I move:
That a sum not exceeding £37,921,000 be granted to defray the charge which will come in course of payment during the year ending on 31st day of March, 1971, for the salaries and expenses of the Office of the Minister for Health, including Oifig an Árd-Chlaraitheora, and certain Services administered by that Office, including grants to local authorities, miscellaneous grants and certain grants-in-aid.
On the purely financial side, Deputies will be mainly concerned with subhead G which is the main subhead of my Department's Vote. It provides for grants to health authorities in respect of expenditure on health services. These grants comprise the statutory grant of 50 per cent, a supplementary grant, averaging about 6 per cent, and a new form of grant introduced for the first time this year, specifically related directly to the relief of rates. The total provision under the subhead is £32,908,000 which is £4,412,000 more than the latest figure for 1969-70.
The new special grant to which I have referred for the relief of rates accounts for £2,500,000 of the increase in the provision under the subhead as compared with last year. As Deputies are aware, there has been considerable pressure in recent years from ratepayers and rating authorities to have a greater share of health costs met by the Exchequer. Notwithstanding the many competing demands on the Exchequer, the Government, mindful of the fact that many ratepayers, particularly those on small incomes or on incomes which do not keep pace with increasing costs, are finding it a hardship to meet rates demands, decided that a special provision should be made available to enable increase in health rates to be contained within a reasonable limit.
Having considered various methods of distributing the £2½ million, I decided that in the interests of the majority of ratepayers allocations should be such as to equalise the increase in the health rate throughout the country. The substantial amount made available was sufficient to limit health rates increases to 2s in the £ and allocations of special grant were made to health authorities to achieve this objective. These allocations were determined on the basis of information received by my Department from local authorities, prior to the announcement of the new measure, as to the health rate likely to be required in 1970-71 if health grants remained at the same percentages as in 1969-70. The allocations varied from area to area depending on the anticipated rates situation for 1970-71. I should emphasise that but for this special assistance, increases in health rates would have ranged up to about 12s in the £.
Taking account of the special grant, the cost of health services in 1970-71 will be met to the extent of about 60 per cent from the Vote for my Department. If the relief afforded by the agricultural grant is taken into consideration, the total Exchequer contribution towards expenditure on health services in 1970-71 will be equivalent to about 76 per cent. I think Deputies will agree that this represents a generous sharing by the Exchequer of the cost of health services and will welcome the additional assistance for the relief of rates which is provided for in the Estimate.
The total net health expenditure by health authorities, which will be shared by the rating authorities and my Department's Vote on the basis which I have described, is estimated at £55,385,000 for 1970-71. This is £3,185,000 in excess of the latest figure for 1969-70. It is estimated that about 70 per cent of the increase relates to improvements in the volume or quality of services.
The main factors responsible for the increases are as follows: increase in capitation rates payable by health authorities for services in voluntary hospitals which account for £650,000; additional bed accommodation, particularly in the new St. Vincent's Hospital, Elm Park, which will take £390,000; improvements in standards in general hospitals run by health authorities, including extra medical and nursing staffs, improved casualty services and ambulance services, an additional £390,000; £400,000 for improvements in standards of treatment and accommodation in mental hospitals; additional places in residential and day care units for mentally handicapped persons and improved standards in county homes which will cost £325,000; increased issues of medicines at dispensaries costing £250,000; an extra four months operation, in 1970-71 as compared with 1969-70, of the increased rates of allowances for disabled persons and persons suffering from infectious diseases approved with effect from 1st August, 1969, which will require £200,000; and improvements in maternity and child health services estimated to cost £130,000. A provision of £435,000 is included for price increases.
Subheads K.1 and K.2 of the Vote provide for grants-in-aid to the hospitals Trust Fund—£3,200,000 under subhead K.1 related to the revenue deficits of the voluntary hospitals and £1 million under subhead K.2 in respect of capital expenditure. These grants are required because there are now no reserves in the Hospitals Trust Fund and the current income of the fund from sweepstakes is not sufficient to meet commitments by way of capital grants, grants to cover the revenue deficits of voluntary hospitals and miscellaneous grants.
The amount sought under subhead K.2 is, at £1 million, the same as for last year. The requirements under subhead K.1 show an increase of £450,000 despite the adjustment as from 1st April last in capitation rates payable for services provided in voluntary hospitals. The increase arises mainly from adjustments of pay and improved conditions for staffs employed in these hospitals and increases in prices.
There has been an enormous increase in expenditure on health services in the last decade. Taking account of both revenue and capital expenditure and grants from the Hospitals Trust Fund in respect of the revenue deficits of voluntary hospitals, the cost has risen from about £18½ million in 1958-59 to about £61 million in 1969-70. Increases in salaries and wages and price increases account for a very large part of this increase. However, even if these factors were eliminated, the increase in real terms of the allocation of financial resources towards betterment in the standard and scale of health services has been enormous. In fact, the volume cost of health services after eliminating increases in unit costs has doubled in the period between 1958 and 1969 during which the volume of production rose in real terms by some 60 per cent, illustrating successive Governments' decisions to make use of national resources far beyond the cold-blooded norm in order to improve health services.
Subhead Q is a new subhead in which a token sum of £100 is provided to enable my Department to meet expenses incurred in the recruitment, training and payment of chief executive officers for the new health boards and the travelling expenses of members appointed to these boards in the current financial year until full responsibility is transferred to them on 1st April, 1971. It is not possible to estimate with any degree of precision what the cost is likely to be and accordingly at this stage I am asking for a token sum. The full amount of these costs in the current year will be a final charge on the Exchequer—in other words I am not proposing that rating authorities should bear any of it.
Having just referred to the initial financial arrangements being made in connection with the implementation of the Health Act, 1970, I feel that I should inform the House about the progress being made towards effecting the main changes under the Act before proceeding to a more detailed analysis of the services.
I am obliged under the terms of the Act to consult the relevant local authorities about the regulations on the consultation and functional areas of the new health boards. I have now sent draft regulations to them for any views they may wish to offer. The draft regulations which I will submit to the Oireachtas for approval before making them will take account of any views put forward by the local authorities. My present intention, which is in accordance with what I said during the debates on the Bill, is to establish the health boards on 1st October next and to transfer to them responsibility for the operation of the health services as and from 1st April, 1971. I expect to have the draft regulations before the House some time next month.
The House will then have an opportunity to debate the resolutions setting up health boards, regional hospital boards and Comhairle na nOspidéal when they come before the Oireachtas —I have already given a general description of these bodies.
The staffing aspect of the new authorities is an important one. I expect that the Local Appointments Commission will be in a position to invite applications for the posts of chief executive officer within the next few weeks. As regards the present staffs of health authorities, I am very conscious of the fact that they are concerned about the implications for them of the pending changes. I am most anxious that none should have a justifiable grievance as a result of the reorganisation which will be necessary and I am now in the process of setting up a joint consultative council to smooth the transfer of staffs. This council, which will include representation from the staffs concerned, will advise me as to the arrangements for the transfers, and will assist me generally in ensuring that the interests of all are adequately protected. Management advice will be available to the health boards so that their role can be effective and to enable them to delegate to the chief executive officers various functions of day-to-day management.
As the House is aware, the new Act provides for the abolition of the dispensary service. I hope to be in a position on 1st April, 1971, to replace it with the proposed choice of doctor scheme. After that date, the office of district medical officer will cease to exist but all serving permanent officers and many of the temporary holders of these posts will have automatic right of entry to the new scheme. It will still be necessary in some areas, in particular, in the remoter and more sparsely populated parts of the country, to appoint doctors on a salaried basis to ensure that the local people have a convenient service. I am most anxious to ensure that the people in remote areas should have no worries in this regard and it is a matter which will receive my special attention.
I am not, however, yet in a position to report agreement with the medical profession on the terms on which general practitioners will participate in the new scheme. I can say, though, that negotiations with them are proceeding in an amicable atmosphere and that I expect to bring them to a satisfactory conclusion within a reasonable period. I think that Deputies will agree that it would not be inappropriate for me at this point in time to put on the record of this House my tribute to the very effective service provided over the years by the dispensary medical officers.
Discussions with the retail pharmacists, who, it is hoped, will also participate in the scheme, are continuing. A difficulty here is to arrive now at agreement on a level of payment which would be reasonable in relation to prices and remuneration prevailing at the commencement of the scheme, one year from now. However, when the impact of the present round of wage increases becomes clearer in a few months time, I expect that it will be possible to agree terms with the pharmacists.
