I move:—
That a sum not exceeding £21,757,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1968, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Árd-Chlaraitheóra), and certain services administered by that Office, including Grants to Local Authorities, miscellaneous Grants and a Grant-in-Aid.
I am grateful to the House for facilitating me in taking, in conjunction with the main Estimate of my Department for the coming year, the Supplementary Estimate for the present year.
I have arranged to circulate to Deputies, tables on the more important statistics which may be of some assistance to them in considering these Estimates. I intend to make only brief comment on some of the more salient points which arise from the consideration of mortality and morbidity statistics.
The number of mothers who died in childbirth in 1966 was 19, an increase of one on the previous year, while the number of deaths of infants under one year of age in 1966, at 1,546, showed a drop of 58 compared with the previous year.
Deputies will have observed from the circulated tables that of the 34,725 deaths in 1966, a total of 16,851, or almost 50 per cent were caused by heart disease and cancer.
The provisional figure of deaths from respiratory tuberculosis, at 306 in the year 1966, is an increase of four on the previous year. The position in respect of this disease improved quite dramatically in the past 15 years—in 1952, for example, 1,207 deaths from that cause were recorded. There are, however, still far too many new cases of the disease occurring each year. In each of the years 1965 and 1964 over 2,000 new cases were discovered, which indicates that the incidence of the disease is still such as to give us cause for some concern. In this regard, I might say that it is very regrettable, indeed, that there are far too many people who do not avail themselves of an annual X-ray examination. Could I make a strong appeal now to the public about this? Prevention is not merely better than cure; it is quicker and cheaper too.
While I am on the subject of people not making use of the free services which are available to them to protect their own and the community's health, I would like to say that I am most seriously concerned at the fact that in the years 1962, 1963, 1964 and 1965, only 47 per cent, 53 per cent, 56 per cent and 49 per cent respectively of the target figures for pre-school children was achieved under immunisation schemes against diphtheria provided by health authorities. This continued failure to come within reasonable distance of the target figure is very worrying, particularly because each year's failure means that the proportion of the population at risk is rising. Health authorities have been asked to make a special effort to bring home to parents their responsibilities to protect their children against this disease.
Against this rather gloomy picture in regard to diphtheria immunisation, it is heartening to find that of the million or so people in the age group recommended for the new oral vaccine against poliomyelitis in the recent campaign, 77 per cent took the full course of three feedings, 84 per cent took two feedings and 88 per cent took one feeding. Incidentally there was only one recorded case of poliomyelitis in 1966.
A major problem facing the community is the provision of proper care for the aged. I am fully committed to the view that it is preferable, where at all possible, to keep old people in their own surroundings. The primary aim must, accordingly, be to provide such services as will enable old people to remain in the community, and to avoid the necessity for institutional care, so far as this can be done. To achieve this a wide range of community services must be provided.
Ideally, a truly comprehensive community service would supply medical care, domiciliary nursing, physiotherapy and chiropody on an out-patient and domiciliary basis; the supply of equipment, such as rubber sheets, bed rests and other aids to home nursing; financial assistance; help in housing; home helps; meals; fuel; laundry services; social clubs; home visiting; help in shopping; advice regarding nutrition and hygiene; and last, but not least, readily available information to the aged, and those interested in their welfare, about all the different services available.
I do not suggest, of course, that every old person would need to be assisted by the provision of all these aids and services; but I mention them as, so to speak, an aggregate list of all that a first class community service for old people could be called upon to supply. The public authorities can do a great deal for the aged; but there are many directions in which a public authority, or indeed a Minister or a Government Department are powerless to help. A public authority or a Minister can supply medical and nursing care, or social welfare benefits or domestic nursing equipment; but, in the provision of the day-to-day help of kindly, neighbourly services these authorities cannot do what only the good neighbour can do. What I mean here is that in any locality— be it urban or rural—there must be developed a sense of responsibility towards our old people, and an impelling urge to care for them. A locality service — given by the spontaneous charity of the old person's near neighbours, or promoted by a parish organisation, or by the clergy or religious, or by voluntary organisations—is what is needed to alleviate the loneliness of the old person, to provide the important little personal services needed by him, and to give that invaluable touch of warmth and humanity which only true charity can supply, and only a lonely, fearful old person can fully appreciate.
Health authorities have been urged to improve and develop their services for the aged, and many health authorities have, indeed, been most active in dealing with the problem, and are providing a commendable service.
