits, has continued to operate a wise degree of financial prudence.
The Estimate for 1962/63 shows a net increase of £1,500,200 over the original Estimate for 1961/62, but the real increase, even over the original Estimate, is less than that figure by £300,000 approximately. If Deputies will turn to the details of the appropriations-in-aid in Part III of the Estimate in the Volume of Estimates, they will find that no provision is made in 1962/63 for a receipt, for credit of the Vote, on foot of licence duty grant and estate duty grant. These grants, prior to the Health Services (Financial Provisions) Act, 1947, were payable to all local public assistance authorities and health authorities in relief of rates for health services. Under the 1947 Act they were merged in the health grant which, in the events which have happened, now amounts to 50 per cent. of net local health expenditure. When the 1947 Act was being enacted, the way was not yet clear for the abolition of this anachronism of assigning specific proportions of certain revenue duties to specific expenditures and the device was therefore adopted of charging the new, compounded, health grant to the Vote and taking account of these old grants as a credit item. The process of rationalising this position has been prolonged but it has now been decided that these Exchequer grants in relief of Exchequer expenditure are to go and, as the Minister for Finance said this afternoon, appropriate legislative proposals to that end will be placed before the House by him in the near future. I would like to emphasise that this is merely a matter of rational book-keeping. The Exchequer will not gain anything as a result of the change and local authorities will not lose anything, immediately or prospectively. The result, however, is to increase the amount of certain Votes, notably the one now before the House.
Taking account of this book-keeping change, the net increase in the Vote provision over the original estimate for 1961-62 is reduced to £1,200,000. Practically the whole of this increase is attributable to Subhead G—Grants to Health Authorities, which accounts for £1,160,000 of the increase, though Subhead A— Salaries, Wages and Allowances for the officers of my Department, accounts for £33,000. Increases and decreases on other subheads are casual and do not call for comment, except for two items where new services are involved.
In the details of Subhead F— Expenses in connection with advisory and consultative bodies, there is a provision of £10 for contingencies. Earlier in my remarks, I referred to the need for a small, but intensive and continuing, scientific survey to measure for the record, in as precise a form as is possible, the effect on dental caries of the introduction of fluorine into public piped water supplies. At the same time I wish, as I have said, to investigate what effect the topical application of fluorine to teeth might be expected to have in retarding dental decay here. As a result I would hope to be able to arrive at a sound opinion as to whether or not topical application might be usefully used as a preventive of tooth decay in areas in which, in the absence of piped water supplies, children would be deprived of the benefits of fluoridation.
When the Estimate was being prepared, my discussions with appropriate authorities and my examination of the question generally had not reached a stage when I could estimate the cost in this year of such a survey under proper scientific auspices. My consultations and examination are not yet complete, but they have reached a stage when it is possible to be a little more precise and I now estimate that the cost will be of the order of £4,000 in the current year. This will include the expenses of an appropriate scientific advisory body, the cost of securing expert scientific opinion from abroad and actual expenses of the survey. To the extent to which the cost cannot be met from the provision in the subhead, I propose that it should be met by virement.
The second of the minor subheads to which I wish to direct special attention is Subhead O, which relates to the training scheme for health inspectors.
Provision for the creation of the grade of Health Inspector was made in Section 75 of the Health Act, 1947, and there are now some 160 persons thus employed by local authorities throughout the country. Under the County Medical Officers of Health, the health inspectors have been doing excellent work for the advancement of public health. As yet, however, no fully satisfactory course of basic training for them has been devised, and no course laid down so far has been found to be fully satisfactory in respect of curriculum, standards and duration. The need, therefore, for a fresh approach to the problem is manifest. I feel that the most satisfactory form of course would be one extending over a period of some years, based on the appointment of students as pupil health inspectors under local authorities, coupled with an extended course of theoretical training. I am proposing to set up a Health Inspectors' Training Board which will organise a suitable course. Until the details are fully worked out, it is not possible to say what the cost will be but the token provision in Subhead O, if approved, will enable a commencement to be made this year.
To revert now to the two major subheads, there is an increase of £33,000, as I have mentioned, for salaries, wages and allowances of the staff of my Department. This increase is due in the main to the general increases in salaries throughout the Civil Service. The full impact of these increases will be borne for the first time in the current year.
Of the increase of £1,160,000 under Subhead G—Grants to Health Authorities, no less than £840,000 is attributable directly to increases in salaries of staffs generally and to increases in the strengths of nursing staffs due to the reduction from a 96-hour fortnight for nurses.
When introducing the Supplementary Estimate for Health last year I mentioned that more than 55 per cent. of the net expenditure of health authorities in that year was attributable to salaries of health authority staffs alone. Incidentally, if I had included the element for staff costs in the payments made by health authorities for services given to their patients in extern institutions, the percentage figures would have been much higher. The fundamental point to be borne in mind, however, when these figures are under review, is that health services are, in the main, services given personally by highly trained persons whose work must be paid for at rates commensurate with their training and abilities. I must emphasise that point because the eighth round increases for medical, nursing and kindred staffs were not related specifically to the cost of living. If they were, the rates of increase would have been much lower. Rather have they resulted from a reappraisal of the value of the work done by those staffs, and while I am as ready as the next to seek to protect the interests of the ratepayers and the taxpayers, I do not feel that I need apologise to anybody for the increases which I have sanctioned in these instances.
But even if my thinking in this matter were conditioned by what I thought we could get away with— which it was not—I would still have to consider whether less generous increases would continue to attract to our services, and to retain, an adequate number of qualified and contented staff. I am convinced that, with competing demands elsewhere, the day is not far distant when, in the absence of increases such as have been granted, we would fail altogether to get suitable staff.
