Committee on Finance. - Vote 54—Health.

I move:—

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.

I move:

"That the Estimate be referred back for reconsideration."

In doing so, it is my purpose to initiate a discussion on the work of the Minister's Department during the past 12 months and on the administration of the Department by the Minister. The speech the Minister has just completed contained a very comprehensive review of the important factors in relation to our health services. I should like to make a few comments on some of the figures to which the Minister referred. At the start of his address, he gave us some vital statistics which are interesting. It appears that in the last 12 months the number of births is down, there are fewer marriages and the death rate is up. That is of course not surprising when we have regard to the economic and other difficulties the country has been facing in recent years. A fall in the number of births, fewer marriages and an increase in the death rate is symptomatic of the toll of emigration on our people. It is certainly interesting to see the effect of emigration on the vital statistics contained in the very formidable report which the Minister, as the responsible Minister, had to give the Dáil this evening.

The Minister also in relation to figures and statistics referred to the mortality rate arising from heart disease and cancer. Once again, the Minister has told us that the greatest single killer is heart disease. The next greatest killer appears to be cancer. With regard to cancer we have had in the last five weeks or so a renewal, certainly a repetition, of the warning given from time to time in recent years with regard to the danger to health from cigarette smoking. I appreciate that for any Minister for Health, and particularly in this country, the link between cigarette smoking and cancer poses problems difficult to solve. The Minister for Health here has not at his disposal the means of research and investigation available in other countries, but we now have available to us the results of such research and medical inquiry. The link between the incidence of cancer and cigarette smoking appears to be clearly established.

It is because of that I must express, purely personally, some slight regret at the manner in which the Minister in his statement today dealt with this problem. I can understand well what the Minister had in mind when he said no useful purpose was likely to be served by the bellowing of propaganda with regard to the association between cancer and cigarette smoking. The Minister is perfectly correct in that but, at the same time, I feel that a sympathetic and—I will not say "paternal"—avuncular approach by the Minister for Health to this problem might be helpful. There are at the moment quite a large number—I believe a growing number—of people who are anxious to be helped in giving up or reducing cigarette smoking. Many parents with young and growing children feel that their duty is not to set such an example in the home that the habit which they unfortunately became affected by would be passed on to their children.

I should like to suggest very urgently to the Minister that more could be done without undue indulgence in propaganda by making available to the public information as to these aids in the form of non-smoking drugs and so on which are so widely discussed in other countries. There are apparently available in Britain and America a variety of aids towards the reduction of smoking. I do not know how effective they are but certainly they are widely talked about. Possibly they are available here. Certainly, information with regard to them should be made more generally available to persons anxious to seek assistance. I would also suggest to the Minister that merely to refer to the duties of parents and teachers in this regard may not be sufficient. I should like to see carefully and wisely conducted some form of educational propaganda in relation to cigarette smoking in the schools and particularly made available to boys and girls on the point of leaving school. While the cigarette smoking habit may be impossible to deal or contend with in those already unfortunately afflicted by it, certainly it should be the concern of the Minister, as I am sure it will be, to try to prevent a future generation of heavy smokers coming along, and there should be an effort to deal with it along those lines.

The Minister gave us some interesting figures on the operation of the maternity services. He referred to the fact that these services have been in operation for Health Act patients since 31st March, 1956. As it was my privilege, as Minister for Health, to preside over the introduction of those services, I feel some pleasure in learning from the Minister that the progress of the maternity services in the past six years has been in accordance with the expectations expressed on their behalf when they were introduced.

I note, however, that in the year under review, there has been a fall in the number of domiciliary births and that fewer mothers in the past 12 months have had their babies at home and more have had their babies in the local authority and voluntary hospitals. The Minister did not comment on these figures but it does appear to me to be a pity that that trend should be so apparent. In the case of the mother with a large family or with a number of children who are already a responsibility, perhaps living in a home where conditions are crowded or perhaps not good for one reason or another one can understand her having her baby in hospital and indeed having a much-needed and well-earned rest.

It is well to remember that most of us in this House were born in our mothers' homes. It is only in comparatively recent years that the tendency towards hospital birth has become so definite. It has to some extent contributed towards the cost of health services. When the regulations under the maternity services were being framed, they were designed expressly to encourage domiciliary births, where conditions made that course possible. In the case of a first or second child and where the home circumstances make it possible, doctors operating the maternity services should encourage domiciliary births.