The well-established voluntary bodies, such as the Society of St. Vincent de Paul, the Legion of Mary and the Irish Red Cross, and the various religious orders, have always helped the aged as part of their charitable activities and have increased their efforts in recent times. A heartening development has been the emergence of a large number of voluntary organisations throughout the country, whose sole purpose is to care for the aged, demonstrating the growth in public awareness of, and interest in, this problem. I have endeavoured to foster this most praiseworthy voluntary effort by encouraging health authorities to make grants under section 65 of the Health Act, 1953, to help to finance the activities of the various organisations. There is room, however, for much more effort on the part of the public in this sphere. There is evidence of a rising tide of consciousness of our duty to others. We can, all of us, perform a most useful Christian duty by helping our aged in a practical way. I appeal, therefore, to the public to extend their efforts—by working in with those already in the field, or by setting up local bodies or committees to help the aged.
We have a number of examples of what can be done by local effort, based on individual charity, and co-ordinating the work of individuals and religious and voluntary agencies.
Most Deputies will, I imagine, be aware of the social experiment being conducted in Kilkenny. The Kilkenny Social Service Council caters, of course, not alone for the aged but for all those in need. The service it is providing for the aged is outstanding. Here, all the different charitable organisations in the area have come together, under one co-ordinating body, which works in full co-operation with the health authority. In Dublin, where a great number of different organisations work for the aged, the establishment of the Dublin Council for the Aged has brought a large number of them together and the active participation of officers of the health authority in the work of the Council has ensured that the necessary co-operation with that authority exists. Similar programmes are being developed in Cork, Galway, Limerick and Waterford. In Carlow and Kildare, the operation of a domiciliary assessment and screening service of all old people before admission to an institution, backed by good community services provided by the health authority and voluntary organisations in co-operation, has led to a noticeable drop in the number of admissions to institutions. Other areas which are particularly active are Tipperary, Wexford, Offaly and Westmeath.
No matter, of course, how good community services are, there will still be a proportion of the aged who will require institutional care. I am very conscious of the need to improve accommodation for the old in county homes, and I shall refer later to the progress already made and the further progress planned in this direction.
During the past year, the Inter-departmental Committee which is representative of my Department and the Departments of Local Government and Social Welfare, has been carrying out a survey of all the various services, public and voluntary, provided for the aged. The committee expects that it will soon be able to let me have its recommendations as to how these services might best be developed, and co-ordinated in the future.
A service which is of particular importance to community care—including, of course, the care of the aged —namely the district nursing service, is being expanded with all possible speed. Health Authorities generally have adopted the recommendations of my Department for the appointment of additional public health nurses, and for the improvements in the conditions of service of the nurses.
The first of the series of training courses being held by An Bord Altranais for recruits as public health nurses will finish at the end of next month, and arrangements are in train for the holding of two or, if possible, three further courses within the next year. As 35 nurses attend each course there should be quite an appreciable addition to the number of fully qualified and trained public health nurses, within the next 12 months. The courses will continue until the service has been brought up to the required strength.
The appointment of superintendent public health nurses to supervise and co-ordinate the work of the district nurses is proceeding in a number of health authority areas where the number of nurses on district nursing duties would warrant such an appointment.
In the provision of domiciliary nursing services, health authorities continue to have the assistance of the nurses employed by district nursing associations and the Lady Dudley Scheme. Successive Ministers for Health have praised the contribution which these voluntary associations have made to the development of our nursing services, and I am very glad to have this opportunity of adding my own tribute to the valuable work being done by them. Health authorities will continue to avail themselves of this help to the greatest possible extent.
As the House is aware, the Commission of Inquiry on Mental Illness has reported to me. Arrangements are being made for the printing of the Commission's Report, and I expect that it will be published shortly.
The population of our district mental hospitals at the 31st December last, was 17,046, a decline of 538 in 12 months. There has been a steady, and satisfactory decline year by year in this figure—only eight years ago mental hospital patients numbered just over 20,000. A contributing factor has undoubtedly been the increasing emphasis on domiciliary and out-patient care and the development of out-patient psychiatric clinics, attendances at which have increased from 4,732 in 1958 to 91,077 in the last financial year.
In the past year a start has been made on the re-organisation of psychiatric services in the Dublin area. This aims at establishing a comprehensive psychiatric service, to include everything from out-patient diagnostic service right through to full hospital care, and after-care services in the community. The re-organisation includes a teaching and training programme for medical personnel, aimed at producing for our psychiatric services throughout the country fully trained and competent psychiatrists. An organisation to conduct research into psychiatric illness is also envisaged. A special programme of care is being planned for the adult mentally handicapped who, until special institutions are provided for them, are being maintained in Dublin Health Authority's psychiatric institutions, and it is proposed to extend further the psychiatric services for children.
During the past year, Dublin Health Authority opened a day centre for emotionally disturbed children at St. Kevin's Hospital. The centre will complement the work already being done for this type of child in the children's unit of St. Loman's Hospital, County Dublin. Work will start soon on a pre-adolescent unit, in which continuing care will be provided for some of the patients in the children's unit in St. Loman's Hospital. Notwithstanding these developments, I am very conscious that the needs of children suffering from psychiatric disturbances are not yet being fully satisfied, and that a provincial centre for such children must rank as a high priority project.
