On the motion that the Bill be read a Second Time, I may say that the purposes of this Bill are, in short, to bring the law relating to the health services up-to-date, to simplify the administration of these services and to add to them where they have been found to be deficient.
The law now governing the health services is very complex and is intertwined with the codes relating to such sanitary services as water supply, baths, washhouses and bathing-places and burial grounds, as well as with the general law dealing with local government. Senators who wish to study the intricacies of this law will find a convenient list of the various Acts and sections of Acts dealing with the health services in the First Schedule to the Health (Transfer of Departmental Administration and Ministerial Functions) Order, 1947, which has been presented to the House. That is the Order under which the functions proper to my office were transferred from the Minister for Local Government. Forty-six complete enactments and portions of 14 other Acts are listed in that Schedule. These include parts of the Public Health and Local Government codes and various Acts dealing with infectious disease, tuberculosis, maternity and child welfare, school medical services, medical registration and similar matters under a wide variety of titles. Some of these enactments are now out of date and the powers given by them have not been used for many years.
The most important provisions still in use are contained in the Public Health Act of 1878 and the various Acts which amended and extended that Act. These Acts deal mainly with sanitary matters which remain proper to the Minister for Local Government and the title of the code is being changed by the Local Government (Sanitary Services) Bill, 1947, to the Local Government (Sanitary Services) Acts. The provisions in the code which relate to the health services, together with the out-dated unused enactments and provisions in other codes dealing with health, are being repealed in the Bill and re-enacted where needed in a modernised form.
The Bill does not purport to codify in one Act all the law dealing with the services for which I am the responsible Minister. That, I think, is scarcely necessary and would hardly be practicable. But, when this Bill becomes law, almost all the legislation relating to my Ministerial responsibilities will be contained in a modern series of Acts which will include, as well as the Health Act, the Mental Treatment Act of 1945, parts of the Public Assistance Act of 1939 and some self-contained Acts dealing with such matters as the registration of members of the medical, dental and nursing professions. We will thus have gone most of the way in disentangling the law dealing with the health services from other codes and in simplifying and bringing it up to date.
Now, as regards the simplification of administration, I have, since being appointed Minister for Health, been struck by the complications in the present local structure of the health services. First, you have the sanitary authorities (the county borough councils, the urban district councils and, for rural areas only, the county councils) who, as well as being charged with the responsibility for providing water supplies, sewerage and other sanitary services, are also responsible for the control of infectious disease, for maternity and child welfare, for certain services relating to food supplies and for the appointment of district medical officers of health.
Then you have other health services (including the school medical service, the tuberculosis service and the venereal disease service) administered by the county council in the entire county. The county medical officers of health appointed and paid by the county councils, are also charged with the responsibility of supervising the health services administered by the urban district councils. This division of responsibility for the health services between two sets of local authorities has hindered their proper development and, in particular, has prevented any close integration of the maternity and child welfare and school medical services.
It is now proposed that the urban district councils should not be left any functions in connection with the health services. The county and county borough councils will be given the sole responsibility for the local administration of this Bill. There will thus be a much simpler framework on which to build up the services which will be developed under its various provisions.
So much for the legal and administrative provisions of the Bill. Now, as regards the services which will be set up under its provisions, these must of course be governed by the extent of our local organisations. By improving the quality and quantity of our personnel and institutions we hope to provide an optimum service in the time to come. In the meantime we shall try to give effect to the schemes as far as we can do so with the organisation at our disposal. Consultation with the various professional interests involved and, in particular, with the National Health Council will also be necessary before regulations are made and promulgated to give detailed effect to the administrative schemes for which statutory authority is being sought here.
Part II of the Bill contains a series of provisions relating to health institutions. Health authorities are given power to establish institutions themselves or to make agreements with the persons managing other institutions. Provision is made for the transfer of institutions from public assistance authorities to health authorities and for the joint use by health and public assistance authorities of institutions such as dispensaries. These provisions are necessary until the final step in the severance of the health services from public assistance administration can be taken. Under Section 16, the Hospital of Saint Margaret of Cortona will be transferred to the Dublin Corporation. This hospital, formerly known as the Westmoreland Lock Hospital, may then be developed by the corporation as an integral part of their scheme for the control and eradication of venereal disease. There is also power in this part of the Bill to enable a health authority to purchase compulsorily for a voluntary hospital in their area any land required for the extension or improvement of the hospital.
