The Health Bill's Parliamentary career up to the present has been unusual. Introduced in Dáil Éireann at the special session on 21st January, 1969, commemorating its fiftieth anniversary, the Bill has passed its Second Stage, after a long and informative debate, by the time the Eighteenth Dáil was dissolved in May. The Bill was reactivated in the Nineteenth Dáil in July, when a resolution was passed directing that it should be taken up again at its Committee Stage. It was then, of course, that I became directly involved with the Bill.
During the Committee and subsequent Stages in the last session of the Dáil, we had very constructive debates on the Bill and several useful amendments were made arising from points raised on all sides of the House. I venture to say that the Bill as now presented to Seanad Éireann has been considerably improved in several respects as a result of these debates.
Much more is contained in the Health Bill than one would infer from its moderate length: it is a highly-compressed instrument for the development of future policy on the health services. The Bill has, indeed, been criticised because of the inevitable appearance of vagueness which is a consequence of this, and for the extent to which details are left to be filled in by Ministerial regulations, orders and directions. I think, however, that when one looks to the nature of possible future developments in the health services, the kind of flexibility which the Bill will permit is highly desirable.
I should point out too that, in the provisions of the Bill allowing for subordinate enactments to be made by the Minister, there are adequate safeguards for Parliament. In particular, this Bill uses to a rather unusual extent the device whereby the more important regulations—such as those dealing with the establishment and constitution of the new health boards—must be presented in draft form to the Dáil and Seanad, and approved by both Houses, before coming into effect. I would, indeed, point out that, as far as the Seanad is concerned, this right to veto such regulations is greater than their powers in relation to Bills; for those the ultimate power of the Seanad is, as you know, merely to delay.
The provisions of the Bill fall into two categories. First, there are the provisions in parts II and III dealing with the reorganisation of health administration and, secondly, there are the remaining provisions, in parts IV and V, which largely codify the law on the major health services and make provision for a number of improvements in those services, to which I will be referring later.
Each county is at present a separate administrative unit for the health services. Except in Dublin, Cork, Limerick and Waterford, where joint local authorities operate the health services, the county council acts as health authority. Under section 4 of the Bill, it is intended to establish larger administrative units, counties being grouped for this purpose. For each such group of counties, there will be a health board. A majority of the members of the health board will be appointed by the county councils concerned. County borough councils and the Dún Laoghaire Borough Council will also appoint members to the appropriate boards. Membership of the boards will also include persons elected by the medical and ancillary professions in the area and some Ministerial appointees.
It has become clear that for many of the services provided in hospitals, and for the general organisation of hospital services, the county is too small as a unit. This conclusion derives not only from studies in this country, but from what we have learnt of similar studies in other countries, notably Scotland and Denmark. By co-ordinating the hospitals for a group of counties, and by concentrating expensive specialised facilities in the larger units, I am confident that a much more economical and effective hospital service can be organised. The needs of the hospital service in this respect are preponderant, as over three-quarters of the total health expenditure is for services in hospitals.
Hospital services employ large numbers of professional and technical staffs of different kinds, some of which — for example, radiologists — are in short supply. By organising the services in units more suited to the requirements of hospital administration, better value will be obtained from the available facilities.
Many county councils now send hundreds of patients each year to hospitals in other areas. This does not, however, give such a county council any say in the operation of the hospital services in that centre. An important attendant advantage of grouping the counties as proposed in the Bill will be that, with few exceptions, the organisation of services for a county's patients will be in the hands of a body on which the county is directly represented. Roscommon and Mayo, for example, can have a direct say in how the specialised services in Galway are organised and Kerry can have a similar say as respects Cork.
One cannot, perhaps, see as being quite as clear-cut the case for having larger administrative units for the other health services. There are, however, important advantages to be derived in the operation of these services from enlarging the administrative unit. If one looks at the map of the country, it is striking to note how many of the towns are on or near county boundaries. Examples are Limerick, Waterford, Drogheda, Carrick-on-Suir, Ballinasloe and New Ross. Centres such as these are going to be increasingly important as foci for the organisation of all the health services. Clearly therefore, for the organisation of the new general medical service with choice of doctor — to which I will refer later — or the public health nursing service, or the child welfare clinic services, there will be considerable advantages to be derived from a combined administration where the facilities can be used without much reference to county boundaries. The larger administrative units wil also permit the more economic employment of social workers and other staff for the child care and geriatric services.