Arrangements are well advanced for the establishment of active treatment psychiatric units at St. Stephen's Hospital, Sarsfieldscourt, Cork, and at St. Fachtna's Hospital, Skibbereen, County Cork. Those units will play an important part in the development of a comprehensive mental health service in the Cork area. New admission and treatment units will open shortly at Clonmel and Castlebar.
Over the past two decades, there has been a notable improvement in the standard of care provided at, and from our mental hospitals. I am confident that the high standard which has been achieved will be maintained and, indeed, bettered. I am not, however, satisfied with the standard of accommodation in our mental hospitals. I know that much has been done to improve our hospitals structurally, but parts of many of these buildings are still very sub-standard as regards heating, lighting, sanitary accommodation, etc. I intend to ensure that in the coming years, money will be allocated, to the full extent that our resources permit, to schemes for improvements in our mental hospitals.
The care of the mentally handicapped is, I am glad to say, also an area in which there is considerable valuable community endeavour. As Minister for Health, my principal immediate objective in the field of mental handicap is to supply the pressing need for residential care for severely and moderately handicapped children. Quite good progress is being made in this problem, and a further substantial amount of accommodation for these children will be provided over the next two years.
The total number of places in the residential institutions for the mentally handicapped at the end of December last, was over 3,600. This represents an increase of about 200 beds over the past year, and nearly 500 over the past two years. Already since 1st January, a further 20 beds have become available at Stewarts Hospital, and an 80-bed unit at St. Vincent's, Lisnagry, is practically completed. Further extensions are in planning, at St. Vincent's, Lisnagry (40 beds); St. Raphael's, Celbridge (50 beds); St. Mary's, Delvin (20 beds); Moore Abbey, Monasterevan (30 beds), and I have offered the Cork Polio and General After-Care Association grants to provide extra accommodation. In addition, I have arranged that certain institutions, which had been used for other purposes, will be converted for the use of the mentally handicapped. These include the former sanatoria at Roscrea and Macroom, the fever hospitals at Ennis and Carndonagh, and a further unit at Peamount Sanatorium. The former industrial school at St. Patrick's, Kilkenny, has already been changed over to the care of the mentally handicapped. Nor is that the full story. Other possibilities are at present being investigated and, as I have already indicated, it is my hope that the next two years will see a very great easing of the problem of residential care for the severely and moderately handicapped.
The development of day services for the mentally handicapped is also progressing. During the year, day centres were opened at Kilkenny, An Uaimh, Carrickmacross, and at Ballymun, Dublin. The planning of centres in a number of other areas is in progress.
The report of the Commission of Inquiry on Mental Handicap has been of considerable assistance to my Department. A White Paper outlining, in detail, the long-term Government proposals in this area will be published shortly.
The general improvement of maternity services, resulting in fewer birth injuries, and the further development of the recently introduced phenylketonuria service should result in a decrease in the number of new cases of mental handicap arising.
In the field of drug control, a National Drugs Advisory Board was established during the year, under the Health (Corporate Bodies) Act, 1961. The Board will be responsible for organising and administering a national service for obtaining, assessing and disseminating information as regards the safety of drugs. It will be concerned with ensuring that new or reformulated pharmaceutical preparations are not marketed here, except after consultation with it, and it will advise me on other matters, such as a scheme of quality control of pharmaceutical preparations.
Comhairle na Nimheanna, the statutory Poisons Council, in June, 1964, made far-reaching recommendations for control of the storage, transport, distribution, supply and sale of poisons. The practical application of these recommendations is not an easy one, and my Department has been examining it. Considerable progress has been made, but I am not yet in a position to say when a comprehensive code can be evolved. I might mention, however, that as a first step in giving effect to the Comhairle's recommendation I have recently made regulations, which came into operation on the 2nd January last, bringing up-to-date and extending the list of preparations which may be sold only through retail chemists, and on the prescription of a doctor, dentist or veterinary surgeon.
We have seen in the newspapers a good deal of comment on the increase in drug addiction in Britain and the USA. The information so far available here would indicate that there is not abuse in this country, to anything like the same extent, but I am watching the situation very carefully and I can assure the House that I will seek additional powers, should this be necessary.
Deputies will be aware of the statements in the public press of alleged shortcomings in the ambulance and accident services. All such complaints are investigated by my Department and, for the most part, it has been established that the press statements to which I refer are incomplete and misleading.
