Senator Mrs. Concannon, when speaking, referred to the position of hospital nurses. That has prompted me to contribute a little to this debate. From reading the motion I thought that we would be confined almost entirely in our remarks to a consideration of the financial relations between the hospitals and the Government. So far, few speakers have confined themselves within these limits. The motion asks that the Government set up a commission to inquire into and make recommendations upon the matter of hospital finance generally. That is just finance, but, further it says "and, more particularly, upon the relations between the voluntary hospitals and the State". I presume, again, that Senator Sir John Keane means financial relations.
Intoxicating Liquor Bill, 1942. - Hospital Finance—Motion (Resumed).
No.
I am glad, because it means that the few remarks I have to make will come within the Rules of Order. The Senator's interpretation of the motion will tend to widen the scope of the debate considerably. We will, I take it, be in order in discussing matters that are not exactly financial. I would like to have the system of hospitalisation at present in force throughout the country discussed under several headings. A debate on such lines would enable the public generally to understand how far we have gone and are likely to go, and what amount of groundwork has been cleared for this scheme of hospitalisation. Running in my mind are improved facilities for the treatment of cases of tuberculosis: their early diagnosis, the treatment of the disease where it is definitely established, the after-care which patients will require after a period of treatment in a tuberculosis hospital. There is also the treatment of rheumatism. It seems to be our national disease, more so even than tuberculosis. We have not any set schemes for the treatment of this malady, which is the cause of very great unemployment and involves the payment of sick benefit to members of the National Health Insurance Society. Then there is the treatment of chronic cases in hospitals, which really should be institutions for the treatment of acute cases. Beds should only be provided for the treatment of cases while the condition of the patients is acute, or during the period immediately following an operation.
To my mind, many cases are kept far too long in the ordinary hospitals instead of being taken to some institution for after-care. To use an A.R.P. expression, there should be "casualty clearing hospitals," in which the acute cases would be treated, and when in a condition of convalescence they could be transferred to an after-care institution. These are matters that run through my mind in dealing with hospitalisation and the treatment of patients, and I would like further enlightenment on them through a discussion in this House. They are entirely outside the financial phrasing of this motion.
In connection with the imposition of State control on the hospitals generally, I feel that without State control it is not likely that nurses and other hospital staff will have their wrongs righted. It is very difficult for each institution, on its own behalf, to provide for staffs individually, whereas under State supervision, State control or State inducement, the hospitals generally could be induced to improve the conditions of the nursing staff and other personnel of the institutions. A little more State interference would help to make the hospitals take greater care of the money they receive from patients. I have an idea that patients in hospitals do not pay always all that they should pay for their maintenance, and greater supervision by an overriding authority would help the hospitals to get greater contributions from patients. Left to the individual institutions, there is a general idea of not trying to get adequate payment from patients while they are in the hospital. I believe it is not the poorer patients who are always to blame in avoiding payments like that. These are matters which I thought originally would be more or less out of order, but as the proposer of the motion has mentioned that they could be interpreted as being in order under the second phrase of the amendment, I would like to put them before the House.
I would just like to say that, in the case of tuberculosis, we are entirely behind the times in this country. There is one case in which I was interested recently. It was that of a young boy who went to Peamount. He was 18 years of age and a member of a pretty large family. The Peamount authorities say that he is incurable. He is sent back home again, to die in the midst of the other members of the family. I would say that, at the least, it is very hard on a young boy who does not realise that he is going to die, that he is sent home from the hospital, particularly if his people are willing to pay. It is an awful state of affairs that he has to go to his own home and mix with other members of the family sleeping in one room. It is unfortunate that that should happen in a country where, in the last ten or 20 years, there has been such discussion on hospitalisation and such funds raised for it.
In regard to the conditions under which nurses have to serve, I do not understand why nurses, who make such a sacrifice and do such excellent work, should have to work longer hours than people in other employment. Despite the fact that there has been a lot of discussion on hospitals within the last 20 years and that the Irish people have been told that our hospitals are in a position to receive any class of patient, if someone suddenly became sick in County Dublin to-night, the only hospital which must have its doors open is the Dublin Union Hospital. In that hospital there is only a certain staff and I feel that they are overworked even in normal times. While I do not know if it applies to the city, it is a fact that if someone becomes sick in Finglas to-night that is the only hospital which must remain open. There are many people who would die rather than go to the Dublin Union Hospital. In saying that, I am not criticising the hospital in any way, as I know that, in the circumstances, the staff in St. Kevin's do their very best but they cannot do impossibilities. After all, if they have a staff to deal with 200 patients, they cannot look after 400, nor can they provide accommodation for that number.
Again, if some poor person down the country has to be sent to a Dublin hospital, it is hard—and these people resent it—that their names should appear in the local papers, stating that the board of health is paying hospital fees for so-and-so. I would appeal to the Parliamentary Secretary not to let that occur.
Could the Senator give me a specific case where that ever occurred?
I will give several. Take the case of someone coming to a Dublin hospital from Mayo. I do not know if this has occurred since the county management system came into operation. One case in Mayo went before the board of health and the name was given.
It went before the board of health, but it never appeared in the paper.
That is not correct. I have some respect for the statement I made. I am not saying that it occurred since the county management scheme came in. If some poor person is sent up by the authorities, it should not appear in the papers. I agree with the Parliamentary Secretary that I have not any knowledge of its appearing since the county management system was introduced, but it did appear heretofore, and I am sure some county members will bear that out.
I do not believe they will.
Senator Tunney must be aware that the county manager only carries out the functions of the county council and the board of health in the same way as they were carried out before. I have never known of a name to appear, where the case was sent by the board of health to a county hospital. It may have come up for discussion before the board of health, but the name was not published.
I hope that it will never appear again. As far as the poor are concerned, I hope that some arrangement will be made so that they will not have to go to these hospitals.
From listening to the discussion this evening I think that, while we may agree with the suggestion made by Senator Keane that some commission be appointed to inquire into the present system of hospital finance, we would also agree that the present is hardly an opportune time to give consideration to such a big question. If such a commission were appointed at present, no matter how desirable it may be, there is the danger that the position would be viewed from the actual conditions of the moment. About 12 months ago, I suggested here that our whole dispensary system was more or less out of date, but I also said on that occasion that we could not do very much about it under present circumstances. I would suggest to Senator Keane that this motion be postponed for the moment and that, later on, some motion be introduced which would go even further. It should take in our whole hospital and medical system and, possibly, even our whole social services, as one is interlocked with the other. Otherwise there would be very little use in having a commission appointed to investigate hospital finance. We must consider, not exactly the money spent or the efficiency of the hospitals, but the services that the hospitals give to the nation. This would not be the best way to deal with the matter without taking the other services dependent upon it into consideration. Therefore I think, in order to give the services that are necessary, more than hospitalisation must be taken into account.