I might mention that the participation of retail pharmacists in the general medical services will involve a major administrative task, the checking and pricing annually of millions of prescriptions issued to eligible patients. Fortunately, it has been shown elsewhere that a task of that nature can be done efficiently and economically by computer. We are planning a similar arrangement here—and I should like to avail myself of this opportunity to acknowledge publicly the assistance given, and being given to my officers in planning our service by the Ministry for Finance and the Ministry for Health and Social Services in Belfast as well as the Northern Ireland General Health Services Board.
These are some of the major changes which we will see under the new Health Act. Work is also proceeding on schedule on the other changes proposed and we are working to the timetable which I outlined at the conclusion of the debate on the Bill in February last.
With the statistical information I supplied to Deputies, I included some vital statistics and comparative expectation of life figures. In broad terms I think these statistics show that we now hold our own with most countries, that we are a reasonably healthy nation and that we have reasonably effective health services.
In regard to expectation of life, maternal mortality, infant mortality and the general death rate we are among the top ten nations.
There are no statistics for the percentage of the population in good health or the percentage of persons delaying treatment because of ignorance or prejudice. There are statistics indicating that the child health services to which I refer later, need to be stepped up to discover and remedy, as early as possible, physical and mental defects. I am convinced that over the next years, we shall have to establish health education services on a more extensive scale.
In common with other countries we are being hit hardest in mortality figures by the new killers of the affluent society namely, heart diseases and lung cancer, and although in both these cases the provisional figures for 1969 show a welcome down-turn as compared with 1968, the position in respect of them leaves very little room for complacency. We can, I suppose, only continue to urge on people the adoption in their own interest of a healthy regimen of life by every means at their disposal. I would have thought in this regard that the public would have paid greater heed to the constant warnings by a variety of health agencies, outside as well as inside this country, of the folly of eating, drinking and smoking too much and not taking enough exercise, but I suppose that the death figures I have mentioned in a curious way reflects the eternal and so often tragically misguided optimism of the human species expressed in the phrase "it will never happen to me". All that a Minister for Health can do in this situation is to continue and, where possible, intensify the health education programme which, assisted by such voluntary agencies as the Irish Heart Foundation, the National Council on Alcoholism and the Irish Cancer Society, is beamed at the public.
I have thought it well to include with the mortality statistics circulated a table of deaths from accidents in the home. At 450 in 1968 the number of such deaths exceeded by 20 the number of persons killed in road accidents in that year. Two hundred and sixty-seven of these deaths in the home occurred in persons aged 65 years or more. As the recently published Report on the Care of the Aged made clear, the elderly, because of failing senses, are particularly vulnerable to accidents in the home and they are, of course, likely to be affected more seriously by such accidents. The more common types of accidents to which the elderly are prone are falls, burns and scalds and gas poisoning. We are, and will be, concentrating publicity on the hazards which the home can present.
During the past decade considerable advances have been made in regard to infectious diseases such as tuberculosis, poliomyelitis and diphtheria. There has been a continuous decline in the number of new cases of T.B. and in the number of deaths from the disease. For example, 4,004 new cases were registered in 1959, whereas the number registered in 1968 was 1,684. Deaths from the respiratory from of the disease dropped from 502 in 1958 to 225 in 1969. Poliomyelitis, diphtheria and typhoid have been reduced, as public health hazards, to manageable proportions.
Unfortunately, the position as regards venereal disease is not quite so happy. In 1968, there were 99 reported new cases of syphilis as against 24 in 1967 and 23 in 1966, while the number of new cases of gonorrhoea in 1968 was 383 as against 247 in 1967 and 207 in 1966. I have asked my Department to keep a close watch on the situation and, in particular, to ascertain as speedily as possible the 1969 figures. If these figures show a continuation of the upward trend then I will set in motion arrangements to have a study made designed to examine all the factors involved in the increased incidence including the socio-economic levels of those contracting these diseases with, of course, all due regard for medical secrecy. From such a study it might be possible to take measures which would control the incidence of these most serious maladies—most serious not only for the individuals concerned but because of the potential they have for infecting others. Indeed, on this particular point I have begun to speculate as to whether there should be penalties in the law to back the protection of the public health. I do not at this juncture wish to take my speculation further, except, perhaps, to add that we take steps to take a known carrier of infectious diseases out of the food business so that the public may be protected.
I have circulated to the Deputies detailed statistics of the local authority hospitals for 1968. These give some idea of the volume of work being performed in these hospitals and the cost involved. It is of interest to note, for example, that the cost of treating one patient in a county hospital averages about £30 a week, or £46 for the full course of treatment in hospital. As might be expected, costs in the major teaching hospitals are considerably higher, being on average up to £38 a week, or £73 for the treatment of one patient for the duration of his stay.
One note of warning which I would like to sound in the interpretation of these figures is that indiscriminate comparisons of the figures for individual hospitals may give misleading results. For example, in two hospitals which belong to the same general category, the type of patient treated in one may be completely different from that of another. It may be the practice in one hospital to admit a relatively large number of long-stay patients. This hospital would then experience a long duration of stay, a low cost per patient week, a high total cost per patient and probably a high rate of occupancy.
Present-day costings indicate the need for constant vigilance in ensuring that the hospitals are operated with maximum efficiency consistent with good medical practice. The hospital is now a large and complex organisation with many specialised components. It is staffed by people skilled in a variety of disciplines, many of whom have reached the peak of their profession. It contains equipment which is elaborate and expensive and which requires highly skilled operatives for its most effective use. Not only does it practise the many and varied techniques of diagnosis, prevention and cure of illness, but it must also play its part in the fields of education and research which are accepted as an essential element of the hospital scene. Over 300,000 patients a year, more than one in ten of our population, are treated in the acute hospitals in Ireland.
Before developing this theme further I think I should say that I do not accept unreservedly that development of medical services should be openended. Some limitation in cost is essential and new, complex and expensive techniques which are of marginal benefit from the public health view-point would have a low priority rating in an area of fierce competition for resources.
It is clear that, as the size and operating costs of hospitals can be equated with those of major industries, so also the need for efficiency of operation is as great as in the industrial sphere. Expert management and administration are essential features of an efficient organisation and, in our efforts to build up the clinical services, we may have tended in the past to play down the importance of good management. We must in the future give more careful attention to this aspect of the hospital organisation by the provision of suitable training at a high level of administration and the use of modern techniques, such as work study and operations research, as management aids. One aspect of the hospital service which will repay attention is "throughput" of hospital beds, or the number of patients treated per bed over a specified period. For a number of years we have been taking part in a world-wide phenomenon of an increasing demand for hospital treatment. The rate of increase in Ireland has been about 4 per cent per year. Expansion of this order makes it imperative that the available accommodation is used as effectively as possible. Bottlenecks and other factors causing unnecessary delay must be identified and eliminated.
I am setting up an organisation unit in my Department which will initiate work study, management study and other forms of examination into hospital administration. The object will be to increase efficiency which, in a labour-intensive organisation means ensuring that the staff do a useful and non-excessive quantum of work in the most effective manner. Such studies must take account of the human service element involved, but I wish to make it clear that neither capitation grants nor deficit payments will be given in future to hospitals, voluntary or local authority, who refuse to participate in such examinations after consultation. This is a final decision.
Capital expenditure on hospitals has to be related to the need to keep overall capital expenditure in the public sector within reasonable limits. That is not to say that it is not substantial During 1970-71 it is expected that £3.6 million will be spent on hospital building works of which £2.2 million will come from the Hospital Trust Fund, assisted by grant-in-aid of £1 million from the Exchequer, and £1.4 million from the Local Loans Fund and other sources.
The statement recently circulated to Deputies contains lists of the major hospital building projects completed during the past year, projects under construction as at March, 1970, and projects now at an advanced stage of planning on which building work is likely to be commenced during the year 1970 and 1971. Projects under construction at present and those on which building work is expected to start by 1971 will have a total estimated cost of approximately £15 million.
One of the most important projects is the new St. Vincent's Hospital at Elm Park, Donnybrook, Dublin, a major teaching hospital of 455 beds. This fine new hospital will replace the existing St. Vincent's Hospital at St. Stephen's Green, Dublin, and will also, if present plans are agreed with all the parties concerned, form the major part of the proposed regional hospital for South Dublin, as envisaged in the Report of the Consultative Council on the General Hospital Services, to which I will refer later in more detail. The first patients were admitted to the hospital during January, 1970. The total number of patients there at present is 54. The intention is to build up the bed occupancy during the coming year on a phased basis so that the hospital will be fully operational by the end of 1970. A nurses' home and training school and a school of radiography will be completed this summer. The total cost of the new hospital, including the nurses' home and training school, will be in the region of £4 million.