Independent of these investigations of specific instances, during the peak holiday period of 30th July to 12th August last, my Department undertook an investigation aimed at checking the effectiveness of the service in responding to accident calls. The findings revealed that out of 602 calls received, the ambulance left to deal with the accident within five minutes of the call in 577 cases. In most of the remaining cases the ambulance left its base within ten minutes of being called. In only two instances could it be said that there was undue delay in getting an ambulance under way.
Steps were taken during the year to improve the services. My Department has arranged a series of courses of training in first aid for ambulance drivers and, in co-operation with the Irish Medical Association, a pilot scheme is being introduced shortly under which, for a trial period, accident cases occurring at night in the Dublin area will be routed to a selected number of Dublin voluntary hospitals in which special arrangements for the care of such cases are being made. The details of these special steps have already been announced in the public press and I do not feel that it is necessary to occupy the time of the House by elaborating on them. I mention them to disabuse unbiased critics of the feeling that nothing is being done by my Department to improve the service.
The House is already aware that, with the co-operation of all the Dublin Voluntary Hospitals, a Hospitals Joint Services Board was set up some time ago for the central supply of sterile goods for use in hospital theatres and wards. I am happy to state that this Board has now commenced the supply of these goods. When the scheme is in full operation it will put us well in the forefront of developments aimed at easing the burden on the hospital service by relieving it of such ancillary services as can be more efficiently and economically developed in a single centre serving many hospitals. With the agreement of the hospitals, the Board is also planning the provision of a joint laundry and linen service for the Dublin hospitals and it hopes that the construction of the necessary premises will be completed early in 1968.
The hearing aid service operated by the National Organisation for Rehabilitation, on behalf of health authorities, continues to function satisfactorily. The staff has been increased and some of them visit different parts of the country periodically to fit hearing aids and to provide an educational advisory service for the parents and teachers of children with impaired hearing. I am examining the possibility of extending this hearing aid service, as soon as circumstances permit, to persons in the middle income group.
The health services, like everything else, have their defects. One of these, in particular, is causing me considerable concern. The dental services in most areas are unsatisfactory. Services for those entitled to free treatment at present—that is, children attending child welfare clinics, national school children, and medical card holders— are mainly provided by full-time public dental officers, whose efforts are supplemented to a limited extent by the employment of private dentists on a sessional basis. The main obstacle encountered by health authorities in recent years, in their efforts to provide a satisfactory service for the eligible classes, has been the difficulty of recruiting, and retaining, dental surgeons. At the moment, 25 dental posts are vacant out of a total of 117. The difficulty of recruitment was due to some extent, I believe, to the unattractive salaries offered, but as a result of a recent agreement at conciliation between the managers of health authorities and the Irish Dental Association, increased salary scales, which, I hope, will be adopted by health authorities, have been approved. This should result in the filling of some of the posts currently vacant. In addition, a number of new dental posts will be approved in the near future for areas that are greatly understaffed at present, so that, in general, there should be a gradual improvement in the public dental service in the coming year.
A fully satisfactory service, available without delay, for all those currently eligible for dental services, cannot, however, be provided without utilising to a greater extent than at present the services of dentists in private practice. The provision of a service in this way would be costly and, before it could begin, it would be necessary to conduct detailed negotiations with the Irish Dental Association. I intend to arrange shortly for such negotiations so that, as the economy expands and more funds become available, we may be in a position to improve the service in this way.
We must, however, recognise that dental decay is so prevalent throughout the community that treatment measures alone will not suffice to bring it under control. Preventive measures are necessary if we are to have any hope of coping with this problem and, now that public piped water supplies are being fluoridated, the amount of dental decay in children should decrease markedly in the coming years. The water supplies in Dublin, Cork, Limerick and Waterford, and in seven towns are already fluoridated. Arrangements to fluoridate many other supplies are well advanced and I expect that a further 40 areas or more will have fluoridated water within the next 12 months. This will mean that, at the end of that period, the number of people using fluoridated water will rise from 950,000 to approximately 1,200,000. The Estimate contains a special Subhead for recouping the capital cost of fluoridating these supplies.
I should like to report to the House on the present position in the development of the specific proposals for major changes in the health services contained in the White Paper published last year.
I should first say that the White Paper dealt not only with such radical subjects as the introduction of a choice of doctor in the general medical service, and of regional administration of the services, but also with the whole range of the services and with several improvements in detail in them which are considered necessary. It will be clear from what I have already said that there have been many such improvements in the last year, and that these improvements will continue at ever-increasing cost to public funds. Thus, in the last year, we had the raising of the income limit for hospital and specialist services, and maternity services, from £800 to £1,200 a year, with a corresponding adjustment for farmers, and the arrangements for the expansion of district nursing services.