There is a great deal of confusion of thought concerning this motion. In fact, we had a variety of views expressed here on the question of hospitalisation, one set suggesting State interference to a greater extent, and another set suggesting that the State should interfere to a lesser extent, and that some new body or commission should be set up to inquire into the whole position "with a view to the establishment of the organisation best suited to the efficient operation of the whole hospital system." The motion seems to presuppose that the present system is not best suited to the efficient operation of the whole hospital system. When Senator Sir John Keane put down this motion "to inquire into and make recommendations upon the matter of hospital finance generally and, more particularly, upon the relations between the voluntary hospitals and the State with a view to establishment of the organisation best suited to the efficient operation of the whole hospital system" one would assume that he had in view our entire hospital system. There has not been any discussion here to-day about our hospital system unless in relation to voluntary hospitals, particularly in Dublin. Our hospital system is something much more comprehensive and far-reaching than the service provided by voluntary hospitals in Dublin. I do not know if the Senator intended that the general question of our whole hospital system should be brought under review in connection with this motion.
On the question of finance, it is suggested here that a new commission should be set up "to make recommendations upon the matter of hospital finance generally." There has not been any indication that I can trace as to what this new system is expected to discover in reference to hospital finances. Are we to abolish the Hospitals Commission set up by statute ten years ago, to whose excellent services tribute has been paid in this House and by many outside it, and to establish some other commission?
What is this other commission going to do that the Hospitals Commission is not capable of doing? I have not got much enlightenment on that point in the course of this discussion. Under the Act of 1933 applications for grants by hospitals have to be referred by the Minister for Local Government to the Hospitals Commission. It is the duty of the Hospitals Commission to investigate these applications and to report. I have not heard it said to-day that they were not the most suitable and competent body to carry out that function. If that is not the case a motion of censure on the Hospitals Commission should be put down, and let us deal with that problem, if it exists. Senator Sir John Keane states that the present system is an improvisation. The present system is a scheme that was deliberately worked out and passed into law ten years ago, with a view to having a complete survey of hospital facilities and hospital requirements throughout the State, and evolving a suitable plan to meet our requirements. That plan must include, and does, in fact, include, local authorities' hospitals as well as voluntary hospitals. In fact our 59 voluntary hospitals include institutions for the deaf and dumb as well as for the mentally defective. As against that we have 59 district hospitals, 44 fever hospitals, 28 county hospitals, 29 sanatoria and tuberculosis institutions, not to mention mental hospitals and county homes.
If we are to deal with our general hospital problem we must envisage and co-relate the hospital activities of local authorities and see how they fit into the voluntary system if the voluntary system is to be retained. Outside the City of Dublin, to a lesser extent the City of Cork, and to a smaller extent the City of Limerick, the poor are being provided for by local authorities in their hospitals. In the Dublin area more specifically, voluntary hospitals are being availed of to supply the place in the hospital system that is supplied by local authorities' hospitals throughout the provinces. Everybody agrees that for all practical purposes voluntary contributions have disappeared as a source of revenue for voluntary hospitals, and that these hospitals are at present being maintained almost entirely, on the one hand out of sweepstake funds and, on the other hand, out of the rates by way of contributions from local authorities for the maintenance and treatment of patients.
Clearly, if the voluntary hospitals are to be availed of to supply in certain areas hospital treatment for the poor, in substitution for local authorities' hospitals, the local authorities and the State must interest themselves to such an extent as to ensure that there will be easy admission to these institutions, and that people for whom there is an obligation to provide hospital treatment will have the best treatment that can be provided. That may not be possible, and probably is not possible, in existing circumstances, because of the bed shortage, but it has never been suggested, and, I think, it is scarcely intended to suggest that that difficulty is one to be solved by the Hospitals Commission, or that we will get forward any more rapidly towards a solution of it by setting up a new commission in substitution for the Hospitals Commission.
Senator Sir John Keane suggested that the Hospitals Commission has no responsibility to anybody only the Minister. I do not know what was passing in the Senator's mind. To whom should the Hospitals Commission be responsible unless to the Minister? The Minister has statutory functions in relation to the distribution and the disposal of sweepstake funds. He acts on the recommendations of the Hospitals Commission. He appoints the members of the Commission, and I fail to see any flaw in a system under which the Hospitals Commission are responsible to the Minister, and to the Minister alone. The Senator did not develop the point. He merely mentioned the fact by way of complaint that the Hospitals Commission had no responsibility to anyone only the Minister.
He complains about delay, not very specifically, just a general complaint about delay. He did give one specific case of delay which I will deal with later on, but I presume he was referring in general to delay in the disbursement of the annual deficits of the voluntary hospitals. Now there has been delay—delay is inevitable. The Minister is responsible for authorising the release of these grants for the payment of deficits, and when we find the deficits rising year by year, until £7,000,000 at 3 per cent. has now to be held invested in order to pay the annual deficits, inquiries must be made from the voluntary hospitals as to the causes of the rising deficits and suggestions must be made as to how it may be possible to reduce these deficits.
Hear, hear.
Such suggestions have been made, and I must say that, notwithstanding the fact that Senator Rowlette said "hear, hear," they have not been received with any great enthusiasm by any of the voluntary hospitals.
Question.
Senator Sir John Keane complained a good deal about delay in the publication of the Hospitals Commission's Reports. The Hospitals Commission were under no obligation to publish a report at all. It is entirely within their discretion whether they should publish an annual report, or a report for five years, or whether they should report at all. They are bound to report to the Minister on the various matters he submits to the Hospitals Commission for advice and recommendation; but they are under no obligation to issue a report to the public. It is well, perhaps, that the House should know that.