It will be noted from the details of Subhead G that £14,440,000, or over 70 per cent. of the estimated net health expenditure by health authorities, is in respect of hospital services. This expenditure consists of the running costs of institutions conducted by health authorities together with the amounts paid by health authorities to voluntary and proprietary hospitals and homes in respect of services obtained by patients admitted to those institutions under the provisions of the Health Acts. It is, I think, appropriate to mention in this connection the grants which the voluntary hospitals receive from the Hospitals Trust Fund towards their revenue deficits and which are estimated to amount to £1,800,000 in the year 1962-63. If we regard these grants as a further contribution from public funds, which I think is the correct view, we arrive at the very considerable total of £16,240,000 as the expenditure of public authorities on hospital services.
The subhead makes provision for an improved service which I am sure the House will welcome. Previous Ministers for Health will remember efforts to improve aural services. The difficulty was to find an agency which would be responsible for the supply, fitting and repair of reasonably priced, but efficient, hearing aids. I am glad to say that for some time the National Organisation for Rehabilitation has been addressing itself to this problem and that it is now on the point of inaugurating such a service. It is arranging for the supply of hearing aids on a contract basis, has secured and is adapting premises for a hearing-aid centre, is recruiting trained personnel and should shortly be in a position to meet demands from health authorities for such aids for Health Act patients on the recommendation of the health authority's appropriate medical specialists.
In anticipation of this development, I have recommended to each health authority that it should provide itself with the necessary equipment to help in the ascertainment of partially deaf children, whose educational development would be retarded by defective hearing, and, further, that they should arrange, as a commencement, that a public health nurse in each area should undergo special training in the use of it. The response I am glad to say has been very satisfactory indeed. All health authorities have either purchased or agreed to purchase the equipment and already two special training courses for public health nurses have been held. The aim is to discover early in life—in the first year or two if possible—children with defective hearing so that to the maximum extent possible their normal development of speech and intelligence will not be retarded.
The hearing-aid service will not be confined to children. When the service gets into its stride, it will be possible to cater for the needs of adults who are eligible for such aids under the Health Acts.
I have already mentioned, under the heading of rehabilitation, the making of regulations under Section 50 of the Health Act, 1953. Provision has been made under Subhead G for the commencement in the current year of regulations under the section. I should, of course, point out that already there is statutory provision for the vocational rehabilitation and retraining of persons who have suffered from infectious diseases—notably tuberculosis and poliomyelitis—and that already a considerable amount has been, and is being, done in respect of such persons.
Another item which, year by year, has being contributing to the increase in expenditure under Subhead G has been drugs and medicines supplied to persons eligible for free issue of these items under Section 14 of the Health Act, 1953.
In passing, I should, perhaps, mention that the supply of free drugs and medicines under Section 14 is not confined to persons who hold medical cards. A person might be ineligible for a medical card because he is regarded as being in a position to pay for the services of his doctor; but his medical condition might be such that he needs, over a long period, a supply of the newer and more expensive drugs. Cases have come to my notice where the necessary supply of these preparations might cost as much as £3 a week, and that indefinitely. The section allows of a supply, or partial supply, in those cases, even if the patient has not a medical card and last September I thought it well to remind health authorities that such was the position and asked them to publicise the fact. If all health authorities had exercised their powers in this respect more generously than they have done, I think that complaints about the operation of Section 14 would have been considerably fewer than they have been.
To revert to the increasing cost to health authorities of drugs and medicines provided for out-patients, the figure has increased from £176,000 in 1956/57 to an estimated £392,000 in the current year. While, by reference to costs in Great Britain and Northern Ireland, the average cost per eligible person is still relatively low, it is important to ensure that there is no unnecessary or wasteful expenditure and I have been considering the problem in consultation with health authorities.
One of the matters under consideration has been the establishment of central pharmacies by health authorities under the control of whole-time pharmacists. It is envisaged that all the supplies of medicines and drugs required by the district medical officers would be ordered through the central pharmacies and that the duties of the pharmacists would include the general supervision of the stocks of medicines held by compounders and district medical officers, particularly with a view to ensuring that stocks likely to go out of date are used in another dispensary district where they may be required or in a health authority institution. The pharmacists could also be of assistance to dispensary doctors in their ordering of drugs, and in advising them of non-proprietary equivalents available, where expensive proprietary medicines are proposed. As a first step in this direction Limerick and Dublin Health Authorities have appointed supervising pharmacists with an overall responsibility for the health authority pharmacy services in their areas. When experience has been gained of the system in these areas, it is proposed to suggest further similar appointments in other health authority areas, if results appear to justify that course.
A list of analogues, that is, the cheaper but equally effective equivalents of proprietary drugs, for use by district medical officers, was issued to health authorities from my Department some years ago. This list is being brought up-to-date and will be issued to health authorities shortly. By using this list, district medical officers will be enabled to avoid the unnecessary use of expensive proprietary drugs.
In the last analysis, of course, the doctor is the final arbiter of what treatment the patient needs and, without his co-operation, little in the way of economical, yet effective, prescribing can be achieved. Having full faith in the integrity of our doctors, I know that they will not impose unwarranted charges on their health authorities by prescribing expensive preparations where equally effective substitutes can be obtained at lower cost.
As the House will already have heard this afternoon, the Minister for Finance, in connection with his Budget proposals, has found it possible to agree to increases in the rates of infectious diseases maintenance allowances and disabled persons allowances. The details of the increases are being worked out preparatory to the making of the necessary amending regulations. The Exchequer portion of the increase will be borne on Subhead G of this Vote and a Supplementary Estimate will probably be necessary in due course.
I trust that the House will accept the Estimate. It shows a considerable increase over previous years. Much of this is due to increases in the remuneration of essential personnel; but some of it is due also to the progressive improvement in the health services and the projected expansion of them in sectors where this has been frequently demanded.