Other building projects in the general hospital field completed during the past year included a training school and staff home at St. John's Hospital, Limerick, new operating theatre, et cetera, at Barrington's Hospital, Limerick, and improvements at the Meath and Jervis Street Hospitals, Dublin. Projects in progress during the year included new operating theatres at the Mater Hospital, Dublin, and the Sheil Hospital, Ballyshannon, new nurses' homes at Temple Street, Dublin, and the North Infirmary, Cork, a new central laundry for Dublin hospitals and various improvements and extensions at a number of other hospitals.
The most important health authority general hospital scheme nearing completion is the 100-bed extension to Sligo County Hospital, to be commissioned this year. It will provide additional maternity beds, specialist facilities for ear, nose and throat and ophthalmic cases and paediatric care, new x-ray accommodation and an out-patients department, an extension of the pathology facilities and some accommodation for medical and nursing staff. Work will be commencing soon on a scheme to provide additional accommodation for 54 nursing staff at the hospital.
Among the more important health authority general hospital schemes now in planning are:—
the 600-bed Cork regional teaching hospital project and the 300-bed general hospital at Tralee.
The detailed schedules of accommodation have been settled for the Cork scheme. Planning is at present being concentrated on the production of economically conceived sketch plans so as to ensure that a scheme for a satisfactory hospital will evolve which can be built at a cost which can be met in the light of other demands on our resources. The Cork Hospitals Board expect that final planning will be completed in sufficient time to enable tenders to be invited by the end of next year.
Regarding the planning of a new general hospital at Tralee, this hospital will provide acute general medical and surgical services, obstetrical care and psychiatric and geriatric units to serve the Kerry area.
This brings me to the FitzGerald Report and, speaking of the examination necessary before evaluating finally the recommendations for nine general hospitals, as recorded in that report, I think I should be absolutely frank with the House in regard to my attitude. In the case of a number of the hospitals recommended, there is little or no controversy. I refer to the choice of Letter-Kenny, Sligo, Castlebar, Tralee and Drogheda as centres for five of the proposed general hospitals.
In the case of the hospitals outside Dublin, running in a line through what I might describe as the North Midlands to Waterford, there are already ample signs of tremendous agitation for the discussion of proposals, preparation of reports and requests for meetings with the various authorities concerned. The FitzGerald Report proposed, in addition to Drogheda, Cavan, Tullamore and Waterford as locations for the enlarged general hospitals. In the same general area there are county hospitals with 110 to 150 beds—in Monaghan, Dundalk, Navan, Mullingar, Portlaoise and Kilkenny. There is also a county hospital at Wexford, where the county council and other bodies have stressed the necessity for preserving surgical facilities there and, indeed, developing them, in contrast with the recommendation in the FitzGerald Report that the Ardkeen Hospital at Waterford should be developed to cover the Wexford area.
It will take some time for me to study in depth the proposals in the report for the location of the general hospitals in this area and to make final decisions regarding implementation or amendment, having regard to financial possibilities. At the same time may I say that I accept absolutely the conclusions in the FitzGerald Report on the changing character of medicine and surgery and the growth of specialities. The choice must be made eventually as to the sites for these large general hospitals. The Government have accepted the whole of the report in principle. I find I might say that the vast majority of up-to-date consultants fully support the general FitzGerald principles and my decision on the general policy to be followed is not subject to modification.
As I have already said on previous occasions, I will not be deterred from making a decision based on, firstly, ensuring that extremely expensive equipment is properly used; secondly, being able to offer specialised consultants, physicians and surgeons, positions of interest which will attract the best talent; thirdly, determining the choice on the basis of reducing mortality and equally reducing the length of stay in the expensive general hospital to the lowest number of days possible, this in turn being related to the possibility of using other smaller hospitals for convalescence, particularly where patients' relatives are some distance away from the general and regional hospitals. I have also agreed to meet local advisory committees set up under the Health Act before the decisions are made.
At this point I must make an absolutely definite statement reflecting the fact that I am realistic and that I absolutely refuse to indulge in politico-ministerial humbug. Whereas I will, of course, study the representations made to me for the use of this or that location for a general hospital centre, I have absolutely no doubt that, having read all the representations, no Minister on earth can make a decision on the basis of valuing the specific statements made by each local committee. There are arguable reasons for choosing the sites of the eastern general hospitals from a choice of hospitals including Monaghan, Dundalk, Cavan, Navan, Mullingar, Portlaoise, Tullamore, Kilkenny, Waterford or Wexford, or for providing more than the total number specified, namely, four.
Each of the policy statements made by a county council, a group or council representing a town, or a special ad hoc committee, will be in direct contradiction to the similar representations made by other such bodies; that is inevitable. The plea of Monaghan would be antagonistic to Cavan and favourable to Mullingar; the plea of Tullamore would be opposed to that of Portlaoise or Kilkenny, and so forth. All any Minister can do is extract from each representation whatever is really significant in studying the question as a whole. I might even decide to appoint a small independent committee to make the final recommendation to me.
It will be noted, however, that Comhairle na nOspidéal will have authority to decide on the types of consultants to be appointed to the general hospitals and their decisions will affect the issue. Any amendment to the plan will almost inevitably mean choosing sites for the hospitals south of this area at different places from those proposed in the FitzGerald Report. There are, quite clearly, borderline cases.
I wish to make it clear that I have got to be advised mainly by experts in the field of hospital development on this matter. I also wish to make it clear that I am not going to confuse the issue or make decisions any more difficult in considering locations for general hospitals covering this area, by reference to what is to be done in the area of the western regional and southern regional hospital boards where the decisions must relate to the areas concerned.
I now come to the question of hospitals where major surgery will cease to be practised as a result of the decisions above-mentioned. I, again, wish to be absolutely frank with the House so that they can see a perfectly clear picture of what is in my mind. First and foremost, I do not consider or believe that surgical facilities in a particular hospital can be taken in isolation in considering what might be described as the total availablty of health services in the immediate area of the counties surrounding a particular hospital and I am going to be absolutely firm on this matter.
So I now set out once again the present and future pattern of health services, distinguishing between policies involving decentralisation and centralisation. I make this distinction because, in my view, it is completely wrong to give such exaggerated importance to the surgical facilities in a hospital without considering the whole field of medical services in an area. I have told those who have made representations about maintaining surgical facilities at certain hospitals that I am concerned, firstly, with keeping people out of hospitals and, secondly, with ensuring for them the best possible attention when they have to go to hospital; attention which will involve the availability for their treatment, in many cases, of more than one consultant.
The services which result in decentralisation, i.e. medical care, health education and what I might describe as medico-social services to people are, in brief, as follows. I will, I should say, be describing some of them in more detail in later portions of my speech.
Firstly, we already have a policy, which will be expanded, for widening the scope of consultant diagnostic out-patient service by the larger health boards through the operations of the regional hospital boards so that more people in rural areas and in small towns will be able to see expert consultants on a variety of illnesses and conditions, the necessary equipment being made available. Consultant work will include psychiatric examinations. I must say I regard this as of just as much importance as doing any surgical work in a particular hospital.
Secondly, in many areas the choice of doctor system for those entitled to free general practitioner services will provide a more varied service and this again will mean a direct contribution towards what I might describe as decentralised medical services. If a number of general practitioners, whose training will inevitably be more specialised in the years to come, decide to set up in a large town and work together as a team, the same position will hold in so far as the area served by that town is concerned. There is the need for more associations by general practitioners with hospitals.
Thirdly, the development of the child health service. Pre-school children will receive at least three or four detailed examinations, not only in the child welfare clinics, where available, but in new clinics where they are desirable, or in the surgeries of general practitioners elsewhere. School children will have more detailed and selective school health examinations.
Fourthly, there will be a continuous expansion of domiciliary care, with the object of keeping people, particularly old people and psychiatric patients not seriously disturbed, out of institutions and at home as far as this is possible. For this purpose, there will be home helps, working as far as possible with voluntary organisations, together with social workers, public health and psychiatric nurses, and other personnel. There will be more visiting of mentally ill persons by psychiatric workers in their homes. There will be more day centres for old and psychiatrically ill persons. There will be experiments possibly in paying boarding-out fees for old people to provide company, for those who would like to look after them.