The Minister also referred, very properly, to smallpox. No doubt he did it in such a clear way because of the current concern in these islands with regard to this dreaded disease. We have been fortunate in that there has been no case of smallpox in this country since the early years of the Twenties. At the same time, our public health officers and those charged with responsibility in this regard have always been conscious of the fact that, with the increasing facilities for communication in recent years, the danger of smallpox coming here might always be increasing. Despite an increasing danger over recent years, the figures in regard to smallpox vaccination have decreased to such an extent that in the past two decades, there has been virtually no vaccination against smallpox. The outbreak, therefore, in the sister island in recent months must have brought our people, particularly people on the east coast, face up against the possibility of an outbreak here.

I would agree with and support the Minister in everything he has said with regard to the need, indeed the urgent need, for parents to avail of the vaccination services. I do not know whether any information has yet been made available—perhaps I am referring to something that has already been decided—but I would express my own personal hope that the international match between this country and Wales will not, in the circumstances, take place. The holding of such a match in these circumstances would be indulging in a very unnecessary public health risk and I have no doubt that most sensible people would concur in that view.

The Minister gave us some figures in relation to the hospital building programme and in that regard may I say a few words for the record? The Minister announced this time last year, with rather a fanfare of trumpets, that there was to be a new hospital building programme, that he had given the green light for certain hospital projects such as the new Coombe Hospital, and so on. In doing so, he referred to the more solvent condition of the Hospitals Trust Fund, of which he is in the capacity, as it were, of public trustee. Today, he again referred to the hospital building programme. He announced that over the next three years some £6,500,000 from the Trust Fund will be expended on hospital building. I should like to say—I have said this before but it is necessary to repeat it every time this subject is discussed—that each of the hospital building projects which the Minister has in mind would now represent a hospital already constructed, had the Minister in 1957 not stopped the hospital building programme I had drawn up.

But the Deputy had no money for it.

The Deputy was not even in this House at the time.

I was listening to the Deputy in Cavan advocating a new hospital, but the Deputy had no money provided for it.

If the Deputy was listening to me advocating a new hospital in Cavan, he was listening to something I never said.

The Deputy was down there.

I am sure I was; I have been in Cavan many times and I am sure I shall be there again. To proceed with what I was saying, in 1956, there was facing the then Government, and me particularly, as Minister for Health, a difficult problem in relation to hospital building. The Hospitals Trust Fund, in order to fulfil the commitments it had to face, was depending on a grant from the Central Fund. It was quite clear, in the conditions of capital shortage facing the State in 1956, that the building programme the Department of Health was expected to implement was top heavy and required a complete overhaul and reappraisal. On my instructions such a reappraisal was carried out. In effect, decisions were taken to build in this city a new Coombe Hospital and a new St. Vincent's Hospital. A decision was taken to build a regional hospital in Cork. A fourth building project was also decided upon. I think it was in connection with St. Laurence's (Richmond) Hospital, but I am not certain about that. In addition, it was decided to proceed with certain local authority building projects, such as the county hospital in Longford, and a number of others which had reached a stage that compelled me to decide they should proceed.

That building programme in 1956 was based on the assumption that the income into the Hospitals Trust Fund in the ensuing years would be of the order of £2,000,000. That assumption was perfectly justified and, had the Minister not decided to scrap that programme, these projects would now be completed, and completed in circumstances that would satisfy even the strictest exponent of financial rectitude because the expenditure envisaged in each year was carefully framed in accordance with the expected income into the trust fund. However, the Minister decided not to build these hospitals until he had stacked up in the trust fund a large surplus. It is interesting to note that in recent years trust funds have been invested in stocks and shares at the direction of the Minister instead of being devoted to hospital building. The result now is that the cost of these hospitals upon which the Minister has decided to embark will be substantially more than it would have been, had the plans and building proceeded some six years ago.

I was amused to hear the Minister say in relation to his hospital building programme that he was disturbed and concerned at the tardiness of various local authorities in submitting their plans, now that the green light has been given to them, but I noticed the Minister did not say that with much conviction. I should like to ask the Minister could he possibly blame these people, who have been entertaining pipe dreams for years about new hospitals and, every time their dreams began to take on the trappings of reality, some Minister for Health came along and scrapped the entire programme?