It seems to me that the line of thought suggesting a closer relationship between the State and the voluntary hospitals is rather a sounder line than the line of thought suggesting that the voluntary hospitals should be completely divorced from Departments of State. Our hospitals, voluntary and local authority, are, in the main, the curative arm of our public health system. The curative arm is a very important arm but, taking the long view, the preventive arm is more important. The Minister for Local Government and Public Health has full responsibility for the operation of the preventive arm, for the creation of those environmental surroundings that help to combat disease — improved water schemes, improved sewerage schemes, improved housing schemes, and so on—all intimately related to the combating of disease. Similarly, he is responsible for school meals, the distribution of free milk, the medical inspection of school children, the medical and dental treatment of school children, the immunisation of children against certain infectious diseases, and so on. Hence, it seems to me, at any rate, that in order to evolve a proper public health system, the closer you can link up the preventive arm with the curative arm the more effective will your system ultimately be.
The Senator complains that there are too many statistics in the reports of the Hospitals Commission. Then he becomes rather childish. He cites as the item that brought him to the conclusion that there were too many statistics in the report that it sets out the number of beds available and the number of occupied beds. In the light of the fact that there is a good deal of complaint as to the difficulty of getting patients into hospital at present, that there is a good deal of complaint against institutions as to whether in fact, when they refuse to admit a patient, they have a vacant bed, I think it is a good thing to have on record statistics as to the number of beds available and the percentage occupied.
Might I just explain? I did not intend to complain about the relative statistics of the number of beds available and the number occupied, but I thought it unnecessary to give the financial expenditure under the head of provisions and all these other things in relation to both categories. I do not see that that served any purpose.
The Senator proceeded to say that the Hospitals Commission is not worth the money spent on it.
A Senator
Hear, hear.
I would be surprised if there were any volume of opinion in support of that view in this House or outside it. Notwithstanding the fact that somebody said "hear, hear" to that expression of feeling by Senator Sir John Keane, many people in this House have paid a glowing tribute to the Hospitals Commission. Many people outside the House seem to think a good deal of the Hospitals Commission, too. I have here a publication entitled, Future Hospital Policy in Dublin, by William Doolin, M.B., F.R.C.S. In this publication is set out a discussion that took place at a meeting at the Royal Academy of Medicine in Ireland in the Royal College of Physicians on the 1st May, 1936. The subject for discussion at the meeting was “Future Hospital Policy in Dublin.” The discussion was opened by Professor Henry Moore, and Professor Henry Moore has not been particularly generous in his criticism either of the Hospitals Commission or the Department of Local Government in many of his public contributions on the subject of hospitalisation. He says here:—
"Both the medical profession and the public must be grateful to the members of the Hospitals Commission, and to their secretary, for their careful and painstaking study of the general hospital situation and for their well-balanced and excellent report recently published; its general tenor and trend have shown that its authors were fully aware of their responsibilities and its publication has removed a load of anxiety from the minds of the great majority of the members of the medical profession."
They should have improved with maturity. They ought to be better balanced now than they were then.
"The Commission deserve our hearty congratulations and we may express the belief that their future efforts will be as praiseworthy as their first one. The Commission recognises the importance of such matters as hospital co-operation, medical social service, and clinical medical research, all of which are sadly deficient in our country at the present time."
On page 7 of the same report Professor R.J. Rowlette said:—
"I associate myself with the appreciation of the work of the Commission expressed by Professor Moore. The members show both capacity and industry and have done their best to gain a full knowledge of the problems which faced them. In their recommendations they have shown both a broad view and a long view. I think that everyone who was brought into contact with them must have been impressed by their patience and courtesy in listening to the views put before them from whatever quarter or interest they came."
And on page 11, Mr. William Doolin said:—
"I think it may be honestly admitted, this Academy, in its deep concern for the welfare of the Dublin school of medicine, regarded the possible results of the deliberations of the Hospitals Commission with a perhaps natural fear. Medical men, if not by nature, at least by force of training, tend to regard the new, the untried remedy, with a certain amount of conservatism, with a scientific scepticism that is essentially protective of the interests of those committed to their care.
"The First General Report of the Hospitals Commission recently submitted to the Minister, however, should go far to allay such fears. It is a most statesmanlike document, one that deserves alike the praise and the thanks of this Academy for the broad conspectus therein provided of the Saorstát hospital problem viewed as a whole: the more one studies that Report the more clearly does one come to realise that the members of the Commission are studying the hospital problems of this country on the broadest lines, for the ultimate benefit, not of particular or vested interests but of the people of this country at large."
I could go on. I fail to see that a new commission is necessary in order to enlighten us on the hospitals position in this country in the light of the very high opinion that is held by most eminent medical men of the Hospitals Commission as at present constituted.
The Senator also complains of the absence of a costings system in the voluntary hospitals. If a system of costings is absent from the voluntary hospitals, it is not the fault of the Hospitals Commission. For years—and I think Senator Keane is aware of the fact—they have been endeavouring to get the voluntary hospitals to adopt a costings system. So far, they have met with little success. I do not know how the new commission that the Senator has in mind will get better results. If the Minister interferes, if he brings additional pressure to bear on the voluntary hospitals to do anything under the sun, to improve their system of accountancy, to establish a costings system, or to do anything else, he will be told that he is interfering with the management of these institutions and that they resent it. If we set up a commission to replace the Hospitals Commission it is safe to assume they would be met with the same line of criticism. We discussed this question of costings here the last time we were discussing hospital matters, and I informed the House on that occasion that a uniform system of accounting, at any rate, had been adopted, a uniform system of annual returns, that at least in one institution a system of costings was being tried out and, if it were found to be satisfactory, that it would be applied to other institutions if their consent or co-operation could be secured.
The Senator's figures on the matter of the total finances in the Hospitals Trust Fund are not altogether accurate, but I do not suppose, unless for the purpose of record, that it makes very much difference.
They do not affect the substance of my case at all.
No. I suppose I need not bother having put on record the actual position. In rough figures, at any rate, there is £8,000,000 in the Hospitals Trust Fund and, in rough figures, £8,000,000 has been expended in one way or another. The interest that has accrued on the money invested has brought in about £1,000,000. The total amount of money, including interest, available from all the Sweepstakes since the Hospitals Sweeps were first introduced amounts to approximately £16,000,000. Of that, as the House is already aware, approximately £7,000,000 has to be held invested to meet the annual deficits of the voluntary hospitals.