Fifthly, I expect the work of the public health nurses to expand and develop during the next few years. These nurses will engage in health education, which will also be done in the schools, apart from radio and television publicity. As the years go by, public health nurses will become, even more than they are at present, the friend of every family in an area.
Sixthly, the ambulance service will be standardised and radio-telephone controlled. Ambulances will be situated at desirable centres for the quick movement of patients and they will work over a larger area because of the creation of the health boards. Ambulances will be properly equipped. The road system will have improved still further by the time the replanning of hospital services will have had full effect.
Seventhly, there will be special seminars for general practitioners to enable them to keep abreast more than ever before, of modern developments.
Eightly, wherever it is possible and desirable, there will be places in smaller hospitals for those who are convalescent after having received acute care, particularly acute surgical care in a large hospital, for the period of which visits by relatives would not have been possible in any event.
Ninthly, even in the regional hospital board areas by themselves, an effort will be made to reduce the number of patients who have to go to Dublin for specialised surgery and treatment. This will be done by a careful evaluation of the kind of speciality that can be developed in the regional hospitals at Galway, Cork and, of course, Limerick and lesser specialities in the new general hospitals.
In connection with the work of the regional hospital centre and another. make it perfectly clear that costs can be saved, in both capital and current expenditure and, at the same time, lives can be saved and people can be restored to greater health with the inevitable change in the pattern of movement of patients as between one regional hospital boards, I wish to Comhairle na nOspidéal, in deciding on the type and number of consultants concerned, and myself, in providing the capital for the hospitals, have to take a realistic attitude. Patients may expect to have to move, in some cases, to new hospital centres in their own personal interest. This is happening all over the world and it will happen, too, here in Ireland. The concentration in centralising policy consists in ending surgery operations in single surgeon hospitals and in the inevitable development of specialist treatment at the regional and other fully staffed large hospitals.
I have also read statements from county councils and other interested bodies regarding the value to a town of surgical facilities in a hospital as a contribution to the expenditure in the town in terms of the surgical staff employed, with their ancillaries, and the expenditure by patients or by the local authority and by the people visiting the hospital. I want to make it absolutely clear that I can take no account whatever of such representations. If we are going to afford any of the future hospital development, it can only come by an increase in the gross national product and the development of industry, together with the maintenance of prosperity in the agricultural and tourist fields.
The towns where major surgical facilities may be ended over the next eight years will have benefited by industrial growth and the general prosperity of the country. Where a county hospital ceases to practice surgery, it is more than possible that the general practitioners will have a greater part in the use of the hospital and that patients will come to the town in order to attend out-patient diagnostic clinics. Hospital beds will be used for other purposes. This completely inapplicable argument has no significance. My decisions will be based on how to attract expert consultant staff to the hospital services of the country, to ensure more modern treatment so as to preserve life and ensure sound health, and, above all, all my efforts will be aimed at keeping people out of hospitals as far as possible and seeing that they stay in the more expensive hospitals for the shortest possible time.
I should also mention the inevitable implications of the Todd Report, which must be faced resolutely and realistically by all the organisations who are going to make pleas for the retention of surgical hospital facilities in various areas. The Todd Report makes it absolutely clear that the medical graduate of the future will be given a very clear indication of prospective openings in the various specialities required, and having made his choice in a speciality which can absorb him he will have an extended course of training in that speciality. This is going to lead to greater specialisation. At the same time, hospital equipment is becoming more expensive and para-medical services more complex in character. I am told by the experts that, within a certain number of years from now, a really competent surgeon with the kind of experience and technical ability required will not apply for a position as a surgeon in a single-surgeon hospital. I am told that the re-grading will be inevitable in respect of other staff in the hospital and that house surgeons and interns will more and more require varied experience and will more and more seek appointments to larger hospitals. I am told that in relation to the Todd Report there will be no place for a registrar in a single-surgeon hospital. Those who are concerned with the future development of good hospital services in this country must face up to this inevitable development of specialities. I counted thirty separate specialities the other day in the course of a review of the consultant position, including four separate specialities in respect of infants of under four years of age. I here quote portion of a report on future hospital development in Scotland, which is the country most like our own, with which one can make a comparison:
Lastly, the number and size of the clinical units which a major hospital contains, and the distribution of these units between the hospitals must be such as to permit an economical and effective distribution of the consultant staff, both those responsible for the clinical treatment and those in charge of the diagnostic and laboratory departments. There are considerations which weigh against individual consultants working in isolation without the stimulus of colleagues and without the facilities for the teamwork between different specialities which is now increasingly required in some advanced kinds of treatment. Smaller units, too, have difficulties in attracting junior medical staff because of the limited experience they can offer to young doctors in training and consultant staff cannot work effectively without supporting assistance.
The problem of the requirements of 300 bed hospitals for nurse training is always with us. In studying the FitzGerald Report there is also the possibility of a temporary compromise solution for a period of years by inducing the voluntary and local health authority hospitals in an area to integrate with each other or integrate with a regional hospital not too far from the hospitals concerned. One example would be the relationship of the Roscommon and Portiuncula Hospitals with Galway Regional Hospital, linkage in respect of out-patient diagnostic services and in-patient services.
Having made this detailed statement in regard to the FitzGerald Report I should make it clear that some time will elapse before I can make decisions on the future of individual smaller hospitals and those interests who either wish to preserve surgical facilities in a particular hospital or who wish to promote the case for the siting of a new general hospital do not need to continue with a spate of representations.
The proper course for me is to instruct Comhairle na nOspidéal on the time schedule for decisions they will be making in regard to the appointment of consultants, to so instruct the regional hospital boards that they can pursue the planning of a first-class hospital system in each area, having as a prime objective the greater integration of voluntary and health board hospitals. At the proper time I will consult the local committees set up under the Health Act, who can present to me the views of, sometimes conflicting, sometimes agreed, organisations or bodies. I will remind the House, finally, that under section 38 of the Health Act, 1970, I must hold a local inquiry before directing the discontinuance of a hospital, so that neither this nor any major change in the user of a local hospital will take place without full consultation.
Child welfare and school health services have been important features of the public health scene for many years. The child welfare service has, in the clinics, provided a medical examination service for young children and a source of advice and help for their mothers. The school health examination service has in general provided three medical examinations for national school children during their school life. To give Deputies an idea of the scope of the present service, I should say that in 1968, 130,261 children or 26.2 per cent of the children on the rolls of national schools were examined. The service has been responsible for the detection and treatment of defects in many children which might otherwise have gone unnoticed. The many medical officers who, throughout the years, have provided this essential service have served the community well and I am glad to have this opportunity of paying tribute to their work. As Deputies will know, the scope and nature of these services was examined by a specially appointed study group.
It had, of course, been clear that the restriction of the pre-school examination service to urban areas was a considerable limitation on its scope since it reached slightly less than half of the total number of pre-school children. So far as the school health examination was concerned the group drew attention to the fact that the examination of large numbers of healthy children was an obstacle to the fuller examination of children needing particular care and attention. These two considerations were at the root of the many recommendations made by the group which I have accepted.
I have indicated that I propose to introduce the new service gradually over a period of four years, commencing in October next. The ultimate objective is to provide a comprehensive medical examination for children at the ages of six months, 12 months and two years in clinics in the major towns. Routine medical examinations in national schools for new entrants will be replaced by comprehensive medical examinations for children over six years shortly after they commence school. Selected groups of these children will be given further medical examination as required throughout their national school life. By next October special training in developmental paediatrics will have been provided for assistant chief medical officers participating in the revised services, and in fact already about half of these doctors have received such training. I should also mention that a working group is being established to produce a standard record card which would be used throughout the child's participation in the child health services.
The pre-school development paediatric examinations in rural areas will be provided by general practitioners as soon as practicable. These examinations will be similar to the examinations provided by assistant chief medical officers in the clinic premises in the larger urban areas. The areas in which the general practitioner examination service will operate and the extent to which general practitioners will require suitable courses in developmental paediatrics are matters which will have to be discussed later this year with the appropriate professional organisations.
The success of the new services for children will depend in no small measure on the degree of co-operation and involvement of the people most in contact with the children. Parents, teachers, public health nurses and school doctors must pool their knowledge and experience of the child, to ensure that he will obtain the greatest benefit from the services being provided. All this involves a public relations campaign and far more emphasis on health education.