The governors of the Coombe Hospital from the early Thirties planned, and dreamed and talked about a new maternity hospital in Dublin. A kinsman of mine associated with that hospital, thought and talked of nothing else up to the time of his death. Those associated with the hospital were heartened in 1955 when they learned that that project was to proceed. Unfortunately, some few months later, they learned that once again it was to be postponed. It has been postponed ever since.

Again, the governors of St. Laurence's had their dreams. What can the Minister say of the effect on them of the lack of any decision in regard to the future of that hospital? In 1955, that hospital was almost ready for the acceptance of tenders. I had to take a decision then to postpone the St. Laurence's project because of the condition of the trust fund. Subsequently, when the revised programme was drawn up, that project had to be reappraised. I do not know whether St. Laurence's is now to have a new hospital. My information is that the authorities in the hospital still do not know. Certainly, if they are amongst the people blamed for being tardy, I find it difficult to see why they should be blamed.

Out near Montrose there are the foundations of a new general hospital designed with imagination, with faith and with hope and where is that project today? The new St. Vincent's Hospital on the Bray Road was given the green light away back in 1954. In the early part of 1956 the initial construction contract was cleared by the Department of Health and handed over to a contractor and the foundations were laid. In the latter part of 1956, or around 1956, there was a ceremony whereby the cutting of the first sod for the laying of the foundations took place. The following year, in accordance with the plans drawn up in my time, the actual construction contract was to be effected, but nothing happened. There the situation now is. The foundations for that hospital were laid seven years ago and since that they have been collecting the frost and snow and rain but nothing else. There again is a hospital that would now be providing care, attention and treatment for sick people if the Minister had not abandoned the building programme of 1956. However, in that respect I have said all that it is necessary to say. May I just go on to refer to another matter dealt with by the Minister?

It gave me great pleasure to hear the Minister's remarks about the continued progress of the Voluntary Health Insurance Board. The Voluntary Health Insurance Board was set up by an Act of this House passed in 1956. It contained an idea which represented a declaration of faith in the community spirit amongst our people. The idea of voluntary health insurance was a new one and it was felt by the Government and by all Parties in this House that the idea of people voluntarily getting together to help share the burden of sickness was a thing worth starting. I have little doubt that the idea would have been adopted whoever happened to be Minister for Health and it just happened that it was my lot to have the pleasure of introducing that legislation.

At the time I said to the House that it was the first measure of social welfare legislation introduced in any Parliament in Western Europe that in my view was not going to cost the tax-payer one penny. Now, some six years later, it is worth recalling that over that period the Voluntary Health Insurance Board which started its operations with a loan from the State— I forget the figure, but it was something like £10,000, a loan which was repaid either the following year or the year after, but certainly within two years of its inception—continued to provide a very fine service for an increasing number of persons. From its operations benefit and good have come to a large section of our community. The interesting thing is that it has not cost the State one penny. On the contrary, the State has made money out of it. The State charged, as it was entitled to charge, the Voluntary Health Insurance Board interest on the initial loan made available to it.

That loan was repaid with full interest and in each year since provision has had to be made by the Voluntary Health Insurance Board in respect of an income tax liability on the surplus it makes on its premium income over its expenditure. So that this Board, which is providing a necessary social service for a large section of the community, is in fact helping to run the State, to a very small degree, perhaps, but it is making a contribution in respect of income tax. I mentioned before this question of the Voluntary Health Insurance Board being charged for income tax and may I mention it again? It appears to me completely wrong and unfair that a State Board, or a board established under Act of the Oireachtas—which is prevented and prohibited by the State from making a profit, which has the obligation under its charter, under the Statute, to turn any surplus back into benefits for its contributors—merely because at the end of twelve months' trading it should happen to have a surplus of some £5,000 or £6,000, which is destined to go back as a benefit in the next year's trading, should attract an income tax liability.

Would the Minister for Health have any responsibility?

None whatever.