At no time was it suggested, however, that the introduction of choice of doctor and the other radical changes could have been brought in by now. It was made quite clear in the White Paper, and by my predecessor in introducing the debate on it in the House on 1st March, 1966, that it represented a pattern for the future, long-term development of the health services, and that each proposed development could only come into effect when the money was there to pay for it. When, as will be seen from the Supplementary Estimate for this year, and the estimate for next year, expenditure in the latter year on the existing services will be about £5½ million more than it was in 1965-6, it is not possible to secure much more money for radical developments in the services at present.
The detailed preparatory work for the introduction of the major changes when the necessary funds are available is, however, progressing steadily. One of the first steps which I took after my appointment as Minister for Health was to arrange for discussions with local health authorities on the proposals in the White Paper. Thus, from September to early November, I visited all the health authorities in the country, with one exception, to discuss the proposed changes. In this concentrated tour, I heard the views of over 300 local councillors and these views gave me plenty of food for thought.
The local opinions expressed on the proposed substitution of a new general medical service for the dispensary service were particularly interesting. I have had an analysis made of the views expressed on this by the 168 local councillors who spoke on it. Of these, 65 were unequivocally in favour of choice of doctor, 50 expressed themselves in favour of choice but had reservations about rural areas, 12 advocated choice within the dispensary system, and 41 were either against, or doubtful, about changing from the dispensary system at all. I found the variation in the views thus expressed most interesting and significant. While it is clear that the majority of local authority representatives accept that there should be choice of doctor, where this is practicable, I think the large number of reservations about changing the dispensary system indicates a genuine volume of unease at how the rural areas might fare, if we were to make a radical change from that system without fully considering its implications for those areas. After the completion of my tour of the local authorities, I remain fully committed to the principle of introducing a choice of doctor where this is practicable, but I am extremely concerned to ensure that, whatever we do, will not leave those living in rural areas with a service inferior to what they have at present.
This was the basis of my directive to my Department in the further development of the scheme for altering the general medical service and, I might say, my attitude on this was confirmed in December by a resolution received from the National Health Council which, while approving in principle of choice of doctor as outlined in the White Paper for all areas where possible, recommended "that there should be a subsidised doctor or dispensary system in remote rural areas; that to attract doctors to remote areas a promotional outlet in this system must be provided; that pilot schemes in selected rural and urban areas should be undertaken before the system is adopted in the whole country and that doctors should, before being admitted to the choice of doctor system, be required to have a certain minimum post graduate training; and that existing dispensary district boundaries should be examined".
In accordance with my directives, my Department have been engaged on a detailed survey of the actual position as regards general medical practice, both by private and by dispensary doctors, which exists in representative areas. Detailed maps have been prepared showing the location of doctors and the distribution of population, and an exercise is being carried out to estimate what the effect in each area would be if the dispensary district boundaries were abolished and choice of doctor were introduced. The object of this exercise is to get a clear picture of the circumstances in which salaried doctors might be needed in rural areas, the conditions under which they, and other doctors, would participate in the scheme, and the details of the arrangements which might be needed for other areas—such as the cities, the towns and the hinterlands of the towns. I do not intend that this study should be a paper exercise only, and am arranging that my Department will discuss the detailed picture for a selection of representative areas with the officers of the local health authorities concerned.
When, on the result of these studies, I have made provisional decisions on the detailed application of the White Paper policy in this field, I will have a memorandum sent to the Irish Medical Association and the Medical Union with a view to negotiating with them on the details of the proposal and on such questions as the method of payment of doctors. I should hope that these negotiations can commence in a few months time.
I would emphasise that what I have said does not represent any retreat from what was written in the White Paper on the alteration of the general medical service. Paragraph 45 of the White Paper clearly recognised that, "on the discontinuance of the dispensary system, special steps would be necessary to retain doctors to provide a service in some of the more remote areas and allowances to supplement the standard payments would be offered to doctors in such areas." That paragraph also envisaged the retention of some dispensary premises for renting to doctors for adaptation as general surgeries. What we are now engaged on is the detailed application of that paragraph and I am paying particular attention to it in the light of the views expressed by local representatives and by the National Health Council. There is no question, however, of a reversal of the Government's policy as set out in the White Paper that there should be a choice of doctor in the general medical service where that is practicable. Neither is there to be any departure from the policy that in organising the new service there should be the least practicable distinction between private patients and those availing themselves of the service.
In the meantime, the dispensary system must be retained and in this respect I have to confess to some unease as to the number of posts in that service now filled temporarily. I can quite understand that this is unsatisfactory to the profession, but I should hope that, when I have gone some way in my discussions with them on the revised service and the picture of that is clearer, we may be able to proceed to fill again on a permanent basis at least some posts, on the understanding that the holder would become absorbed into the new service when it is established. That, however, is a proposal which I would need to discuss in detail with the profession before deciding definitely if effect could be given to it.