The future pattern of health services will be based on the 1966 White Paper and on the four reports published in recent years on the general hospital services, on mental illness, on mental handicap and on child health and will involve both decentralisation and concentration of resources. Clearly, decentralised facilities should be used as much as possible: this will be more economic and more satisfactory for the patients. Hence, running through our future planning, there will be increased emphasis on the development of the role of the general practitioner, the extension of the public health nursing services, of domiciliary care for the mentally ill and the mentally handicapped and of the pre-school and school health examinations. Out-patient diagnostic facilities will also be provided by visiting consultants at many centres.
These services should reduce the need for intern hospital care and the length of stay of patients in hospitals. In particular, the provision of more out-patient specialist services will enable diagnoses to be effected without hospital bed occupancy in many more cases. The involvement of most general practitioners in the country in the services for the lower income group will help considerably in the full co-ordination of the general practitioner services and the hospital services. The admission of general practitioners to hospitals, on the lines recommended in the FitzGerald Report, will also mean that many patients can be looked after in the smaller local hospitals by their own doctors.
Concentration of resources in fewer centres will follow from the needs of highly specialised medical and surgical procedures, which can only be organised in large units. The development of new techniques, the requirement of complex laboratory equipment and the needs to have highly skilled teams of workers for such procedures has inevitably led to the conclusion in this and in other countries that there must be a concentration of acute surgery and specialised medical care in larger units. For this kind of care, therefore, we must accept that there will be a concentration of resources.
This increased specialisation in medicine is reflected in the recommendations of the Todd Report on medical education in Britain, which will provide for increasingly specialised training for medical practitioners in different fields. We are examining the implications of that report for us. It seems inevitable that, if we are to maintain our present close connections in medical education with Britain which means that our medical graduates are free to practise there, we will have to make corresponding adaptations in our present medical training.
Looking ahead, we can see a pattern of health services in which the increasingly specialised and well-equipped larger centres are closely connected with the smaller units, through visiting consultants and through the involvement of general practitioners in hospital work. The various centres will, of course, have to be properly integrated through the use of better-equipped ambulances travelling on improved roads. It is only by pursuing the policy on these lines, for interconnected specialised and smaller units that we can make available to the people the full benefits of modern medical developments. What I have just said, therefore, must be the essential basis of our future policies.
A further significant justification for taking health administration out of the ordinary local government pattern lies in the ever-increasing State financial assistance to meet the cost of the health services. The Government, by the 1966 White Paper, committed itself to an acceptance that the cost of specific further extension of the services would not be met in any proportion by the local rates and, since 1966, the fraction of local health expenditure met by payments from the health services grant has risen from 50 per cent to about 56 per cent and is likely to rise further as services are improved and extended.
In addition, for rural areas, the State, from the agricultural grant, makes a further substantial contribution to the cost of the health services through relieving farmers from paying rates. As a consequence of this, State funds now meet, over the country as a whole, almost three-quarters of the total cost of the health services and this is a proportion which can be expected to increase in the future. These financial considerations, with the administrative factors which I have mentioned, provide what I think is a complete justification for the change from the present administration by local authorities to administration by health boards representing, as the 1966 White Paper stated, "a partnership between local government, central government and the vocational organisations".
The Bill does not go into detail as to the number of health boards or as to their constitution. In accordance with section 4, these will be determined by Ministerial regulations. However, before making these regulations, the Minister will be required to obtain the views of the relevant local authorities and the Minister for Local Government and, as I have said, the House of the Oireachtas must approve of drafts of the regulations before they can come into effect.
The formal processes for the establishment of the new administration must await the enactment of the Bill, but the House will be aware that I have been formulating my tentative proposals in this respect, so that there will be no unnecessary delay in setting up the health boards. In September last, I circulated a memorandum giving tentative details of these proposals. Copies of these were sent to Members of this House.