Part III of the Bill, dealing with the mother and child service, contains the most important proposals in the measure and I will therefore explain in some detail what exactly are the powers sought in this part of the Bill and secondly how I propose to implement them.
Sections 21, 22 and 23 impose a duty on health authorities to arrange for safeguarding the health of mothers, children not attending any school and children attending certain types of schools. In the exercise of their powers under these sections, health authorities will be governed by regulations which will be made by the Minister under Section 28 of the Bill. Before making these regulations, I intend to have full discussion with the National Health Council and to obtain the views of the various professional bodies which will be affected. That does not, of course, mean that I will be bound to accept in full the suggestions offered.
There are various ways in which we could set about providing a service of this nature. We could, for instance, base it, as the present maternity and child welfare and school medical services are based, on a special whole-time public health staff. While, from the administrative point of view, this would be a convenient method, I think that it is very desirable to ensure that the mother and child service should not be divorced from the ordinary general practitioner service provided at present by the dispensary doctors. Such a procedure would permanently divide the whole system of general medical care into two artificially created branches and it would deprive the local practitioner of a portion of his paying patients without creating any justification for an increase in his salary. It is my intention therefore to seek by negotiations the co-operation on agreed conditions of the district medical officers. Such conditions would of course include an appropriate increase in these officers' salaries. I appreciate, of course, that many of the present dispensary districts will need to be divided and that, in some cases, assistants to the dispensary doctors will be needed when the service is brought into operation. A comprehensive survey of the present dispensary districts and of the medical facilities available in each is at present being conducted in my Department to find out what divisions and changes of districts would be needed to arrange that no doctor would be called upon to undertake too much.
The district medical officer, in the administration of the service, will be helped by a maternity nurse, who will attend to mothers and infants, and a child welfare nurse, who will look after children over one year of age. Clerical assistance will also be available where necessary. It is intended to provide in each county adequate facilities, including health centres and clinics, for use by the medical and nursing staff for inspection and treatment.
Provision will be made for the care of the teeth and for eye treatment by dentists and ophthalmologists employed by the health authorities.
Consulting obstetricians will be appointed to attend women who need their special attention. Arrangements will also be made for the provision of other specialist services. It is hoped that, when the service is fully developed, there will be full provision for the prevention and treatment of ailments of the ear, nose and throat, orthopædic defects, juvenile rheumatism and other defects calling for specialist treatment.
The general administration of the service in each city or county will be supervised by the city or county medical officer.
Much criticism has been directed to this part of the Bill on the grounds that it entails undue interference with the rights of parents to provide for the physical needs of their children. I would like, therefore, to make clear at this stage the extent of the compulsory powers sought. First, I must emphasise that no power is contained in Section 22 or Section 23 of this Bill which would allow a health authority to provide medical or surgical treatment for a child against the wishes of its parents. If such a drastic power were sought it would be necessary to be quite explicit about it in the Bill—just as we are explicit about compulsory inspection, compulsory immunisation and compulsory detention of infected persons.
Treatment, therefore, will not be compulsory. The various facilities for the treatment of defects of which I have just given an account will be available for use by any child whose parents wish it. The State or the health authority will not be able to use any stronger methods than advice and persuasion to try to get parents to allow their children to avail of the service.
That is the position in so far as actual treatment is concerned. Medical inspection to ascertain defects is another matter. That may be made compulsory in particular districts and for particular periods. Section 25 of the Bill provides that, where an inspection is arranged for a child, the parent shall either submit the child to that inspection or else produce a certificate signed by a registered medical practitioner stating that he has examined the child within a prescribed period preceding the time fixed for the inspection by the health authority. In other words, a parent will be obliged to have his child seen regularly either by a medical officer of the health authority or by a private doctor.
This section will not be applied automatically throughout the country when the Bill comes into operation. It is provided that it shall have effect only in any county or county borough as respects which the Minister has made an Order applying it. The extent of the statutory provision proposed by this Bill in relation to compulsory medical inspection is, therefore, that, if the Minister applies Section 25 to any area, parents in that area will be required to have their children inspected at fixed intervals either by their own private doctor or by a doctor employed by the local authority. I am sure the House will agree that that does not mean that the health authorities are to take over entirely the responsibilities of parents in relation to the physical health of their children.