That is a very large sum, and I think that we may reasonably assume that, in the near future at any rate, the financial position of the voluntary hospitals will not be much improved by voluntary contributions. I think it is unlikely that there will be any large-scale influx of money by way of voluntary contributions towards the maintenance of the voluntary hospitals. Consequently, we have to ask ourselves, if we were in a position to build to-morrow, if this emergency were over and building materials were again available—in the meantime I hope we will get well advanced with our plans —how could we give effect to the recommendation of the Hospitals Commission regarding the provision of the four large hospitals contemplated in the City of Dublin? It seems to me that that problem can only be solved by getting the local authorities to take considerably greater financial responsibility for the people who are being maintained in these hospitals at the expense of the Hospitals Trust Fund.
That may seem a strange suggestion when you look at it from the narrow point of view of the people residing in Dublin, but when you look at it from the point of view of people from the provinces, when you realise that they have to make provision for the hospital treatment of their own poor and that they have to strike a rate for the purpose—and, if it is an increasing problem they have to strike a correspondingly increased rate—one must have some difficulty in appreciating the case that is made here for the voluntary hospitals in Dublin, that the deficits that they incur for supplying to the ratepayers of Dublin City and County free hospital treatment, should not be borne, in part at any rate, by the rates of the area concerned.
Senator Rowlette has talked about the rifling of the Hospitals Trust Fund by the Oireachtas. He was good enough to admit that it was by an Act of the Oireachtas that this deliberate system of robbery was carried out. The Oireachtas decreed, by Act, that the hospitals of the local authorities should benefit from the Hospitals Trust Fund. That seems to me to have been a very sound decision. There are no voluntary hospitals in Galway. Senator Rowlette suggests that, if the people of Galway get grants out of the Hospitals Trust Fund, they are "rifling" it, of They are legally "rifling" it, of course. Similarly in the case of the people of Monaghan, Cavan or Donegal or any other county in which a hospital has been built. But are they not as well entitled to get assistance in providing hospital accommodation and treatment for their poor as are the people of Dublin? I cannot see that there is any difference. Those who buy sweepstake tickets are not entirely inspired by an overwhelming desire to contribute to a charitable object. Neither are they entirely, or particularly, concerned with the poor of Dublin. If charity enters into their consideration at all, I should say that they would have in mind the poor of Ireland.
But I think that the vast majority of those who buy sweepstake tickets buy them on the offchance that they might win a prize. Consequently, we may dismiss the viewpoint that the people who buy those tickets are overwhelmed with the desire to assist a charitable work. The argument is, therefore, irresistible that the poor in every other part of the State have an equal claim on those moneys with the poor of the City of Dublin. I do not think that the local authorities should be charged with rifling the fund, even with statutory authority, if, as a result of the provision of that new source of revenue, they have been able to make reasonable and proper hospital arrangements for their own poor. That is as it should be and they are as well entitled to relief as the people of any other area.
That brings us to a further development of that line of thought. When a local authority down the country desires to send a case to a city hospital for special treatment, it is called upon to pay a minimum of two guineas a week. The voluntary hospitals are not at all satisfied that two guineas a week is an adequate sum. I do not pretend for a moment that two guineas is sufficient completely to cover the cost of maintenance and treatment. But I do say that if everybody receiving treatment in the voluntary hospitals contributed two guineas per week, or had two guineas contributed in respect of them, it would make a very material difference in the finances of these hospitals. My Department has brought that matter rather forcibly to the notice of the voluntary hospitals. We have not got a very encouraging response. We have been harping on this matter for a considerable time but we have not made much headway. To my mind, it is along that line of development we can hope to release sufficient capital sums when this crisis is over fully to implement the report of the Hospitals Commission. We hope fully to implement it and I believe it will be possible to do so. We also hope that, when normal conditions are restored, the Hospitals Sweepstakes will again become, if not the source of revenue they were in the past, at least a substantial source of revenue.
Senator Sir John Keane must have got lost and confused in the maze of figures included by the Hospitals Commission in their report. He says that 25 additional beds have been provided since the Hospitals Commission came into being. I am perfectly certain that he did not intend to mislead the House. He must have misread the report. As a matter of fact, 1,486 additional beds have been provided in the voluntary hospitals.
In the general hospitals?
General and special. I shall get the figures regarding the general hospitals for the Senator, if he so desires. Where the Senator got the figure 25 puzzles me.
In my reply, I shall tell the Parliamentary Secretary where I got it.
The Senator says that no progress has been made in the scheme for the four Dublin hospitals. That is a slight exaggeration of the facts. Last time we were discussing hospitals, Senator Barniville told us how he had been burning the midnight oil working out plans for his particular hospital. That kind of hard work is necessary. It actually takes three, four or five years——
With the present Hospitals Commission.
Little political jabs in a debate of this kind will carry the Senator nowhere. Senators have to deal with the hard facts of the situation. If Senator Barniville desired to have a full schedule of the exchange of communications with the hospital for which he speaks but which, perhaps, he does not represent——
I do not represent the Mater.
It is a good thing to know that the Senator does not represent it; that he is merely doing the politician here——
I resent that. This matter has nothing to do with politics. I represent the National University here. I do not represent any hospital.
If that schedule of exchange of communications with his hospital were tabled here, Senator Barniville would, I think, apologise for the suggestion that there has been any delay in the Department of Local Government——
I do not apologise. The hospital would have been built ten years ago if there was any sense in the commission.
If that is so, then it should have been built before Fianna Fáil came into office and before the commission was set up.
Who is introducing politics now?
When the Senator mentions ten years ago, there must be some political significance in it.
The Parliamentary Secretary's dates are wrong.
What is the Parliamentary Secretary doing now, when he refers to Fianna Fáil, but introducing politics? Yet, we were told that there were no politics involved in this question.
I do not pretend for a moment that I have no politics. If I had no politics, I would not be here.
Hear, hear.
The Chair suggests that the debate be confined to the terms of the motion.
We had another little difficulty regarding these four major hospitals in Dublin—a difficulty with which Senator Rowlette is quite familiar. I do not suggest that he deliberately suppressed his knowledge of this little complication. Probably, he overlooked it. The fact is that the Meath Hospital was included in the scheme of amalgamation of certain hospitals in which Senator Rowlette and Senator Keane are particularly interested.
No; at no time.
The fact is that it was recommended that the Meath Hospital be included in the scheme of amalgamation.
And it refused at the first opportunity.