This memorandum proposed the division of the country into eight areas, each to be served by a health board, the population served to range from 921,000 for the Eastern Health Board down to 178,000 for the health board for the midlands. The memorandum also set out a proposed constitution for each of the boards. After its circulation, I arranged a series of meetings for each of the eight groups of counties to explain the proposals and to test, informally, local reactions to them. I would here like to express my appreciation of the helpful and constructive attitude of the local members and officials who attended these meetings. They have been most useful to me and I am now having what was said at these meetings digested, so that I will be able to put out formal proposals for consideration by each county council and other local authority concerned as soon as practicable after the enactment of the Bill. When considering these proposals, each county council will have before them a report of the meeting attended by their representatives. All the members of each council will thus see what representatives of other counties in the area have said and the views which I expressed at these meetings on the many points made. In this way, each county council when sending me their views, should be able to appreciate their implications for their neighbours and for me. After the formal local consultations the House will have the draft regulations before it for its consideration.
At this stage I do not intend to say anything more on the details of the establishment of the health boards. These boards will be the basic administrative bodies for the health services in the future, but the Bill provides for a number of other bodies at different levels which will have specific functions. For each county, or for a part of the county in some cases, there will be a local committee whose functions will be mainly advisory. Local councillors will be in a majority in the membership of these committees, it being intended that there will be a number of councillors from each of the county electoral areas. It is my intention that these committees will be live factors in the new arrangements and that their meetings will be properly attended and serviced by the officers of the health board.
These local committees are included in the new administrative structure because of the importance of maintaining local contact with the operation of the services. This, indeed, has been one of the major problems in the design of the new administrative arrangements — to combine the establishment of units large enough for efficiency and economy with local humane personal contact between those engaged in the day-to-day operation of the services and the people using the services. Not only is it intended that the local committees to which I have referred will be involved in this, but it can be expected that the new boards will, in the day-to-day operation of the services, act to a great extent through officers stationed in county centres and other towns.
At the level of the health board itself, there might, indeed, be some clash between the particular interests which the members — and particularly the local authority representatives — will have towards the services for the people from the local area which they represent and the broad interests of the board. It will be important that each member of the board, in acting on the board, will regard himself as part of a corporation with the wide responsibility of providing comprehensive health services for the whole area which the board serves. The members should, I think, become accustomed to looking at their problems in this way; they should eschew too much concern with minor issues and should be prepared to leave the management of the services to their staff. The Bill, I should mention, does not apply the details of the present county management system to the health boards, but its provisions are flexible so that the chief executive officer and his subordinates can be given sufficiently free play in the exercise of management functions.
The balance between what the members, sitting as a board, do themselves and what they leave to their administrative and other staffs will, I think, vary from board to board. In the case of the proposed Eastern Health Board, which will include Dublin, I am told that the experience of those on the Dublin Health Authority indicates that anything less than a delegation of the functions now given to the manager under the Management Acts could lead to difficulty. The smaller boards may not need such a widespread delegation to their administrative staff. I propose, before the boards are set up, to have a study made on the best administrative structure and administrative techniques for them, so that each board will have this available before they become responsible for operating the services.
At this stage, I would like to refer to another issue which has arisen in the Dáil and elsewhere — that is the possibility of having representatives of the administrative and other staffs of the boards included among the membership. This would be quite a novel departure in the field of health administration. An officer of a local health authority is by law debarred from becoming a member of it.
In relation to the health boards, I had already indicated that this rule could be set aside in the case of a doctor or other professional person who would be elected as a member of the board by the doctors practising in its area. It has been represented to me that this would be an unfair discrimination against the other staffs of the board, including the clerical and administrative staff and the manual workers. Accordingly, it has been proposed to me that these should be entitled to elect representatives to the board.
I have carefully considered this issue but I do not think that it would be desirable to make this change Firstly, the professional officers who might get on to the board will not be there as officers, but as doctors, dentists, nurses or pharmacists Secondly, administrative and clerical staff will be in a somewhat different position in the management hierarchy in the board and I do not think it would be right that, say, a staff officer working up to the chief executive officer in his administrative capacity should then, as a member of the board sit in judgment on the chief executive officer's actions, or the actions of any other member of the staff. Accordingly, in the passage of the Bill through the Dáil, no amendment of this kind was made.
I do agree, however, that it is important that the members of the staff at all levels should become involved in the generation of ideas on the better administration and operation of the services. Perhaps some form of joint council between the staff and the management would be the most appropriate thing for this. I intend that this should be studied in conjunction with the plan for the management of the new boards to which I have already referred. I think it is not necessary to make statutory provision in the Bill requiring health boards to establish such councils. I considered this but concluded that, as the success of such councils depends on the willingness of management and staff to go into them and work in them voluntarily, a compulsory statutory provision for their establishment would be psychologically unwise, at least at this formative stage.