In the recently published report on the care of the aged, a copy of which I circulated to each Deputy, great stress is laid on the need to develop community services in the belief, as I have said earlier, that it is much better to help the aged to live in the community than to provide for them in institutions. The important role being filled and to be filled in future by voluntary organisations was emphasised. My Department accepting that view fully, expanded further in 1969-70 the scheme of grants to voluntary bodies engaged in the community care of the aged. The health authorities were authorised to give grants totalling £75,000 to voluntary bodies performing worthwhile social work for old people in the community. The Department have encouraged them to make full use of the scheme in order to boost voluntary effort and each authority has full discretion to make grants, within the financial limits of the scheme, without seeking my specific sanction in each instance.
The wide range of activities being supported includes clubs and recreation centres for old people, occupational therapy, chiropody, social worker services, meals on wheels, reading and television rooms, social evenings and outings, home repairs and renovations. A major assessment of the services for the aged provided by grant-aided voluntary bodies is at present being undertaken by my Department. The aim of the assessment is to identify more clearly the type of community services for the aged which should be given priority and the areas of the country where greater voluntary effort needs to be stimulated. I intend subsequently to issue guidelines to health authorities which would assist them in getting the best return in terms of the aged for the grants available.
In the current financial year the authorised level of these grants has been increased to £100,000. When it is realised that the equivalent level of grants only two years ago was £12,000, the readiness of the Government to step up their commitment to voluntary bodies looking after old people in the community can be readily appreciated.
While the first consideration should be to develop the community care services to the maximum extent possible it will, of course, be essential to continue to provide effective institutional services. As I see it, the cornerstone here would be assessment and diagnostic centres established on a countrywide basis to which patients for whom long-stay institutional care is felt to be necessary would be referred in the first instance. In such centres the individual patient's specific needs would be determined and he or she would be referred to appropriate medical, intensive rehabilitation or long-stay accommodation as the case might require.
The time required for bringing into full effect over the country as a whole such a concept of institutional services for the aged must necessarily be fairly long. Some of the organisational changes necessary will be affected by the decisions to be taken on the pattern for hospital and specialist services in the future. It will also be appreciated that there is no single blue-print on which the organisation of institutional services might be based. The question of utilising all the services available, whether at regional centres or county or district hospitals or voluntary hospitals, will have to be considered. Variations to suit local conditions or population concentrations will be necessary. For example, in areas of heavy concentrations of population the organisation of day-hospitals and efficient domiciliary services would considerably ease the strain on the institutional services. Furthermore, the institutional services cannot be planned in isolation. There must be effective co-ordination of all services designed to cater for the aged from housing to hospitals and of all the agencies, whether health or local authority or voluntary agency that play a part.
During the last decade considerable progress has been made in the development of improved institutional services for the care of the aged. We have been proceeding on the basis that in each county there should be developed units to serve as long-stay hospitals. The new nursing units which have been built are geared by modern standards to provide for the care of the chronic sick. Accommodation is also being made available in which physiotherapy and occupational therapy services can be provided. Where feasible, some of the units are being located on the sites of county hospitals or in as close association with them as possible. Good accommodation which was surplus to other requirements has also been availed of as in the case of St. Mary's Hospital, Phoenix Park, Dublin, some units at James Connolly Memorial Hospital, Dublin, and at the Western Regional Sanatorium, for example.
There are many aged persons who, while not ill, are so frail, sometimes physically and sometimes physically and mentally, that it is not possible to care for them effectively in the community. I have been considering how the needs of such persons might suitably be provided bearing in mind that our resources are not unlimited and that even among priority projects, the competition for a share of funds available is intense. In broad terms, we have had to be flexible and pragmatic, however desirable it might have been in a situation of unlimited resources to aim for the ideal. Therefore, in some areas where upgraded services have already been provided in new buildings for long-stay patients the opportunity has been availed of to accommodate on the same sites some of the aged who do not need care of a hospital character in special separate accommodation suited to their needs. In other areas, separate schemes have been planned. A scheme for a 48-place home has been planned for Boyle, County Roscommon, in which county the long-stay accommodation for the chronic sick is being provided at Roscommon town. Tenders will be sought in the near future for this scheme. Tenders are also being sought for a home located at Kilrush which will also accommodate 50 aged persons, the long-stay hospital accommodation being sited at Ennis.
On social and humanitarian grounds I tend personally to favour these small local homes to house the frail who, while still requiring institutional care, do not need hospital care. I have, I might say, directed my Department to consider the question of evolving a standard plan of accommodation for about 40 aged persons which would be capable of being built and run economically and to plan for their provision in future as our resources permit. What I envisage is that homes provided under such a plan would be centrally located, convenient to church and shops as far as this can be achieved. I am happy to be able to report that considerable progress has been made and that we hope that work on about ten such homes will commence this year. A feature of these homes will be that half of the residents will have a room to themselves with built-in wardrobe and wash-hand basin while the accommodation for the remainder is based on the assumption that they will need more supervision and help which could best be provided in small three-bed rooms with convenient toilet facilities.
While much remains to be accomplished in so far as providing for the aged is concerned, reasonable advances have already been made in some areas and a considerable volume of work is in progress. New or reconstructed accommodation has been provided for 1,900 patients. Schemes in progress or for which tenders have been obtained or invited will provide places for 1,400 patients. Schemes in planning will account for another 950, and schemes under consideration will provide for almost 1,900 further places. The total cost of the programme, covering some 6,000 old people, comes to about £12 million.
One of the major improvements in the health services in the past decade has been in the field of domiciliary public health nursing. Ten years ago only a limited service was available, provided to a considerable extent by voluntary agencies such as the Queen's Institute of District Nursing and the Lady Dudley Nursing Scheme. When the needs of the country were assessed some years ago, it was decided that about 600 nurses would be needed to provide a satisfactory service for each area, and by the mid-sixties the halfway stage had been reached towards the target. By recruiting and training about 250 nurses in public health duties in the past four years that target has now been practically reached.
The public health nurse is a most valuable member of the health team in her local community. The duties which she undertakes are many and varied, ranging from the practical home nursing of the aged and chronic sick to the general supervision, in association with the local medical practitioners, of the health of children from infancy to the time they leave national school.
Another important role of the nurse is the health education of the people in her area and she is qualified to speak on matters relating to health and hygiene to school children, to parents or teacher groups, or to other residents or organisations. She is trained to involve herself in the community in which she lives and works, to become the friend and adviser of the families which she meets, and to keep her door open at all reasonable hours to those in need of her help.
The syllabus for training public health nurses has been expanded and further additional courses will soon become available.
I would like now to turn to the care of the mentally ill. The House will recall that a Commission of Inquiry reported in 1966, covering in a most comprehensive manner the whole field of the psychiatric services. In general the commission's recommendations were accepted and, as with the Report on Mental Handicap, the development of services has, in practice, been following for several years the lines recommended by the commission.
I would like to refer to some of the principal developments.
There seems little doubt that we have too many patients in our psychiatric hospitals. The commission pointed out that, at the time it reported, the number of in-patients in our psychiatric hospitals was the highest in the world in proportion to population. At that time the overall number of in-patients was 18,642. In the three years since then it has been reduced to 17,218, a reduction of 1,424. While this is heartening, it is very important that the reduction in numbers should continue; the commission recommended, in fact, that the aim should be to reduce the number of long-stay beds by 5,000 over a period of 15 years, and I am anxious and hopeful that this will be achieved. Every effort must be made to ensure that patients admitted to our psychiatric hospitals receive intensive care so that they may be returned to the community as quickly as possible. Apart from the obvious advantages to the patients concerned of shortening the period in hospital, intensive care reduces the build-up of long-stay patients, take pressure off accommodation which in many cases is still over-taxed, and permits better facilities to be provided for those patients who must necessarily spend a longer time in an institution.
The commission recommended that the grouping of patients in large numbers should be avoided and that hospitals exceeding 750 beds should be divided into smaller units. It also recommended that the contribution and potential of the private mental hospitals should be taken into account in determining the extent of the services which it is necessary for health authorities to provide. Some years ago two of the largest hospitals in this country were St. Brendan's, Dublin, and St. Ita's Portrane. The sheer weight of numbers made difficult the provision of adequate care and treatment in these institutions. With commendable zeal, the health authority set about a scheme which would lead to a very great reduction in the number of patients admitted to these hospitals and would provide a better service for those who needed it.