The fact is that it was recommended that the Meath Hospital should be included in the scheme of co-ordination of a certain group of hospitals. That was a recommendation of the Hospitals Commission. It seemed to be a desirable development, but the Meath Hospital was not inclined to come in. If we do not adopt recommendations of the Hospitals Commission, we are subjected to a good deal of criticism, and, if it were possible, we would be held up to a certain amount of ridicule. Consequently, we tried to have the recommendation of the Hospitals Commission given effect to. We negotiated with these people—we spent a very long time negotiating with them—in the hope that perhaps we would get them to come into the scheme as recommended by the Hospitals Commission, but, as Senator Rowlette has told the House, they refused. When they refused, we had to change our hand again. We had then to consider: Is it worth while going on with the other three when the Meath Hospital is excluded?
Finally, we decided that we would go on with the other three. It required legislation, fairly comprehensive legislation, and when it comes to legislation for voluntary hospitals, I can assure the House that many ticklish points will be raised. Sometimes people are agreeable; sometimes they are disagreeable; and sometimes it is very hard to get them to see reason, but you need not hope to have legislation affecting the interests of any group of voluntary hospitals produced overnight. Consequently, a considerable amount of time was spent—not wasted —in drafting the legislation to deal with the amalgamating group of voluntary hospitals. That legislation has now been agreed upon. There is not any particular hurry about it, I think, because if we had that Bill passed through the Oireachtas, I do not think we could build that hospital, nor do I think that the promoters claim that it could be built.
There is not much use conjecturing, but it seems to me, at any rate, to be doubtful that we will be in a position to build any hospitals in this country within a number of years until building materials are again available, but in the meantime we can do a certain amount of preparatory work and legislation can be introduced at any time. The only drawback at the moment is that the Oireachtas will be fairly fully engaged with financial business for the next few months, after which we shall have some other diversion.
The Senator talks about notorious delays in the Department. He does not go on to give us any definite particulars as to the notoriety of the delays, but he complains that expenditure is growing and then asks how it could be otherwise—referring to the emergency conditions—it is natural to expect that there should be a growing expenditure. To a certain point, I agree with him, but, at the same time, in justification of the notorious delays in disbursing these moneys out of the Hospitals Trust Fund, for which the Minister has responsibility as the head of a State Department, it is well to remember that, in 1933, the deficits were roughly £50,000 and that, in 1938, they were roughly £115,000. There was no emergency in 1938 and yet the deficits increased from £50,000 to £115,000. I think these figures in themselves constitute an adequate and complete reason for any delays, any negotiations and any questioning that may have taken place between the Department or the Hospitals Commission and these voluntary institutions.
In all this story of the delays and suggested, though not actually alleged, incompetency, there is just one instance mentioned. It was mentioned by Senator Sir John Keane, that is the case of the Cork Street Fever Hospital. If I have to weary the House with the story of the Cork Street Fever Hospital, do not blame me.
You have three-quarters of an hour yet.
I should like to give Senator Sir John Keane some time to reply, or perhaps we could carry the debate over to another day.
I should prefer to finish it to-day.
When the Senator introduces these contentious questions and gets in his "wipes" at the Ministry, I must defend the citadel.
Let us hear about the Cork Street Fever Hospital.
Senator Healy wants to hear about the Cork Street Fever Hospital and wherefore the delay. I avail of the opportunity to put on record the facts regarding the Cork Street Fever Hospital. When the proposal to erect a new fever hospital was decided on, a provisional committee was established in the year 1935 as an advisory committee for the purpose of carrying out preliminary investigations in connection with the selection of a site. The first difficulty arose in relation to the area of the site to be acquired. The Hospitals Commission had recommended a site of about 30 acres. The provisional committee decided that the site should have to have a minimum of 100 acres, and although the Minister intimated that the maximum area to be sought should not exceed 50 acres, the provisional committee adhered to their view. There was good reason for delay there. The Hospitals Commission were right; the Minister was right; or these people were right; but at any rate there was a difference as between 50 acres and 100 acres for the site. Notwithstanding the advice of the Hospitals Commission and the advice of the Minister, they proceeded to take their 100 acres.
No progress could be made until the Dublin Fever Hospital Act, 1936, came into operation, and the Dublin Fever Hospital Board was constituted as from 1st January, 1937. Meanwhile, the Dublin Corporation had, at the instance of the Department, instituted a new procedure for ascertaining the most suitable site for the proposed sanatorium, and were in 1936 conducting a survey of the entire district in and about the City of Dublin with a view to selecting the best site for the institution. It was considered desirable to await the completion of this survey. That was a sound commonsense attitude and I do not think there can be any criticism on that score. The provisional committee referred to had selected a site at Blackditch, which was subsequently adopted by the Fever Hospital Board. The corporation had rejected that site when considering the question of a site for a sanatorium.
There was room for thought there. The provisional committee selected a site which the corporation had already rejected and the Minister was expected to approve of this selection of a site which was not considered suitable for a sanatorium, without any delay. The Minister, being a responsible man at the head of a Department of State, does not act in that irresponsible way. Alternatives were suggested by the Department but the Fever Hospital Board gave their preference to the site at Blackditch, and, in November, 1937, the Minister authorised the board to negotiate for the purchase of that site. The price of the refusal was that we could not get on with the fever hospital proposition at all; but although we believed they were wrong, although they selected a site which the corporation had already rejected, in order to get on with the job, we had to approve of the site.
When consideration of planning was taken up, it was evident that the board wished to plan on a very elaborate basis. When planning a hospital, it is necessary to have regard to its future operation, and to endeavour to secure that the upkeep and running costs will be kept as low as possible, while at the same time providing for efficient treatment of patients. Economics in initial cost often produce economics in running expenses.
At the end of November, 1938, the first outline schedule of accommodation was submitted by the board for a hospital with accommodation for 400 beds, the number recommended by the Hospitals Commission. While the schedule was being considered in the Department, the board submitted a new proposal for a hospital of 500 beds. This fundamental change created a difficulty, and it was not until the middle of 1939 that the board agreed to go back to 400 beds.