Personally, I am entirely in favour of voluntary methods in medicine and I do not intend to apply this section except where it is quite clear that there is persistent neglect in a given area to have children submitted for inspection under the voluntary system and that the health authority for the area have used persuasive methods to the utmost without success.
I may be asked what is the justification, even in the special circumstances stated by me, for compulsory medical inspection of children. I think that it does not require much thought to convince oneself that non-intervention by the public authorities cannot in modern circumstances be contemplated with equanimity. It would be all very well if each family were a self-contained, isolated unit but where children of all families are daily mixing in schools and streets, and travelling from place to place in buses and cars, the State has, I submit, the duty to find out if the physical condition of any child presents a danger to his companions or to the public. It has been found, from experience of the present school medical service schemes, that it is the children with infectious or verminous conditions who are generally kept away from school on inspection day. The ascertainment of the non-infectious ailments such as bad teeth, defective eyesight or diseased tonsils or adenoids has met with little opposition. I do not think that compulsion would be justified if the purpose of school medical inspection were merely to find defects of this nature. But the school medical service must be related to the services for the ascertainment, prevention and eradication of infectious disease and verminous conditions, which are in the interests of the community as a whole and not of individuals alone. Furthermore, apart from infectious disease, conditions might exist in an area which might be a danger to all children living in it and which could only be conveniently found out by ascertaining whether any children have been affected by such conditions. I am referring to such things as mineral deficiencies in certain districts which might give rise, for instance, to widespread goitre or to other deficiencies causing certain types of malnutrition. If the health authority are in a position to ascertain whether there is an abnormal incidence of such diseases or conditions in any part of their district it will be possible for them to take steps to remedy these deficiencies with consequential benefit to the local community as a whole.
Finally, the inspections under the mother and child service will enable the health administrators to find out what areas in the country and what classes of children are particularly prone to various types of ill-health. This type of research will have a very great value as a basis for improved administration and for the introduction of special schemes of amelioration.
Part IV of the Bill deals with infectious disease and infestation. Many of the clauses in this part are re-enactments of existing law. Others are additions to that law rendered necessary by modern conditions. Power is given to the Minister to specify what are infectious diseases for the purposes of the several relevant provisions in the Bill and to make regulations for the prevention of the spread of such diseases. It is intended that the diseases so specified shall include tuberculosis and venereal disease.
The regulations may include provisions requiring adult persons to submit themselves or the parents of children to submit such children to measures of protection or immunisation against any disease but there is a clause under which anyone who objects in a prescribed manner will be exempted, except where the Minister by Order directs that compulsory immunisation is necessary locally to eradicate an epidemic.
I think it well to refer at this point to the repeal of the Vaccination Acts by this Bill—a matter on which there has been much misunderstanding. Senators will be aware that these Acts provide for the compulsory vaccination of all children against smallpox and that the service provided under them has been instrumental in eradicating that disease in this country. While it is intended to repeal these Acts in this Bill, the power to require compulsory vaccination will be retained. Smallpox will be placed on the same footing as other diseases. If the Minister is satisfied, after consulting his medical advisers and the National Health Council, that vaccination should remain, then he can arrange for it in the regulations under the Bill just as effectively as if the authority were still contained in those old Acts which are being repealed. I have no intention of abandoning the existing machinery for smallpox vaccination as long as there appears to be any danger of the disease recurring in this country.
This part of the Bill also contains provision for the compulsory detention and isolation in institutions of persons who are probable sources of infection and who cannot be properly isolated at home. Section 38, which deals with this matter, extends to over two pages of the Bill and contains a very detailed set of safeguards which, I think, should prevent any unjust or unnecessary detention under it. This provision is not entirely an innovation. There have been various clauses in the health laws since 1878 enabling infected persons to be removed to hospital, and since 1940 the Minister has power to order detention under an Emergency Powers Order. The laws which conferred the existing powers are being repealed in this Bill. I do not intend to apply Section 38 to any but the most dangerously infectious diseases, such as smallpox, some forms of tuberculosis, typhus, enteric, diphtheria, infantile paralysis and venereal disease.