The day-to-day operation of the services and the general planning of the future services will be in the hands of these health boards. They, therefore, will be the essential nuclei of the new health administration. However, as I have mentioned, there will be subordinate local councils under them and, above the health boards, it is intended that there will be, for larger areas, three regional hospital boards to coordinate the planning and development of hospital services. These are provided for in section 40 of the Bill.
The health boards will be responsible for the administration of the hospitals which are now owned by the local authorities. It must be remembered, however, that about 44 per cent of all the general hospital beds in this country are in voluntary hospitals, the ownership of which will not, of course, be affected by the Bill. Most of these voluntary hospitals are in Dublin, but they serve a region extending into the areas proposed for at least four of the proposed eight health boards. In the south there is a connection in medical teaching between Cork and the Limerick hospitals.
It is clear that none of the health boards could thus be entirely self-sufficient in the provision of hospital services and co-ordination must be exercised over wider regions. Hence, section 40 of the Bill provides for three regional hospital boards based in Dublin, Cork and Galway with functions, as section 40 states, "in relation to the general organisation and development of hospital services in an efficient and satisfactory manner in the hospitals administered by health boards and other bodies in its functional area which are engaged in the provision of services under the Act."
One half of the members of a regional hospital board will come from the health boards included in its area and the remainder will be appointed by the Minister as representing others involved in the provision of hospital services and in medical education. The co-ordinating function of these three bodies should be highly important. They will have devolved on them work now done in my Department and will take over much of the work of the Hospitals Commission. The regional hospital boards will play a large part in integrating the services of the voluntary hospitals with those of the health board hospitals by arranging for appointments of consultants with responsibilities in both types of hospital and by organising common services.
Section 40 of the Bill provides also for a body, to be known as Comhairle na nOspidéal, which, at the national level, will regulate consultant appointments, and thus the development of specialties, in the hospitals providing services under the Act. The proposal to establish this body was generated by the FitzGerald Report which pointed out that there is a danger of uncontrolled proliferation of specialties in the various hospitals which are, of course, under independent managements. It is highly important, both for the quality of the services and for ensuring the best use of resources, that there should be control on the creation of new specialties in hospitals and the appointment of new consultants. This will be the main task of Comhairle na nOspidéal.
It is expected that the comhairle will also become involved in selection processes for at least some of the consultants in the hospitals providing services under the Act. At present, consultants in local authority hospitals are selected through the Local Appointments Commission and those in the voluntary hospitals are selected by the hospital authorities or, where teaching appointments are concerned, by joint arrangements with the teaching bodies. The FitzGerald Report emphasised the desirability of having a common corps of consultants, under the regional hospital boards, who would serve in the different kinds of hospitals and who would be selected by common selection procedures. We must aim under the Bill to achieve this.
It will not be easy to arrange common selection procedures for consultants. Such procedures must have the essential features of those of the Local Appointments Commission but must also have regard to the traditions and requirements of the voluntary hospitals and the teaching bodies. I will ask An Comhairle, when they are set up, to give some priority to examining this issue.
I might sum up the essential functions in relation to hospital services of each of these bodies by saying that Comhairle na nOspidéal will control the disposition of specialties and the selection of consultants at the national level, that the three regional hospital boards will be the planning and co-ordinating bodies for the public authority hospitals and the voluntary hospitals and that the health boards will be responsible for administering services in hospitals, and for ensuring a satisfactory relationship between these services and the other health services.
The details of this division will arise more appropriately at Committee Stage, or indeed when, later on, the regulations setting up the various new bodies come before the House. I have told the Dáil that, at that stage, I will circulate an explanatory document setting out the functions of the different bodies so that Members of both Houses, those concerned with the operation of the services, and the general public will have a detailed picture of the general pattern of the new administration.