I am going to suggest he has, if the Minister will bear with me. When the scheme was being drawn up and introduced here, I, as Minister for Health, had discussions with the then Minister for Finance and it was agreed that a section would be introduced in the ensuing Finance Bill exempting the Board from income tax liability. Unfortunately, my colleague at the time the Finance Bill came to be introduced, was no longer there. I am going to suggest it is the duty of the Minister for Health to investigate that particular commitment—I regard it as a commitment—made by the Minister for Finance to the Minister for Health.

I can see no record of it.

I am aware there was no record.

There was no record, I have gone into that.

I appreciate that, but I can only suggest to the Minister that he should discuss this matter with the Minister for Finance. I have raised it with the Minister for Finance many times in the House and I have always gathered from him that it is not a matter for him initially but that he would be interested in the views of the Minister for Health. I suggest the Minister for Health take it up with him.

That is as much as I want to say with regard to the matters covered by the Minister's statement. May I say, however, that the motion to refer back the Estimate has been tabled by us in order to emphasise the fact that we are not satisfied there is in operation at the moment any clear, definite, logical health policy whatsoever? As far as we can see, the Government are groping and muddled with regard to health policy and that has had the effect of creating administrative problems.

All these wonderful figures the Minister refers to in his very comprehensive statement must not conceal from us the fact that at the moment under the administration of our health services, for two-thirds of our people, the State provides no form of medical service whatsoever. It means that two out of every three have to fend for themselves, unaided, unhelped in any way by the State in relation to the provision of doctors or of necessary drugs and medicines for sickness in their homes. That is a glaring weakness in the structure of our health services. At the same time, as the services are administered at the moment, there is maintained a series of absurd charges for hospital treatment for sick needy people who, when they go to hospital, when they are no longer earning, are charged maintenance rates for services which their circumstances require should be provided free.

No doubt the Deputy will bring evidence of this to the Select Committee of which he is a member.

I think that was an unwise intervention by the Minister. Perhaps the Minister will realise how serious it was before he has finished.

It is not assertions I want but evidence.

These glaring defects are apparently clear to everyone but the Minister for Health.

It will be easy for the Deputy to make that point clear to the Committee.

The Minister has been increasingly anxious in recent months, particularly since the last general election, to prevent a discussion on these matters and for that reason he had the House appoint a Committee to find for him a health policy.

Is the Deputy trying to get out of it?

I have never tried to get out of anything in my life and I do not intend to start now. The Minister hoped the setting up of that Committee would prevent any further discussion in this House on the glaring defects of the health policy he is pursuing. I told him at the time that would not be so and warned him that despite the operation of the Committee, we could continue to advocate an entire reform in the administration of his Department and of the policy now being pursued by it. That is the reason this motion to refer the Estimate back has been tabled.

We are far from satisfied that the Government have any real appreciation of the glaring defects in our health services or in the manner in which they are administered. As far as the evidence goes, it appears that the member of the Government chiefly responsible is entirely satisfied with the present health policy. "Point to defects," he says. He has no regard for the fact that he has behind him, from Cavan, Donegal, Cork and elsewhere, Deputies in his Party whose postbags outside are full of letters asking for their assistance in trying to secure medical cards or to have hospital bills reduced. Apparently none of the mutterings behind him has reached the Minister's ears or if it has, he pays no attention to it.

Does the Minister live in some sort of balloon, entirely removed from everybody else? Does he not appreciate the fact that health or medical cards are sought after as so much gold dust by unfortunate needy poor people because they represent the means whereby essential lifesaving drugs and medicines can be obtained when illness affects a family? That is because under this absurd policy the Minister believes in there is no medical service or assistance for two out of three people.

We on this side of the House—other Parties can speak for themselves— have declared our views in that respect quite clearly. It was one of the issues on which we fought the last general election, and if the Minister thinks he is going to silence us by a Parliamentary Committee to relegate health into the background, he is making a grave mistake. We know we are right. We know there has to be a very definite change in health policy and we will continue to advocate that, irrespective of what the Committee on Health Services or any other body may decide to say. Talking of committees, it is interesting to see that there are at the moment, presided over by the Minister for Health, a whole variety of commissions of one kind or another—mental illness, handicapped children, poisons, cancer —and now there is one on health.

None of which is presided over by the Minister.