This scheme involved the administrative division of the mental hospital district embracing Dublin city and county, into seven areas, each having its own team of psychiatrists, nurses and supplementary staff and its own acute unit. There were already two large private psychiatric hospitals in Dublin and in order to provide as good a service as possible, without unnecessary proliferation of hospitals, the health authority had discussions with them. As a result the authorities of the St. John of God Hospital at Stillorgan and of St. Patrick's Hospital, James's Street, have each agreed to provide a full psychiatric service for one of the seven areas. This is the first time in Ireland that voluntary hospitals of this kind have undertaken the provision of services directly on behalf of the public service, and is a development which is most welcome. Both hospitals have long experience in psychiatry and have, I believe, much to contribute to the public psychiatric service. Discussions are also taking place with other hospitals in Dublin and I hope that these will lead to further useful developments. In Cork, new units have been opened at St. Fachtna's Hospital, Skibbereen, and at Sarsfield's Court and efforts to reduce the large number in Our Lady's Hospital in Cork city are continuing. In Galway, a new unit is being provided at the regional hospital.
A very important recommendation made by the Commission on Mental Illness was that, in general, short-term psychiatric care should be provided in psychiatric units in, or associated with, general hospitals. One such unit had already been provided at Ardkeen General Hospital, Waterford, on an experimental basis when the commission reported and since then further units have been brought into operation. I have already mentioned the units at Skibbereen and Galway. Similarly, a new unit associated with an adjacent general hospital has been opened in Clonmel. It is hoped that an additional psychiatric unit will be in operation soon at the County Hospital, Castlebar. There are plans for additional units at Galway (in association with the regional hospital as I have already mentioned) Limerick, Kilkenny and Letterkenny. In addition, it is visualised that there will be psychiatric units at the general and regional hospitals recommended in the Report of the Consultative Council on the General Hospital Services.
For long-term patients, the commission stressed the need for planned and purposeful activity within the existing district mental hospitals. In many of the district mental hospitals occupational therapy and industrial therapy are being developed to fill this need.
Schemes for the renovation and upgrading of some of the accommodation at existing mental hospitals are under way, for example at Ballinasloe, Ennis, Enniscorthy, Cork, Monaghan, Mullingar and Sligo. The improvements include the provision of central heating, new or improved sanitary and bathing accommodation, improvement of kitchen and dining facilities, renewal of electrical and boiler installations, fire precautions, improved staff accommodation and upgrading of furnishing and equipment. Tenders have been received for a scheme of improvements at Youghal and will be sought soon for the provision of a new kitchen and for major improvements at St. Kevin's Hospital Unit at Cork. Proposals are also being considered for improvements at Castlebar, Killarney, Letterkenny, Newcastle and Portrane.
Some new buildings are also being provided at existing mental hospitals. Work is to commence very soon on the building of new units for 100 patients at Kilkenny to replace units that are sub-standard. Patients in these new units will be accommodated generally in six-bed wards which should help considerably in their proper care. The units will have their own separate recreational and rest-rooms and dinning facilities. A 50-bed unit on similar lines is being planned for Killarney.
Another point stressed by the Commission on Mental Illness was the need to develop community as distinct from purely hospital services. There has been a welcome expansion of out-patient clinics. The commission also recommended that a limited number of hostels should be set up on an experimental basis in the larger centres of population. This is being done in Dublin.
The commission emphasised the need to provide for special groups such as children, alcoholics, drug addicts, persons in custody and psychopaths. A special children's residential unit had already been provided by the Dublin Health Authority at St. Loman's Hospital when the commission reported and a day unit at Garden Hill, adjoining St. Kevin's Hospital, was later opened. Three additional units for mentally ill children are now being provided. One has already opened at Beaumont, Dublin, and is receiving patients from provincial areas. A second unit in Dublin which will also receive provincial patients is being planned; the third unit will be in Cork.
So far as alcoholism is concerned I want to make it clear that reports emanating from the Irish National Council on Alcoholism and the Medico Social Research Board have made it absolutely necessary for me to formulate a new policy in a bid to combat this particular form of mental illness. Apart from what it does to its victim, alcoholism causes untold misery and stress to the family and relatives of the alcoholic. I have been told that in some shorter stay private mental hospitals there are more relatives of alcoholics undergoing psychiatric care than there are alcoholics. I must, therefore, examine the whole problem. The public at large have tended to shovel this problem under the carpet. I am removing the carpet.
With regard to persons in custody, one of the commission's recommendations was that the Central Mental Hospital at Dundrum, Dublin, should be retained for certain patients in this category but that it should be administered by the Dublin Health Authority and used for other patients besides custody patients—in particular aggressive, and some non-aggressive, psychopaths. As the House is aware, the Health Act, 1970, now enables arrangements to be made for the transfer of the administration of this hospital to the regional health board. The Dublin Health Authority is actively pursuing the establishment of a department of forensic psychiatry which will embrace the Central Mental Hospital and will involve the linking of the services for that hospital with the psychiatric services of the authority. In due course I envisage a very substantial improvement in the services available at the hospital and their development on the lines of the commission's recommendations.
The Commission on Mental Illness made several important recommendations as to medical education and training. We now have four chairs of psychiatry in Dublin where previously there was one. Chairs have been created in Cork and Galway and steps to appoint professors are in train. This alone is a considerable advance and should result in a much-needed improvement in undergraduate medical education. One in every three or four cases coming before a GP has psychosomatic content or presents a psychiatric problem. No matter how much we increase the number of psychiatrists, doctors generally must receive far more extensive psychiatric training in future.
By co-operation between the teaching bodies, Dublin Health Authority and my Department, a post-graduate course in psychiatry started in Dublin last autumn and at present 41 doctors are undergoing a planned and systematic course of training. The extension of the scheme to other areas later this year is at present being examined.
The commission recommended that there should be a positive programme of public education in regard to mental illness. The Mental Health Association of Ireland will help in this respect. It was established in 1966 and has received financial assistance from my Department and the health authorities. I might mention that its establishment was also in accordance with a specific recommendation of the commission for the setting up of a national voluntary body.
The commission recommended that a national advisory council should be established which would provide advice on any matter relating to the mental health service. As I will shortly indicate to the House a somewhat similar recommendation was made by the mental handicap commission and I have decided to implement that recommendation in a slightly modified form. On the mental illness side, however, I have not yet decided to implement the commission's recommendations for the establishment of an advisory council, as I am not satisfied that this would be desirable just now. We are at the moment at a transitional and active stage in implementing the very many recommendations of the Commission on Mental Illness. The commission have themselves provided expert advice in relation to a vast field of endeavour and, as I have already indicated, there is substantial agreement on the measures which now need to be taken. Our immediate problem accordingly is to implement generally accepted improvements. Later, when this has been attended to, the need for a national advisory council can be more fully considered and this will be done.
I would draw the attention of Deputies to the growing concern expressed by consultants at the huge and increasing intake of anti-depressants, tranquillisers and sleeping pills by ordinary people not requiring intensive psychiatric care. The level of consumption in this country seems likely to compare at some future date with that in Britain where, according to Sir Derek Dunlop, the former chairman of the British Drugs Advisory Board, there were 45 million prescriptions under all these heads in 1968 and where 10 per cent of the hours of sleep were drug-induced.
Recently 18 leading British consultants expressed grave concern about this trend, arising because the human personality is not, even at its best, particularly strong and in the reported words of Monsignor Jeremiah Newman, president of Maynooth College, in a recent and thought-provoking address to the Christus Rex Congress "one of the gravest problems of our day is that the social environment of contemporary urban industrial society is tending more and more to be anything but conducive to the best development of the human personality". The full impact of urbanisation on the human personality has not yet hit us in this country, although there is evidence to show that it is developing and will be developing further to become a serious problem to a Minister for Health endeavouring to improve the mental well-being of the community.
Man's material and scientific progress and achievement have tended on the one hand to give him a superiority complex blinding him to his inherent weakness and at the same time exposing him to pressures he does not fully understand. The mass media with their inevitable concern with disaster, war, disorder and crime represent another aspect of the pressures of modern society and it is not difficult to see that modern men and women, because particularly of the visual impact of television, must feel that they belong to a generation set upon as no generation was ever set upon—and this despite better living conditions and standards and well developed social services. The vulnerability to stress is all the greater when the established order, cultural, temporal and religious is being questioned and is in some disarray on all sides. Then, too, impatience with discipline and restraint of any description impels modern man to a frenetic search for a utopia which does not, and indeed I suppose cannot, ever exist. And so when the inevitable letdown happens the anti-depressant and the tranquilliser is turned to.