Lest what I have said should leave the House under the impression that the establishment of these new bodies will lead to a proliferation of public authorities concerned with health services, I would mention that, while 12 bodies will be established under the Bill, it will abolish 13. Included among those abolished will be the Hospitals Commission, the dissolution of which is provided for in section 41. Clearly, with the establishment of the new bodies proposed in section 40, the functions of the Hospitals Commission could not remain as they are now. The very important contribution which the commission make to the health services at present can in future be made by Comhairle na nOspidéal and by the three regional hospital boards. The staff of the commission will be absorbed into these bodies. It has been said in the Dáil, and I should like to repeat it here, that this decision does not imply any dissatisfaction with the way in which the functions which have been conferred on the commission have been discharged by them. Indeed I should like to take this opportunity to thank the chairman and other members of the commission and their staff for the contribution which they have made and are making to our health services.
The establishment of the new administration will involve the transfer of many members of the staffs of the present local authorities to the new bodies. Most of these will, I should expect, find themselves carrying on their duties much as at present, although working to a different and ultimate superior. I have had discussions with the organisations representing different classes of staff on the transfers and I am arranging to set up a special ad hoc joint council to help smooth over any difficulties which arise on the transfers.
I should now like, a Chathaoirleach, to refer to the provisions in Part IV of the Bill dealing with health services. My remarks on these will not go into great detail, as this will be more a matter for Committee Stage.
Essentially, the provisions in this part of the Bill on eligibility for services do not represent any departure in principle from the present law; each service will still remain available only for that group in the population judged to be unable to afford to arrange it from private resources. However, there are some significant changes. In the first place, the definitions of persons with "full eligibility", as referred to in section 44, will be determined on the basis of an assessment only of a person's own means and that of his wife. Secondly, the Minister will have power to lay down standards for assessments of eligibility under this section; at present, each local authority are a law unto themselves in this matter and there are fairly wide differences in the standards followed.
The definition of "limited eligibility" proposed in section 45 is a reenactment of the present definition of the classes entitled to the hospital services, but the new section does provide for flexibility in that the Minister will be able to make regulations varying the limits. Such regulations would be subject to approval in draft form by both Houses of the Oireachtas before being made. A new provision has been introduced by section 46 which will require that each decision on eligibility by an officer of a health board will be subject to an appeal.
The most important change in the services themselves which is provided for in the Bill is that referred to in sections 57 and 58. Under these sections, it is intended that a new general medical service will be brought in, offering choice of doctor to those entitled to use the service. The proposals for this service have been under negotiation with the Irish Medical Association and the Medical Union for some time in anticipation of this Bill. Agreement has been reached on most points in the frame-work of the new arrangements. It has been agreed.
that most doctors under the new scheme would provide their services on the basis of an agreement with the health board; that an eligible person would, subject to certain restrictions — mainly as to distance — be allowed to register with any participating doctor willing to accept him and would be allowed to transfer to another doctor after giving proper notice;
that persons could be assigned to a participating doctor where this was necessary;
that special arrangements would operate for group practices and partnerships;
that there would be control on entry by doctors into the service;
that future vacancies in the service would be filled by public competition;
that patients would normally be seen in the doctor's private premises, but the health board would have power to make accommodation in clinics or health centres available to general practitioners where appropriate; and
that special arrangements would be incorporated to keep doctors in remote areas.
It has been agreed too that special guarantees in relation to entry into the new service will be given to those now holding posts as permanent district medical officers.
As regards the method of paying doctors under this scheme, I have told the profession that I am willing to operate a fee-for-service system of payment, provided that it can be shown not to be excessive in cost. At the present time, the organisations are considering a memorandum which I have sent to them indicating what I think the level of charges should be and the basis on which they should be calculated. I hope it will be possible to complete negotiations on this soon.
In the meantime, negotiations have been held with the representatives of the retail pharmaceutical chemists and with the manufacturers, importers and wholesalers. Here again, I am confident that the final details of arrangements for the supply of drugs and medicines through the retail chemists can be completed fairly soon. In the meantime, practical preparations for the operation of this part of the services are in train. It is intended that pricing of prescriptions and calculation of payments will be done centrally through a computer — a system which should also give us invaluable detailed information on consumption of medicines and drugs.
The other changes made in relation to the services are, perhaps, in points of detail but many of them are highly important details. For the hospital services, changes are made in eligibility, so that free treatment for children of all income groups will be provided for specified diseases and disabilities of a permanent or long-term nature, such as mental handicap. Charges for out-patient services will be abolished and flexibility is introduced into the provisions for charges for in-patient services, so that these can be varied by regulations. Out-patient services, too, will be available for children of all income groups for specified long-term diseases and disabilities.