Not presided over by the Minister but certainly established by him. Surely whatever need there may be for a specialised, limited inquiry as to particular problems such as mental illness or mentally retarded children, it appears to me that no case whatever could be made for the setting up of a Parliamentary Committee, manned by the Minister's opponents, to find for him a health policy. We do not need a Parliamentary Committee to tell us what our health policy should be.

It was a majority of the House that set up that Committee.

The Minister is not in a schoolboys' debating society. He is in Dáil Éireann and everything the Minister says will appear on the records of the House and may be read.

Despite the efforts of Deputy O'Higgins, the Committee was set up.

In any event, I hope the Minister, on reflection, will agree that his intervention some time ago was unwise. May I suggest to the Minister that we will continue, on every appropriate occasion and in every orderly way, to advocate the policy we stand for and hasten the day when the Fianna Fáil Health Act and the policy enshrined in it will be scrapped and something better and worth while put in its place?

May I inquire from the Minister what is happening in relation to his row with the doctors? The Minister has been Minister for Health continuously over the past five years. When he went in, no doubt he felt happy that the heat was off health and that he was met with a measure of goodwill.

Not at all. The very day after the Deputy went out, the I.M.A. provoked that quarrel.

Hear, hear

The record is there.

Did the Minister hear the voice of Fianna Fáil behind him? Is it to that the Minister is speaking? The fact is that when the Minister became Minister for Health, there was laid up and available to him and to his Department a considerable measure of goodwill, established as a result of mutual understanding and patience—

And manifested in a demand which they dared not make to the Deputy when he was Minister for Health because they did not want a row.

May I be protected from the disorderly interruptions of the Minister for Health?

Does that mean that I shall get it? I know it is only necessary to mention it to get the help and protection of the Chair.

There is no necessity to repeat it.

When the Minister became Minister for Health in 1957, he had charted for him a primrose path. He had only to walk along it and he would have been garlanded with flowers.

The Deputy knows where the primrose path leads to.

Watch the Minister; he is going to talk again. However, it was not very long, only a matter of months, before the signs of discord became apparent again. I was interested to see, after he became Minister for Health, that the following June he went along as the guest of the I.M.A. to their annual beano. He was met and fêted there, as he should have been, as the Minister for Health, and accorded all the honours. He spoke at the annual banquet of the I.M.A. in 1956, expressing the accord which existed between his Department and the I.M.A. Something happened after that. The Minister says it was the fault of the doctors; the doctors say it was the fault of the Minister. It is not possible for us in this House or for the general public outside to decide whose fault it was. Certainly, we have had a profusion of enormous statements issued by the Minister dealing with all aspects of his current dispute or disputes with the I.M.A. They have been dreary and rather boring to have to read through. I think I am the only person in the country who reads them: I have to do it. However, I still do not know the basis of this dispute. What I am concerned with is the fact that it should have continued.

Last October, when the Minister, as a result of a vote of this House, got his seal as a member of the Government and was once again given the responsibility of the Department of Health, surely he could have said: "Well, let us start off with a clean sheet"? Surely he could have wiped the slate clean and asked the I.M.A. to discuss with him the problems which affected doctors in operating health services throughout the country? Apparently he has decided not to do that.

They do not represent the doctors operating the health services. The doctors operating the health services are there in spite of the I.M.A.

It is certainly a most disturbing fact that in the past five years, the Minister for Health has never once met any deputation from the I.M.A., not once. I do not believe that could be said of any Minister for Health anywhere else in the world. He has never met any group representing the professional class who are supposed to carry out health services. He has refused to meet them. Not only that, but he has gone out with a hatchet and waved it all around the place in order to try to destroy the ordinary association of doctors called the I.M.A. What is the sense of that?

Does the Minister for Health want to be remembered as the Minister who destroyed the I.M.A.? Is that the kind of monument he wants erected to his memory and to his work in the Custom House? If that is his concern, well, I pity him. The I.M.A. may have its faults—I am aware of many of them —but I do not believe that any assault upon that association will have any result other than to strengthen it.

I am not making any assault on them. I am leaving them to stew in their own juice.

Every time this question of accord between the profession and the Minister is referred to, up comes the Minister to start off by slanging the I.M.A. and everyone associated with it.

I have not referred to the I.M.A. for years. The Deputy is doing all the talking about the I.M.A.