I would make it clear that I in no way wish to interfere with the right of practitioners to prescribe these anti-depressant and tranquillising remedies. Rather do I wish to bring all the professions concerned together to discuss this growing trend of over-indulgence in these panaceas to see whether there can be modifications of treatment, more moderation in prescription and, above all, the use of other procedures. Alternative procedures involve questions of time, staff and training, and may pose problems not easy to solve. I intend to seek the advice of experts —medical, psychiatric and religious— on these problems and, if necessary, to appoint a special group to examine them and suggest solutions.
I have mentioned some, but only some, of the very many matters calling for our continued and urgent attention in the very wide field of the psychiatric services. They indicate in broad outline the need for a progressive and determined effort to develop and improve these services and I envisage this proceeding in as organised and systematic a manner as possible.
As with mental illness a commission of inquiry surveyed the whole field of mental handicap and furnished a comprehensive report. This report was circulated widely and the views of various interested bodies and individuals were obtained. There was little disagreement with their findings. The development of services in this country has, for several years, followed the pattern recommended by the commission; the report has been of considerable value in this respect.
The commission gave considerable thought to the question of numbers. It may seem a simple matter to find out how many mentally handicapped persons there are in the country. This is not so. There is, first of all, the problem of finding those who may be mentally handicapped. Their full diagnosis and assessment requires the services of a skilled team and the full assessment of many involves examination over a period. In practice, exact figures as to the total number of the mentally handicapped are not available in any country and estimates vary widely. Instead, therefore, of providing an estimate of numbers, the commission wisely, in my view, on the basis of all the information available to them and including information from other countries, recommended targets for the development of services for the immediate future.
I know that many Deputies are particularly interested in the provision of residential accommodation. Here the commission recommended that the target should be of approximately 2,700 additional places in special residential centres. When the commission reported in 1965 there were a total of 3,100 places available. There are now 4,050 places. I have circulated particulars of these to Deputies, and also of an additional 1,500 places which are in course of construction or are being planned, and which should become available over the next three or four years. It will be seen, therefore, that the targets set by the commission in regard to residential places will be met almost completely. The only exception is in regard to residential accommodation for the mildly handicapped to which I will refer later. I am deeply conscious of the fact that, at the moment, a waiting period is often necessary before a child can be admitted to a residential centre and this can cause considerable hardship, particularly in the case of the moderately or severely handicapped. I can assure the House that the provision of additional accommodation is being pressed ahead as much as possible. When this accommodation is available the waiting period should no longer be a problem.
One of the most heartening features of developments in recent years is the rapid growth in the numbers of mentally handicapped being dealt with on a non-residential basis. The commission accepted, as a general principle, that community care, that is care provided outside residential centres, is therapeutically better for a handicapped person in that it permits a fuller development of personality and avoids the difficulty of adjustment to normal life which is frequently experienced after prolonged care in an institution. At the time the commission reported there were some 600 receiving services on a non-residential basis. By the end of last year this number had increased to 2,400. I have included details in the information circulated to Deputies in connection with the Estimates.
In regard to the mildly handicapped the commission recommended that the targets should be to provide services, either on a residential or a non-residential basis, for approximately 5,000 children of school-going age. I might explain that provision of educational facilities for the mentally handicapped, mild and moderate, is the responsibility of my colleague, the Minister for Education, while I deal, broadly, with all residential services, but our two Departments work in the closest co-operation on these matters. It is feasible to provide services on a day basis for a large proportion of the mildly handicapped. At present services are being provided on a day basis for 1,300 pupils and on a residential basis for 900 pupils. Here, too, it will be seen that considerable progress had been made towards meeting the target set by the commission. In the provision of residential accommodation, however, priorities have naturally to be determined and it was decided to concentrate on accommodation for moderately and severely handicapped children and for adults. The provision of accommodation for adults is essential if the centres designed for children are not to become saturated with adults who cannot be restored to the community after their training and education as children. Since the commission reported some 200 residential places have been made available for the mildly handicapped; but until I see to what extent the population can be catered for on a day basis I have decided not to increase the residential accommodation for this particular class but, as I have said, to concentrate on accommodation for the moderately and severely handicapped.
Concurrently with the increase in the extent of services, improvements are being made in the standards of services. In the past it was accepted that custodial care was all that was feasible and, indeed, necessary. The commission placed great emphasis on the need for training and education to enable the mentally handicapped to make the best use of their abilities. This, of course, requires skilled staff. We have not solved all our problems, but there has been a very welcome increase in the numbers of doctors, specially trained nurses, psychologists and specially trained teachers available for the provision of services. We are still short in many areas of an adequate number of physiotherapists, occupational therapists and speech therapists, but we are trying to rectify these matters as quickly as possible.
One of the recommendations of the commission was that an institute of mental handicap should be established. I have decided, however, to establish a consultative council which on its own initiative or at my request can make recommendations in regard to any aspect of our mental handicap service. The council will be broadly representative of those caring for the mentally handicapped and I am sure it will be of considerable help in securing that, in a short time, our services for the mentally handicapped will be as good as those in any country in the world. I have already been assured by independent specialists in mental handicap who have travelled abroad that we are generally ahead of all but two countries in Europe in our services and we owe a tribute above all to the religious orders and also to the lay associations who have made this possible.
Current expenditure by the State and health authorities on the maintenance of the mentally handicapped, that is, excluding capital expenditure, is considerable and runs to about £4 million in a year. The current programme for residential places will cost £3 to £4 million—excluding capital expenditure on schools which is the concern of the Department of Education—and will, at present money values, add about £1 million to the annual maintenance costs.
While it would be idle to pretend that our dental services are all that one would desire, nevertheless there have been considerable improvements in the public dental service in recent times. Dental clinics with modern equipment have been provided in most health authority areas. The number of whole-time dental officers employed in the service has increased from 74 in 1959 to 118 in 1970 and there has been a welcome willingness for more private dentists to provide sessions for health authorities—the number doing so has increased from 61 in 1959 to 98 in 1969.
It has been departmental policy to encourage health authorities to increase the number of dental officer posts and to appoint senior dental officers to supervise and promote the development of dental services. Chief or senior dental surgeon posts have been created in 18 health authority areas and it has been the experience that the appointment of such staff has resulted in a major improvement in the services provided. Improved conditions of service and remuneration for public dental officers were introduced in January, 1968. For incremental purposes credit was allowed for previous experience in dentistry and dental officers were permitted to provide up to two additional sessions per week, outside normal working hours, at special fees. The current scale for a dental officer compares favourably with the salaries paid for similar posts in Britain. This has been reflected in the improved recruitment in the past two years when twenty new appointments were made to the service.
It will be continuing policy to try to keep up improved recruitment to the public dental service so that the dental services for those who are at present eligible may be brought up to a reasonable standard. Until this position has been reached it will not be practicable to extend dental services to other categories of persons. In any event, experience in other countries has shown that, even with optimum staffing and clinical facilities, the dental caries problem cannot be solved by treatment methods alone. For this reason emphasis must continue to be placed on the education of the public, particularly the children and teenagers, in dental hygiene and on preventive measures like the fluoridation of public water supplies.
Since the programme for the fluoridation of public water supplies was initiated some years ago, fifty-three public water supplies have been treated, serving a total of about 1,300,000 persons, including those in the major urban areas of Dublin, Cork, Limerick, Waterford, Galway, Dundalk and Drogheda. A total of two million people are served by piped supplies but it is estimated that only 1? millions of these could be given the benefit of fluoridation because many of the supply schemes are so small that they would not be suitable for the installation of fluoridation equipment. Supplies serving an additional 161,000 people, are expected to be fluoridated during 1970. It is intended, as far as is feasible, to treat within the next five years all public water supplies which serve 1,000 persons or more.
It has been clearly established that fluoridation results in a substantial improvement in dental health, especially in the case of children. We should be able to achieve a similar result here. A special committee is supervising a long-term scientific study, which commenced in selected areas in County Cork, in June, 1967, to measure very precisely the effects of fluoridated water on children's teeth. Studies are at present in progress also to assess in a more general way the effects of water fluoridation on Dublin city and Cork city school children after about five years' experience of water so treated. Meanwhile, it is of interest to note the results, recently published, of the interim study carried out by the dental staff of the Kildare County Council into the incidence of dental decay in first permanent teeth of children in Naas, where the water supply has been fluoridated since 1964. The survey claims a reduction of 25 per cent in decayed first permanent teeth of children in the combined age group 7-10 years after five years' fluoridation and a reduction of 64 per cent in such decay among seven year old children who experienced fluoridation from two years of age. This survey, though limited in scope, tends to confirm similar results obtained elsewhere and is a hopeful pointer to the long-term effects of fluoridation in other fluoridated areas of the country.