Following approval of the preliminary schedule of accommodation, the board submitted a detailed schedule of accommodation and a plan of the hospital showing the lay-out of the buildings. It was only after repeated and lengthy discussions that the Minister succeeded in convincing the board that it was possible to achieve considerable economies in construction cost without in any way affecting the efficiency of the hospital, and that those economies would in fact produce further economies in upkeep and running costs. In addition to the economies secured in the essential components of the proposed hospital, the Minister had considerable difficulty in convincing the board that in the present circumstances the provision of a swimming pool for nurses, a covered ball alley at a cost of £1,500, and 23 cottages for male employes at a cost of £650 each, would be an extravagance that could not be justified. The Minister had already recognised the need for recreational facilities and had agreed to such provision on a generous scale, including tennis courts, a ball alley—uncovered—a recreation hall, a billiard-room for the medical staff, and common rooms for nurses and domestics.
Another matter in connection with which unnecessary delay took place was the appointment of a consulting engineer. The Minister, realising the importance of the institution for the treatment of infectious diseases, and also that questions of temperature and ventilation should receive special consideration in the planning of the hospital, was anxious that the best possible advice should be obtained for the designing of the engineering services. It was essential, not only that competent consulting engineers should be appointed, but that the most competent available should be employed. It was felt that the Hospital Board would find it difficult to select from among the applicants the most suitable candidate for each branch of the engineering work, unless they were guided in the selection by expert advice. The Minister, accordingly, decided that in the selection of the consulting engineers the board should be advised by the professors of engineering from the National University of Ireland and Dublin University. The board, instead of asking those advisers to select the most suitable of the applicants, asked them to submit a panel of suitable persons for the posts, and proceeded to make a selection from that panel. The Minister, therefore, had to request the board to obtain from the selectors the name of the most suitable applicant for each branch of the work. Considerable delay would have been avoided in this matter if the board had been prepared to act in full accordance with the Minister's recommendation, which was eventually adopted by them. That is how the delays occurred.
When the final schedule of accommodation and draft sketch plans were submitted to the Department on the 15th August, 1940, it was found that the schedule of accommodation did not contain amendments which the board itself had agreed to after long discussions with the Department on the previous draft, and that the plans submitted did not even agree with the schedule of accommodation accompanying them. This position involved the detailed reexamination of the proposals and the preparation in the Department of a lengthy statement containing corrections and recommendations for the amendment of the plans. These amendments were practically all accepted by representatives of the board at a conference in November, 1940. Since then, the preparation of plans has proceeded, and the board have practically reached the position when they can start the site development works.
The estimated cost at the beginning of 1941 was £519,126 12s. 0d., and the actual and prospective commitments from the Hospitals Trust Fund for other hospital works did not permit of a grant based on that figure. Apart from the position of the Hospitals Trust Fund, the Minister had to remember that the future maintenance of the hospital would involve a large charge on the general body of the rate-payers in Dublin City and County. The utmost care, therefore, had to be taken to ensure that the cost would be kept at a reasonable level in view of the other burdens falling upon the rate-payers.
The principal economies achieved as a result of the examinations of the proposals of the board by the Department are:
(1) A more compact plan on the site, thus making considerable saving in the construction of roads, ducts and engineering services, with a consequent saving in running cost.
(2) A reduction in the number of separate cubicle blocks.
(3) A reduction of the ancillary accommodation to be attached to each ward block. For instance, each ward block of 26 beds was provided originally with five bathrooms. The number of bathrooms was reduced to three, representing a total saving of 20 bathrooms for the ward blocks.
(4) The floor space per patient originally proposed to be provided in the cubicle blocks was 144 square feet. This has been reduced to 110 square feet, and as there is accommodation for 140 patients in the cubicle blocks, the floor space saved amounts to approximately 4,700 square feet, exclusive of the saving in corridors, etc. Some saving was also made in the floor space allocated to each of the 260 patients to be accommodated in the ward blocks.
(5) It was originally proposed that each maid should have a separate room. It was eventually agreed, following representation from the Minister, that the maids should be accommodated in cubicle dormitories; thus reducing considerably the cost of their accommodation.
(6) Savings have been recommended in many other sections, such as the admission block, the chapel, the nurses' quarters, garages and other buildings.
I think that that is a very good example of what causes delay in the planning of new institutions, and I think that anybody with an open mind will agree that if my Department spent time on the examination of these proposals, it was time well spent and the results of the examination of these plans would accrue to the ultimate advantage of the people who maintain that institution. The alterations that have been made in the plans have not lessened in any way the efficiency of the proposed institution as a first-class modern fever hospital. The reluctance of the board to co-operate with the Department, and the incompetent manner in which they handled certain of these matters, must, I think, be held responsible for any delay that occurred. So much for what the Senator described as the notorious delay that has been associated with this matter, and for the allegation that the Department of Local Government and Public Health and the Hospitals Commission were responsible.
The Senator also spoke of the out-patients in the Dublin hospitals, and said that that was a matter that was over-due for examination. Again, that is one of the matters that has been very strongly pressed on the management of the voluntary hospitals. The group of the Irish Medical Association who are particularly concerned with hospitals and dispensaries went into this matter and spoke in the most emphatic language of the abuses that were associated with the out-patient departments of the voluntary hospitals. Notwithstanding that, and notwithstanding the repeated pressure from the Department of Local Government and Public Health on the same matter, we have not yet been able to induce the voluntary hospitals to make any radical change in that regard. The position is, as any impartial person who is interested in this question must admit, that the out-patient departments of the Dublin voluntary hospitals are being cluttered up with a type of patient who could very well be treated by the dispensary doctor. It seems to me that the out-patient departments are not serving the function that they could very well serve. In my judgment, the local doctor, the family doctor, or private practitioner, when he comes across a case that seems to be rather obscure, or where he is doubtful as to the diagnosis the best course would be to give a note to his patient to go to the out-patient department of a voluntary hospital where all the skill of the staff of that hospital would be available to aid him in the diagnosis of the illness and the treatment of his patient.
If such a system were established, with the staffs of the out-patients' department reporting back to the doctor who sent the case there in the first instance, there is no reason why a big proportion of those people could not continue to be treated either by the private doctor at home or by the dispensary doctor.
People may say there is not sufficient accommodation in our public assistance dispensaries. That is not an excuse at all. At any time when a reasonable case was made to my Department regarding the provision of additional dispensary facilities, those additional dispensary facilities were provided. If the voluntary hospitals will put their own house in order, and leave us to look after the poor in our public assistance dispensaries, we will do our job all right. Apart altogether from the poor who go there, there is no doubt that there is abuse of the out-patients' department by people who could afford to pay. People come up from the country, stay a couple of nights with a relative and slip around to the out-patients' department, and people in the City of Dublin who have a good share of the world's goods very often go to the out-patients' department and get treatment at the expense of the Hospitals Trust Fund, when in fact they should pay for that treatment. As well as that, the out-patients' departments are cluttered up with people who are not looking for treatment at all but are merely looking for national health insurance certificates.