For the middle income group, a service will be introduced under section 58 whereby that group will be indemnified against meeting heavy expenditure on drugs prescribed by general practitioners. Under that section, a person who can show that he has spent a specified basic amount within a period will be entitled to claim a refund of the balance, or a part of the balance of his expenditure in that period from the health board. This will be in substitution for the present "hardship" arrangements for the supply of drugs to persons in that group, which operate unevenly throughout the country. A new provision is also introduced whereby drugs for long-term ailments will be provided free of charge for persons in all income groups. A scheme of this kind at present operates for diabetics and its extension to other long-term diseases is highly desirable.
A new provision is included in section 60 for a home help service. This provision will allow health boards to assist in the maintenance at home of persons who might otherwise have to receive hospital care. The way in which this assistance can be given is not specified in the section and it is sufficiently flexible to allow the health board either to pay for persons to act as home helps, to give grants to voluntary bodies doing this or to do whatever else might be necessary to assist persons covered by the section to stay at home. This is a highly important section. Basically it has a humanitarian purpose but it also has an economic objective of keeping sick and infirm people out of hospital in so far as that is appropriate and can be arranged.
Section 65, dealing with the child health services, provides for many of the changes recommended in the report of the study group on those services which was published in August, 1968. The section allows for child health services to be arranged, where this is thought desirable, in general practitioners' surgeries and it is intended that this will be done in rural areas. As far as the school health examination service is concerned, the section largely repeats that of the provision which it replaces. It is concerned only with elementary schools. The study group report referred to the possibility of extending this service to secondary and vocational schools at a later date. No provision has been made for this because such an extension on a comprehensive scale is a long-term project and cannot be envisaged until the service for elementary schools is brought up to an adequate standard. However, it has been pointed out to me that there would be an advantage in making some provision whereby pilot examination schemes could be operated in secondary or vocational schools and I may consider on Committee Stage an amendment which would allow such schemes to be operated.
Part V of the Bill contains a number of important provisions. I would draw particular attention to section 76. This was introduced on Committee Stage in the Dáil with the object of giving the Minister an interim power to control the possession of drugs with hallucinogenic or other undesirable effects, pending the enactment of a comprehensive Bill on drugs and medicines which, I hope, will come before the House in the present year. There is ample evidence that there is urgent need for a section of this kind.
Section 82 gave rise to considerable discussion in the Dáil. Under this section, responsibility for operating the home assistance service will be left with the local authorities. It was put to me that this was undesirable as that service is closely connected with the health services and that both should be operated by the health boards. Having discussed the issue with the Minister for Local Government and Social Welfare, I came to the conclusion that the best thing to do in relation to this service was to endeavour to arrange that the local authorities would, under section 24 of the Bill, delegate to the health boards the day-to-day operation of the home assistance service. In this way, the local authority would maintain budgetary control and responsibility, which is important seeing that the whole cost of the home assistance service is met from the rates. I am initiating with the Department of Social Welfare and the local authorities the steps necessary to make arrangements on these lines. I should mention, however, that the whole future of the home assistance service may be thrown into the melting pot in the future in a general review of assistance services to be undertaken by the Minister for Social Welfare.
I have not, in this introductory statement, endeavoured to deal with all the changes proposed by this Bill: I have but selected the most important. I think it will be quite clear from what I have said, however, that it proposes many important and desirable changes in the health services and their administration. I commend it to the House for a Second Reading.
Before concluding, I should perhaps give the House an outline of the programme which I have in mind for the implementation of this Bill, on the assumption of its being enacted in the near future. I would propose to initiate the necessary statutory discussions with the local authorities to finalise the details of the new boards immediately on the enactment of the Bill. Simultaneously, steps would be initiated under section 12 to recruit the chief executive officers. I should hope to put the detailed regulations on the new administration before the Dáil and Seanad for approval before the summer recess. This would permit of the establishment of the boards by October. However, I would not envisage giving the health boards operational functions in the health services until 1st April, 1971. This would permit them to settle down and to plan for the changes in the services. I would expect that most of the changes in the services would also come into effect on 1st April, 1971. The other steps required for the full implementation of the Bill would also be taken in accordance with a detailed programme on this basis which I have prepared.