The White Paper referred also to the possibility of arranging for the supply of drugs under the general medical service through retail chemists. My Department has had general discussions on this proposal with representatives of the retail pharmacists and of the manufacturers and wholesalers of drugs. A number of matters need to be clarified, but I expect to be in a position to make a definite policy decision on this, more or less in step with the decisions which will be taken following the discussions with the doctors.
The other major proposal in the White Paper is for the transfer of the administration of all the health services from the present local authorities to new regional boards. Many local councillors expressed themselves as being against the idea. I have not been convinced, however, that we should abandon the proposal in the White Paper for establishing these boards, which would be made up of persons appointed by the Minister for Health— these would include doctors and other professional people—and members elected by the county and county borough councils for their areas. I think that the general case argued in Part V of the White Paper for setting up these boards is unanswerable and that, particularly as far as hospital services are concerned, a wider unit of administration than the county is essential if we are to progress towards having a more logical and effective pattern of health services in this country.
I can appreciate loyalty to the tradition of the county as a social, sporting and political entity, but we must not blind ourselves to the fact that for the practical operation of many health services county boundaries are awkward and unsuitable. The aim is to provide the best and most convenient service for everybody and I am convinced that we can achieve this only if we have regions, each of which will contain a number of counties, or parts of counties.
The House will, of course, be aware that new legislation will be needed to make this change to regional administration. It is my intention to introduce this legislation so that it can be discussed and enacted this year. This legislation will also make the several other amendments of the present law which will be required to give effect to many of the changes mentioned in the White Paper. These will include the enabling provisions for regulations specifying more clearly than at present the group entitled to the general medical service, the establishment of more formal provisions under which those in the middle income group can get assistance in the purchase of drugs and medicines, the abolition of charges for out-patient specialist services, the doubling of the maternity cash grants and provision to allow health authorities to arrange programmes for screening for symptoms of diseases specified in regulations. I have considered the possibility of separate, earlier legislation to deal with at least some of these changes, but I am satisfied that it would be better that one Bill should cover all the legislative changes needed for giving effect to the White Paper.
This then is the stage reached in the development of the White Paper proposals—a stage where, having made many practical improvements in the health services in the past year, we have also made considerable progress towards the detailed evolution of the new pattern. It is my intention to see that this progress is not halted and that the development of our health services will continue to the limit of the resources in money and personnel which will be available.
In a rather intemperate speech on the health services made by Deputy Ryan recently in Mayo, among many other sweeping statements he said that: "No advance can be made in health services in this country until there is a basic change in the whole approach to them." I think that I have given here today enough concrete examples of progress to refute this sweeping generalisation, and others with which the Deputy's speech abounded.
In explaining the details of the Estimates now before the House, it is necessary for me to refer first to the amount which the House provided in March last for the services of the current year. The total of the Estimate then submitted was £17,337,000, and I now find it necessary to seek an additional sum of £2,470,000. This very large deficiency arises under the heading of Grants to Health Authorities, and it reflects two things, an unexpected and unprecedented rise in the revenue expenditure of the health authorities, and the operation of the arrangement under which for the current year, the rates have been relieved of the burden of health costs in excess of those falling on the rates for the year 1965-66.
The original Estimate for the current year was based on a projected expenditure of £31,255,000 by health authorities. This was the total of the estimates supplied to my Department by health authorities in October and November, 1965, but statements furnished towards the end of 1966, show a total figure of £33,760,000, an increase of £2½ millions. In order that the rates should be relieved of any part of this added burden, it must be borne on the Vote.
The principal causes of the increase are the improvements in the pay of large numbers of health authority staffs, and the reduction of the working hours of hospital staffs, mainly nurses. Of the £2½ millions increase it is estimated that £1,075,000 is attributable to these factors. The cost of medicines, both in the hospital services and the general medical services, also continues to show a steep rise which accounts for about £300,000 of the increase in requirements. The running expenses, other than remuneration and drugs, have risen by about £300,000 beyond the levels provided in the original Estimates. These include building maintenance, heat and light, and food, and, of course, the increased expenditure reflects a degree of improvement of standards. Allowances to disabled persons show an increase of £120,000, due to the increased rates which came into operation on 1st November, 1966, and also an increase in the number of recipients. Payments to voluntary institutions, in respect of patients receiving services under the Health Acts, are greater by almost £200,000 than was envisaged when the original Estimates were prepared.