There is also provision in this part of the Bill for the rehabilitation of persons suffering or recovering from infectious disease. This section will be applied particularly to tuberculosis, where it is often essential to follow actual treatment with training for work suitable to the condition of the recovered patient and such as will enable him gradually to resume his proper place in the life of the community. Section 44 of the Bill provides for the maintenance by health authorities of dependents of persons suffering from infectious diseases and of persons who, although not themselves diseased, are compelled to take precautions to prevent others being infected.
Part V of the Bill will supplement the existing law relating to the purity and standardisation of food supplies. It is intended to give the Minister power to make regulations to ensure that the public health will not be endangered from the careless manufacture, preparation and sale of food and to standardise foods which are of special nutritive importance. I am sure it will be welcomed by honest manufacturers, traders and caterers who are at present at an economic disadvantage in relation to less scrupulous persons who do not take proper hygienic care in the presentation of their products. I intend to have full consultation with the trade before making regulations under this part.
I do not think that I need add much to the explanation of the remaining parts of the Bill which was given in the memorandum which was circulated with it. In the Dáil, new sections were added in Part X to allow health authorities to provide a home nursing service, to make it clear that residences could be made available for officers and servants working under the Bill and to allow any modifications of existing enactments rendered necessary by the passing of the Bill to be made by the Minister.
As regards the National Health Council, I would like to say that, while I have not made up my mind as to its exact composition, it will include representatives of the medical, dental, nursing and allied professions and other bodies interested in the matters which will be dealt with by my Department. As far as possible, I will appoint to this council and to any subsidiary advisory bodies, persons nominated by appropriate vocational bodies. While the Minister must retain his responsibility to the Government and the Oireachtas for the policy in relation to the health services and must, therefore, make the final decisions on their administration, I can say that every opportunity will be given to the members of the National Health Council and any other consultative councils to put before me their point of view—or perhaps I should say their various points of view.
As regards the financial provisions, Section 27 provides for a 50 per cent. State grant for the mother and child service and Section 44 contains provision for a similar 50 per cent. recoupment of expenditure on maintenance of persons suffering from infectious disease and the dependents of such persons. There is already provision in the Estimate for a 50 per cent. grant towards local expenditure on the prevention and treatment of tuberculosis and for recoupment of 75 per cent. of approved expenditure on venereal disease. The greater proportion of public health expenditure by local authorities (including institutional and medical expenditure which is for the time being treated as part of the cost of public assistance) is not subvented from State sources except in a minor degree by certain grants or parts of grants which pass through the local taxation account and are specifically referable to these items of expenditure.
It is proposed in the White Paper which will shortly be published to review the future position of these financial relationships. The White Paper is being pressed forward for publication as quickly as possible, but it was not found possible to have it available for discussion in connection with the Bill or with the Department's Estimates when they were before the Dáil. When questioned on the Committee Stage of the Bill in the Dáil, I did, however, intimate that I contemplated a readjustment of liability, which would mean that the local rating authorities would not be made liable for additional commitments for some of the services under discussion for a long time to come.
I have now got a stage further in the negotiatíons which I have had with the Minister for Finance, and in the submission of my proposals to the Government, and I am now in a position definitely to declare that the health programme will be so financed that it will not involve local health authorities in any expenditure additional to what they are contributing from the rates at present until such time as the State grants will have reached a very much higher proportion of the total expenditure than they amount to at present. This means that the Government is willing to meet, for a considerable number of years to come, the whole of the additional revenue expenditure that may be involved in implementing the provisions of this Bill, and in giving effect to the further proposals for reform which will be outlined in the White Paper. Capital expenditure will continue to be met under the existing system whereby the local hospitals building schemes are financed partly from the Hospitals Trust Fund and to a lesser extent by loans raised by the local authorities.
It will probably require legislation to give effect to these proposals and a Bill on the matter may have to be introduced before the close of the present financial year. In the meantime, I am sure that my announcement will be welcomed by local authorities and that it will prove an incentive to them if such is required, to co-operate in giving full effect to this Bill and to the further proposals for reform which will be made in due course in the White Paper and in the legislation based thereon.