This is a free country. Certain Parties in this House enabled it to be free and we are entitled to express our opinion. Just because the Minister frowns does not mean that I shall keep silent. The Minister and his colleagues frowned in the past but we have the right to speak. Even if it worries and embarrasses the Minister, I shall still continue to talk about his row with the doctors until such time as the Minister has taken some steps to bring it to an end.

It is absolutely absurd in a small country such as this, with quite a large health problem, that there is not available to the Minister in an orderly, regular, constitutional way, the advice and the help of the leaders of the medical profession. It is absurd that that should be so and it is quite wrong that any Minister, out of a sense of pride, or whatever it may be—

Propriety.

Ministerial propriety is only another way of saying "pride."

Indeed it is. When I was Minister, I was never——

——backward in admitting it, if I did not know something. The Minister tries to give the impression he knows all the answers. It may be water under the bridge now but it would be helpful, in this year when he is desperately looking around for some health policy, if the Minister would admit he does not know all the answers. He has at last had to admit, by his move to establish a health committee, that there is something wrong in the policy he is pursuing. Could that not instil into the Minister some awareness of the fact that there are possibilities in the medical profession, that there is a wealth of wisdom that might be availed of in helping the Minister, the Government and the country in devising a new health service and a better health policy? I appreciate that I may have spoken longer than I intended to, but, to some extent, the Minister is responsible for that.

You have discharged the virus.

I would again like to congratulate the Minister on the comprehensive nature of his factual report to us in relation to the operation of the health services, such as they are. We are not satisfied that the nature and construction of these health services accord with the requirements of this country and we were sent here in pursuance of a clear health policy. Therefore it is our duty to vote against this Estimate and accordingly, for the reasons I have stated, I have moved that the Estimate be referred back.

I cannot but agree with Deputy O'Higgins when he says that the Minister gave us a comprehensive report on the health services. This, followed by an hour long speech by Deputy O'Higgins, makes it difficult for me to have anything at all to say on the Health Act. I regret very much that this Estimate appears to have been rushed forward this evening. As far as I am concerned I had no prior notice until some time to-day that it was to be taken after the Budget. However, I feel that I can express my views on it even without the preparation which I would have liked to have had the opportunity of making.

Much of the criticism of the Health Act, whether in the House or by local representatives on health authorities, appears to be caused by the confusion that exists about the benefits obtainable under the Act. A good deal of the criticism that we get, particularly from local representatives on health authorities and county councils, comes from the fact that people believe that the medical card is the beginning and end of the health service. There appears to be an idea current throughout the country that unless you are the holder of a medical card you get no benefit from the Health Act, that you are deprived of the right to health services.

Time and again the Minister, local authority officials and other people have endeavoured to show the benefits of the Health Act, 1953. Notwithstanding all the propaganda, there still remains an ignorance of the benefits of the Act which accounts for the fact that so many people feel that the cost of the Health Act far outweighs its value. I do not accept that view. I believe that the Health Act is a good Act. In 1953, I, in common with my Party, supported the then Government in putting through the Health Act, not that we thought it was a perfect Act but because we thought it was a marked step in the improvement of our health services and that the people would benefit from it.

People assume that unless you have a medical card you do not come under the Health Act at all. It is true that to get the full benefit, to get all and every benefit, the holding of a medical card is a very important factor. But there is a big section of the people, the middle income group, which can secure advantages under the present Health Act for which they pay through rates and taxation. I would suggest and I would urge on any individual or group of individuals joining in any scheme, that they could not get for the same amount of money anything comparable to the medical service that the middle income group can secure under the existing Health Act.

It is quite true that maladministration can deprive and has deprived many people of the middle income group of the benefits that should rightly be given to them under the Health Act. As an instance of what I am saying I would like to quote from the Minister's speech this evening. On the third last page of the Minister's written speech he states:—

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 these 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.

I would like to say to the Minister that most local authority representatives have never heard that that circular was issued. Local authority officials, in the main, comprise the secretary of the health authority and should he suppress that circular, as I suggest that circular has been suppressed throughout the length and breadth of the country, that is, to my mind, the reason for most of the campaign that is going on.

Progress reported; Committee to sit again.
The Dáil adjourned at 10.30 p.m. until 3 p.m. on Wednesday, 11th April, 1962.