Of the total increase in the expenditure of health authorities, one half must be met by way of grant in accordance with the Health Services (Financial Provisions) Act, 1947, and the balance must be met by way of supplementary grant, in order to maintain in the current year the "freeze" of the local rates. The issues within the financial year amount to 95 per cent of the total estimated grants, and the additional provision now sought is accordingly £1,190,000 to cover normal statutory grant, and £1,075,000 to cover supplementary grant. It is necessary also to provide an additional £215,000 for balances of grant payable in respect of the year 1965-66, arising from the fact that the final accounts of the health authorities received after the close of the year, show that the interim statements, on which the original provision was based, fell short of actual expenditure. The predominant cause was the upward revisions in the previous year of the pay of certain health authority staffs, much of which involved considerable retrospective payment.
The total of these increases in grants to health authorities is £2,480,000, against which may be set a relatively small saving of £10,000, which leaves the net supplementary requirements at £2,470,000.
To turn now to the Estimate for the year 1967-68, I have to seek a total sum of £21,757,000 which represents an increase of £1,950,000 over the total 1966-67 requirements, including the Supplementary Estimate. Here, again, the predominant factor is the rising levels of expenditure by health authorities, which for the next year is estimated at £36,500,000, an increase of approximately £2¾ millions over the current year. Again salaries and wages of health authority staffs are the greatest single factor, showing an increase of £1,270,000 as compared with the revised figure for the current year. The reduction of the hours of work of nurses and other employees involves the recruitment of additional staff which will be fully reflected in the 1967-68 costs, but only partly in the costs of the current year. This, combined with staff increases to improve standards, especially in mental hospitals, accounts for much the greater part of the increase.
The estimated amount to be paid as allowances to disabled persons shows an increase of £200,000, due to the operation for the full year of the increases in rates of allowances effective from 1st November, 1966, and to a continued increase in the number of recipients.
The estimated expenditure on medicines shows an increase of £155,000. This is not as great an increase as has been recorded from year to year, in recent times. Nevertheless, the steep continued increase under this heading is engaging the attention of my Department.
The costs of institutions conducted by health authorities, apart from costs of salaries and medicines, are estimated to rise by £350,000. This is due in part to a very desirable up-grading of standards, especially in accommodation for the aged and chronic sick, but it also reflects a rise in the cost of goods consumed in the institutions.
Additional accommodation in voluntary hospitals, mainly as a result of the opening of the new Coombe Hospital, together with a continued increase in the rate of occupancy in extern institutions generally will, it is estimated, involve an addition of £390,000 to the expenditure of health authorities.
An estimated increase of £370,000 in a miscellaneous group of services including child welfare, ambulance and administration makes up the £2¾ millions by which the 1967-68 expenditure is estimated to exceed that of the current year.
Deputies are aware that the special undertaking regarding the "freeze" of the amount to be met from rates applied to the year 1966-67. This was set out in the White Paper on the Health Services and their Further Development. In respect of the year 1967-68, in the absence of further special arrangements, the Exchequer grant would be the statutory one, which provides for recoupment of one-half of the revenue expenditure on health services. As has already been announced, however, the Government has decided to continue to provide supplementary grants so as to cushion the rates against rising costs. The grants available to health authorities in respect of next year will accordingly consist of the normal 50 per cent grant, a supplementary grant equal to the amount of supplementary grant payable in respect of the current year, and a further grant allocated according to the capacity of each rating area to meet its share of the cost of the services. On the basis of estimates furnished to my Department by health authorities amounts of supplementary grant which will be payable have been calculated and notified to each authority. The amount which will be contributed by the Exchequer in the year over and above the amount of the statutory contribution, will be £2 million of which 95 per cent or £1,917,000 will be paid within the year. , As I have said, the basis of the provision, which I have included in this Subhead, to enable me to pay these grants is information supplied to my Department by the health authorities themselves in the form of estimates of health expenditure which in the aggregate showed an increase of £5½ millions over the 1965-66 figure. There may be instances in which individual health authorities have to provide for liquidation of adverse balances brought forward from previous years, and, naturally, the Exchequer cannot be expected to make good such deficiencies. However, on the basis of the health authorities' estimates as furnished to my Department in respect of the services of the year 1967-68, I have so allocated the supplementary grant that in the areas where capacity to meet further charges is most limited, the increase in the rate necessary to meet health costs in 1967-68 should not exceed 9d. in the £. In the areas more favourably placed as regards capacity to bear the costs, the rate increase for health purposes should in all but a few cases, be not more than 1s 3d. To achieve this degree of relief of rates, the Exchequer, as I have already mentioned, is assuming a liability of more than £2 million over and above the normal 50 per cent statutory grant.