That is the kind of service we get from our out-patients' departments, owing to lack of organisation. Under the present scheme of things, I think a very big advance in our public health services could be achieved if the voluntary hospitals would agree completely to modify their outlook in relation to the functions which their out-patients' department ought to serve in our hospitals system.
Senator Sir John Keane said at some stage—I do not know what he meant—that the Minister is not the best person to decide the matter of disbursements out of the Hospitals Trust Fund. I wonder who would the Senator suggest should decide those matters? If a Minister of State is not the best person to decide on a matter regarding which he has statutory obligations, and if some outside body ought to be set up, between him and the people affected, to decide those issues for him, then I wonder what on earth we have Ministers of State for at all. If the Minister delegated to the Civil Service or to a commission or anybody else a function that ought properly to be discharged by him, we would hear a very loud cry about bureaucracy. If we delegate to somebody else, we are wrong; if we do it ourselves, we are wrong too. It appears to me that we are going to be wrong in any case.
Senator Sir John Keane made a further reference that I should. be reluctant to think he seriously meant. He stated that, in regard to those matters, the Minister would be subject to political pressure. That is an extraordinary statement for a man holding the responsible position in the public life of this country that Senator Sir John Keane holds. Does he seriously think —if he does not think it he should not suggest it—that in the disbursement of those funds any Minister would be influenced by political pressure? If he thinks so, will he cite a single case that he knows of where a Minister has been swayed by political pressure in determining the grants to be given out of the Hospitals Trust Fund? If he is not prepared to cite such a case, he should not make such an allegation here. I do not think he believes it himself. I would be very much surprised if he did. Perhaps I am reading more into his words than he intended them to convey, but to me they had a very nasty meaning.
Coming to Senator Foran's contribution to the debate, it will not take very long to dispose of the only point that struck me about it. He made one very foolish statement—a statement altogether inconsistent with any facts that have ever come before me. He said we have equipment lying idle in hospitals down the country, and that the hospitals are, for all practical purposes, derelict. I do not know whether people make statements like that without any consideration or without having any facts before them, but my experience is that our local authority hospitals down the country are overcrowded. Invariably, the complaint that I get everywhere I go, and in all the communications relating to this problem that come to my Department, is: "We have not sufficient bed accommodation." I do not know where on earth those institutions can be where the equipment is lying idle and the beds are lying idle. I never heard of them, and I do not believe they exist. I do not suggest that Senator Foran was deliberately misleading the House, but I do suggest that somebody has been misleading him.
In the time at my disposal I cannot deal in detail with the progress we have made in giving effect to the recommendations of the Hospitals Commission. I have dealt in some detail with the position regarding the four Dublin hospitals. Legislation has been passed regarding one of them. Legislation is ready for introduction in the case of another; if the financial business of the coming session permits, it will be introduced during that session, but, if not, it will be introduced afterwards. The other two hospitals are busy planning. Many exchanges of views have already occurred, particularly in the case of the Mater Hospital, between their technical advisers and the Minister's technical advisers. They have made considerable headway. In the case of one other voluntary hospital, they are now ready to proceed with the planning. So far as the local hospitals are concerned, we have provided 13 new county hospitals; 23 new district hospitals—I can give the geographical location of those hospitals to anybody who is sufficiently interested—10 fever hospitals; extensions to tuberculosis institutions in Wexford, Kerry, Cork, Leix and Limerick County Borough; a new sanatorium has been provided in Rathdrum, County Wicklow, and a new tuberculosis hospital in Cavan is almost complete. Extensive works have been carried out at such mental hospitals as Ballinasloe—including Castlerea—Mullingar, Limerick, Sligo, Ennis, Grangegorman, Portlaoighise, Castlebar, Monaghan, Ardee and Killarney, and smaller works at other mental hospitals.
It may be said, perhaps, that the local authority hospitals have advanced more rapidly than the voluntary hospitals. That is true. That is due to the fact that we had considerably less difficulty in our negotiations with the local authorities regarding site location, bed capacity, etc., than we had with the voluntary hospitals. On the other hand, I think perhaps it might be a blessing in disguise that this hospital in which Senator Barniville is so much interested was not built before Fianna Fáil came into office, and that the programme of hospital development in Dublin City has not been completed even up to the present, because, when we realise that it now takes £7,000,000 invested at 3 per cent. to pay the deficit of the voluntary hospitals, we must ask ourselves the embarrassing question, what would become of these voluntary hospitals if that £7,000,000 had been expended in building new hospitals?
I shall deal first with the subject on which the Parliamentary Secretary seemed, I thought, to get unduly heated, and that was my reference to political pressure. I feel that every Minister is subject to Party pressure. Surely, that cannot be disputed? His Party have claims upon him, and there is no question of personal corruption. The Parliamentary Secretary talked as if I were accusing the Minister of giving money away to his political friends. I did not do so. There are all kinds of questions in relation to hospital policy. There are, for instance, questions of municipal hospitals versus voluntary hospitals. There are all kinds of political wirepulling in matters of that kind. That is as far as my suggestion went. If the Minister was not always the best judge, and if he should not be given the absolute deciding voice in matters of that kind, it would be better to try to devise some sort of organisation which would combine other representatives with the Minister, or with officers of the Department, in those decisions. There is no ground for the Parliamentary Secretary getting as heated as he did when I made that remark. We are living in a world of reality, and to suggest that there is no such thing as Party or political pressure influencing decisions, is to ask one to believe that one is in a fairy land.
As to the neglect of legislation in connection with these amalgamated hospitals, I know that legislation takes time. The Parliamentary Secretary says that things cannot be done overnight. I know that, but there is a difference between overnight and six years. I feel there, again, that I may be wrong and I am not making any charge, but it would seem that the State hospital got far more expedition in the matter of legislation than did the voluntary hospitals. I do agree that if they push the matter forward now, not very much harm will be done, because building cannot be undertaken at the present time. But it is important to get the legal authority established and to get on with the plans. We know the time they take, and the sooner they are prepared, the better. I cannot believe it is going to be a controversial matter when it comes to Parliament.