Concurrently with the programme for fluoridating public water supplies, the Department has asked health authorities to consider promoting, in areas where fluoridated water supplies will not be available, schemes for the topical application of fluoride by means of regular mouth rinsing by children with a suitable solution.
So far as education in dental hygiene is concerned, I am with the co-operation of Radio-Telefís Éireann, in process of having dental educational filmets made for showing on television aimed primarily at the young. These will supplement the other efforts of my Department—notably the school film shows—and of the dental health education committee of the Irish Dental Association who do such excellent work in this particular field.
Since I became Minister for Health questions relating to drugs and their control have commanded a considerable amount of my attention. The largest overall problem was that relating to medicinal products generally. I am preparing legislation and hope to introduce it later this year, which will enable me to apply a comprehensive system of statutory controls for ensuring the safety, quality and efficacy of all medical preparations available on the market in this country. The need for such controls is bound up with the pharmaceutical revolution of recent decades and with developments in other countries. Not only have such controls become essential for the protection of the public but they are also seen by the pharmaceutical industry as a logical prerequisite in safeguarding the prestige of its products and in facilitating international trade both now and in the years ahead.
In the meantime the service operated by the National Drugs Advisory Board for assessing the safety of new drugs has been working smoothly since it commenced in 1967. This service depends on the voluntary co-operation of the pharmaceutical industry, and its success, for which the board and the industry deserve the highest praise, augurs well for the future when the procedures involved will have the force of law. Side by side with this activity the board have an effective system for recording adverse reactions to drugs which are discovered by doctors in the course of their hospital and private practices and for supplying information to the medical profession based on its assessment of the data available from these and other sources. In addition, the board has, during the past year, commenced a service for providing all doctors, at regular intervals, with up to date information on various classes of drugs. This service, as well as enabling the medical profession as a whole to keep abreast of the latest developments in therapeutics, should contribute greatly to stability and rationalisation in prescribing.
Draft poisons regulations have been prepared by my Department. This draft, which is a lengthy document, was based, on recommendations made by Comhairle na Nimheanna. When the regulations have been enacted they will form a comprehensive system of control over a wide range of toxic substances and will replace existing controls contained in the Poisons and Pharmacy Acts and in the earlier regulations made some years ago. The new controls will cover conditions of sale, labelling, storage, the registration of manufacturers and wholesalers and the licensing of sellers of agricultural poisons, other than pharmasicts.
As they are so far-ranging, I decided to give all interested bodies an opportunity to comment on the proposals at the draft stage and accordingly invited their observations. The consultations were widespread and a large number of organisations have submitted their views. These are at present being examined and will be considered in compiling the final draft.
I might say at this stage, however, that very many of the comments deal with what I might call the agricultural poisons, which are an area of some controversy and it will be necessary to have detailed discussions with the Department of Agriculture and Fisheries before arriving at final decisions on a number of the substances.
A more disturbing problem, perhaps, is that of drug abuse. A working party had been established to consider certain aspects of the problem in this country and shortly after I took up office they submitted certain interim recommendations to me. These concerned matters which, the working party felt, could be dealt with in advance of their final report and in some respects the recommendations were an endorsement of action which I had already taken. While I do not wish to go into too much detail at this stage, there are a few points to which I should like to make special reference. Section 76 of the new Health Act will enable me to make the unauthorised possession of certain drugs a punishable offence. I expect to be in a position to make the relevant regulations in the near future, following consultations now in progress with a number of bodies in a position to assist me in their preparation.
So far as amphetamines are concerned, I consulted the medical profession regarding possible curtailment in their use and when I met representatives of the profession to discuss the matter there was unanimous agreement that statutory measures should be taken to restrict the availability of these drugs. I, therefore, made regulations in December last prohibiting the manufacture, importation and sale of amphetamines and certain analogous substances, subject to the granting of licences in exceptional cases.
So far as the prevention and treatment side of the problem is concerned happily the position has not been reached where large numbers of persons are in need of care for drug dependence. There had been, however, a long-felt need for special facilities where drug abusers could get the kind of advice and treatment they required and I am grateful to the Dublin Health Authority and Jervis Street Hospital for their co-operation in the provision of a combined out-patient and residential care service which is now fully in operation.
There is a growing awareness on the part of the public of the importance of measures designed to ensure the quality and safety of food for human consumption. This is recognised at international level through the work of the Codex Alimentarius Commission which is sponsored jointly by FAO and WHO and of which this country is a member. The commission, working through a series of committees, is at present engaged on the drawing up of standards for all the principal foods whether processed, semi-processed or raw. Each standard will contain requirements aimed at ensuring for the consumer a sound wholesome food product, correctly labelled and presented. Each standard will include provisions in relation to description, essential compositional and quality factors, additives, including pesticide residues, contaminants, hygiene, labelling, methods of analysis and sampling and weight.
The National Codex Committee which was recently set up by the Government will advise on the acceptability from this country's point of view of the standards as they evolve. Legislation will be necessary to enable this country to comply with the accepted standards and any such legislation will involve other Minister besides myself, including the Minister for Agriculture and Fisheries and the Minister for Industry and Commerce.
In the meantime, amongst other matters being examined by the food advisory committee which was established under the aegis of my Department, are the problems associated with the presence in food of pesticide and antibiotic residues. The question of antibiotics in food is further complicated by the phenomenon which is now referred to as infectious or transferable drug resistance whereby a micro-organism which is resistant to one or more antibiotics can transfer such resistance to other microorganisms although these have not been exposed to the antibiotics concerned.
My predecessor appointed a committee to advise on the measures which should be taken, in the interest of public health, to further and maintain a programme of education and training in food hygiene and other related aspects of hygiene. I understand that the committee has almost completed its work and I await its report with interest.
In the field of international health this country continues to play an active part. Our co-operation with the World Health Organisation currently includes carrying out a pilot scheme of registration of ischaemic heart disease. This scheme, in which we are co-operating with 15 other countries, is part of the world-wide effort to combat cardiovascular diseases. We are also taking part in a World Health Organisation project in relation to drug monitoring which provides for an international exchange on drug reactions. In Europe our full participation in the work of the Council of Europe public health committees includes representation on the committee of specialists in blood problems which is holding its next session in Dublin in May. Apart from contributing to the international effort to combat ill-health, co-operation with these organisations gives this country the considerable benefits derived from exchange of information, control of communicable diseases and access to facilities such as the exchange of blood and blood products. Irish men and women also, and the universities, hospitals, laboratories, surgeries or other areas where they work, benefit directly from the fellowships allocated annually to this country by the World Health Organisation and the Council of Europe. In the context of our application for membership of the European Community the practical demonstration of our interest in European co-operation in the field of health should also be of value. The steps which we have already taken to comply with the agreements and recommendations of the Council of Europe public health committees will, of course, facilitate our entry into the European Community.
Deputies will have observed from the material circulated to them in advance of this debate that there are over thirty bodies, committees or organisations which operate in conjunction with my Department in either an executive or advisory capacity or in a combination of both capacities. The vast majority of persons on these organisations act in an unremunerated capacity giving of their spare time and energies in a public spirited desire to serve the community. Their work is of invaluable assistance over a wide ranging area of the health services and it is, I think, fitting that I should include in this introductory speech on the Estimate for my Department a "Thank you" on all our behalf to these people.
After only some months of experience as Minister for Health, I still, naturally, have to continue studies of our health problems before I could attempt comprehensively to list the priorities in health matters with absolute precision. At this initial stage I am, I feel, on safe ground in listing the following matters as being essentially part of any list of long term and short term priorities which I will draw up:
Improvement of the child health services with the emphasis on the early detection of abnormalities, defects or diseases in infants and children.
An expanded and more detailed health education programme with an emphasis on the prevention of coronary disease and encouragement of the public towards the use of preventive services such as vaccination and immunisation.
An expansion of screening services.
The attainment of the accommodation goals we have been set for the mentally handicapped.
Accepting that psychiatric illness, mild and grave, will become an ever-increasing problem and preparing to meet the shortage of psychiatric personnel.
Encouraging the extension of the formation, wherever required, of community associations to engage in a co-ordination of facilities, central and local authority and voluntary, for young and old.
Improving and integrating the whole hospital service with special emphasis on better outpatient diagnostic services following the advice of the FitzGerald Report and the improvement of domicilary services generally.
Applying consultant management techniques to hospital administration.