There are some aspects of the trend of costs of the health services on which I should like to comment. The total revenue expenditure of health authorities in respect of the year which ended in March, 1965 was £27.8 millions. As I have explained the expenditure for the year commencing 1st April next is estimated at £36½ millions. The increase in the period is thus approaching £9 millions, or 30 per cent. The causes of this increase, of course, include improvements of services, additions to institutional accommodation and extension of the limits of eligibility for institutional and specialist services; but to a very considerable extent the growth of the cost is attributable to increased remuneration of staffs and, more recently, reduced working hours. Staff costs have, in fact, now reached the point where they constitute more than 62 per cent of the total costs of health authority institutions. I do not suggest that improvements in the conditions of employment were not justified; but I would point out that the possibilities of further improvement and extensions of our health services must depend substantially on the optimum use of the present manpower and equipment. Any avoidable duplication of services, particularly institutional services, is a waste of scarce and expensive skills, as well as a waste of capital equipment, and, therefore, a dissipation of resources which could be used towards development of the services.
Capital expenditure on hospitals during 1967-68 is expected to be about £3.6 millions, of which about £2 millions will come from the Hospitals Trust Fund, supplemented by a grant-in-aid from the Exchequer of £1 million, and the balance from the Local Loans Fund, and other sources. The programme to be financed in this way —as Deputies will see from the statement I have circulated—includes new or improved medical, surgical and maternity facilities, accommodation for the mentally ill, for the mentally handicapped and for the aged in need of institutional care. Work on some of the projects included in this programme is already well advanced. It is expected that the new Coombe Hospital in Dublin will be opened for patients in the very near future. This new 265 bed maternity hospital will be a valuable addition to the hospital services in the Dublin area. It will provide 156 maternity beds, 58 gynaecology beds and 51 paediatric beds—almost double the accommodation in the old Coombe Hospital. Progress on the new St. Vincent's Hospital, at Elm Park, Dublin, is such that most of the building work should be practically completed by the end of 1967. This new general teaching hospital will provide some 450 patient beds, as well as the usual ancillary facilities.
To complement and supplement the community service for the care of the aged, a special effort has been made to improve the accommodation for old people, who cannot be looked after in their own homes. Major reconstruction and improvement schemes in progress at Athy, Castlebar, Castleblayney, Clonakilty, Ennis, Longford and Trim will provide accommodation well up to modern standards for about 1,300 persons. Further schemes which will commence in 1967-68 at Carrick-on-Shannon and Roscommon and, in completion of works carried out over the past few years, at Stranorlar, will provide accommodation of similar standard for 370 persons.
A number of other schemes have reached an advanced stage of planning, and are expected to get under way during the year, for example, staff accommodation at Nenagh County Hospital and at the North Charitable Infirmary, Cork.
A major extension, for 100 additional patients and 21 staff, is in course of construction at Sligo County Hospital. It is expected that the new extension will be opened next year. Planning of the new county hospitals at Wexford and Tralee is going ahead, and preparatory work on the planning of the new regional hospital and dental hospital at Cork is proceeding.
Following submission of a report of a group, consisting of members of the Board of the hospital and officers of my Department, on the accommodation to be provided in the new St. Laurence's Hospital, the medical authorities of the hospital are at present carrying out a more detailed examination of the functions and requirements of each Department of the hospital.
The position in regard to the building of a new hospital by the Federated Dublin Voluntary Hospitals is that the Federation have appointed a project team to report on the existing hospitals, on the site proposed for the new hospital and on the extent of the facilities to be provided in the new buildings. I understand that the report of this study, with the views of the Federation, will be available fairly soon.
The rapidly-rising cost of hospital building makes it imperative that all reasonable economy should be secured, both in design of building, and in the utilisation, where practicable, of new techniques in construction. The Hospitals Trust Fund, which in the past was the principal source of capital for hospital building works, is not now able to meet all demands made on it. It has been necessary for the Exchequer to provide additional moneys and a sum of £1 million is provided in the present estimate for this purpose.
My Department continues to enjoy the most cordial and beneficial relationships with the World Health Organisation, the Council of Europe, and other international organisations. By invitation, the annual meeting of the Regional Committee for Europe of the World Health Organisation is, this year, being held in Dublin in September next. Delegates from some 30 countries will be present.
I would like to thank Telefís Éireann for their generous support of my Department's endeavours to educate and inform the public in health matters during the past year. I have obtained the utmost assistance and co-operation from them.
It is only since I was appointed Minister for Health that I have come to appreciate the extent to which voluntary, unpaid effort enters into the administration and operation of the health services. The persons concerned in supplying this effort include the elected members of the health authorities—a fact often overlooked —the members of the boards of voluntary hospitals, religious congregations, and the professional and other members of various officially appointed bodies, including the National Health Council, the National Organisation for Rehabilitation, commissions and committees of inquiry and the corporate bodies set up to deal with particular aspects of the services. I have already mentioned the increasing number of bodies which assist with community services. To all of these I feel that the best thanks of the nation are due.