The Parliamentary Secretary talked about out-patients and suggested that the remedy for the present confusion lay in the hands of the voluntary hospitals—if they would only refuse to take those people and throw them back on the dispensary system, the dispensary system would be adequate to deal with them. I am not intimately in touch with the dispensary system, but I am told that the dispensary officers are asked, in some cases, to deal with 180 people an hour, with totally inadequate equipment. Of course, it cannot be done and the dispensary officer sends them on to the hospitals and the hospitals have this nondescript accumulation of cases with which they try to deal. I do not think it would be satisfactory if they attempted to be unduly harsh in their segregation, if they were to say to a patient: "You are not seriously ill and you can go back to the dispensary system." That would be totally against the spirit in which the voluntary hospitals try to do their work.
The Parliamentary Secretary laid great stress on the tribute paid by persons connected with the medical association to the work of the commission. Dr. Moore was one of those who paid a tribute. I hope I paid a tribute to the work of the commission. Let me point out that this tribute was paid in 1936, when the commission had published its first report, and that was put before this medical body. I think that first report was admirable and very necessary.
I will come now to what I feel is the defect in the present position. The commission has survived its utility. It was required to make that survey that took place in 1936, but, having made its report, I feel it might have relapsed into a much smaller and totally different class of body. What I feel—and it is only a matter of opinion—is that the commission has survived its utility and, like many other bodies, it is striving to justify its existence by issuing a mass of statistics, many of which are not worth the money. I do not think I said the commission was not worth the money. The record will show what I did say. I said that that vast mass of statistics, most of which could not be used in practice, was not worth the money. That is different from saying the commission was not worth the money. I do feel that the commission has survived its usefulness and a totally different organisation is called for.
I do not know if the Parliamentary Secretary meant to be deliberately confusing when he talked about commissions. He rather suggested I asked for the setting up of another commission to replace the existing one. I did not. I asked for a body to inquire into hospital finance generally and report on the system best suited to the efficient operation of our future hospital system. It might recommend the abolition of the existing commission and possibly the establishment of some joint body along the lines of the Electricity Supply Board, but I never asked for a permanent commission. Perhaps I did not make myself clear, but I will mention briefly that my objection to the present organisation is that you have a hospital with its advisers and architect and board; then you have the commission, and then you have the Minister with his officials and his own architect. Altogether it is an unsound organisation. There need not be any heat about it. I consider it is a bad organisation, and I would like an inquiry in order to see whether we cannot get hold of a better one and leave politics and all that sort of stuff out of it.
The Parliamentary Secretary suggested I should not have made a point of comparison between the available and the occupied beds. I think it is quite right that the commission should give us the figures of the total available beds and occupied beds, but I do not think it was necessary to give all those statistics of financial apportionment that have been given with reference to the available beds and the occupied beds. That is a patent example of the unnecessary work the commission is doing, and I feel it is an example of work that is being carried out simply because there is not other more useful work to do.
With regard to reports, the Parliamentary Secretary got very hot with me because of certain remarks I made about political pressure. I think I am entitled to get a little bit hot with him when I point out that for four years the commission has not published any report, although previously it did so. Surely that requires some explanation. When I am told that the commission need not publish a report, am I expected to leave it at that, and to take it from the Parliamentary Secretary that no more reports are going to be published? If that is the policy, then I think he should be frank about it and say whether the Minister or the Government have received any reports from the commission and, if so, why they have not been published. What is the reason for the sudden decision to hold them up? I think that the Parliamentary Secretary has not been frank with the House on this matter and that I am entitled to get hot with him about it. It may be a minor matter but I think he has not been frank with us.
I do not want to take up any more of the time of the House. I have dealt with what I consider to be the outstanding points. What I have in mind is the setting up of a commission to make a fresh examination of this whole problem. The motion is really only an indication of my approach to it, and if agreed to would have to be examined by the responsible Department. The terms of reference and so on for the commission would then have to be drawn up. I should like very much to see the relations between the rate-aided hospitals and the voluntary hospitals brought within the purview of such an examination. It is very important that we should have some close co-ordination between the treatment of cases in the county hospitals and the more specialised treatment that possibly may be given in the Dublin general hospitals. Senator Mrs. Concannon rather suggested that my motion covered too narrow a field. My answer is, make it as wide as you like, and let there be an examination of the whole problem. We certainly should not accept it that the present organisation is satisfactory and that all is for the best in the best of all possible worlds.
On the question of delays, because I mentioned Cork Street Fever Hospital half the time occupied by the Parliamentary. Secretary in replying was taken up in dealing with that hospital. He referred to the delays that take place as regards meeting deficits. Why should there be these delays? Why could not 90 per cent. of them be paid on account, thereby saving the charges that borrowing involves, and let the investigation into claims go on? Why is it considered necessary to penalise bodies because it is assumed that their administration is extravagant? Are some of the deficits met more quickly than others? I should like an assurance on that point. Generally, I think the delays are pretty much the same in all cases, but I may be wrong in that.
The Parliamentary Secretary took me up rather sharply on the reference I made to the provision of additional beds. I think that what I said on that was absolutely correct. I said that the recommendation made by the Hospitals Commission was that 600 additional beds were needed in the case of the Dublin general hospitals. The record, I think, will show that I did make that statement. The figures before me indicate that 23 additional beds—not even 25, the figure I mentioned when speaking at the opening— had been provided up to 1938. I know that additional beds are being provided in the new county hospitals in greater numbers—in more spectacular places up and down the country. The Department may find it easier to deal with the local authorities than with the existing voluntary hospitals. Is that the explanation for that, and is that a true picture of the position? I agree that the Minister has greater power and more authority in the sphere of local government than he has in the case of these Dublin hospitals. Even if that be the case, I do not think it satisfactorily explains the spectacular results in one case, and the almost negligible results in the other.
I thank the House for the way it has listened to me on this matter. I feel that the motion has served a useful purpose. I was sorry there was any suggestion of political feeling about the motion. I certainly had none. My only reason for putting it down was because of my interest in the poor of all classes. I strongly feel that the present system is not the one best fitted to serve their needs, and that is why I moved the motion.
Is the motion being pressed?
I do not want to press it to a division, but I should like to get the feeling of the House on it.
Question put and negatived.
The Seanad adjourned at 9 p.m. until 3 p.m. Wednesday, 14th April, 1943.