Post WWII to HSE

Department of Health

The modern Irish Health System originated in legislation passed after the Second World War. The legislation provided for a basic system of healthcare, which was in no way as comprehensive as the UK National Health Service, founded shortly earlier.

The National Health Service was established in the UK by the Labour Government, which assumed office after World War II. The post-war period saw a significant but more modest development of the Irish public health system. The Hospitals Trust Fund continued to finance hospital construction.

The Department of Health was established for the first time in 1947 as a separate department. Formerly, it had been part of the Department of Local Government. Shortly afterwards, the Health Act of 1947 significantly increased financial aid from the central government to the local authorities.

A White Paper on the health system was published in 1947. This proposed an extension of hospital services to most of the population together with general practitioner services under the dispensary system. This was seen as a possible first step in the extension of a health service available to all citizens free of charge.

Dr. Noel Browne Tenure

The Tuberculosis (Establishment of Sanatoria) Act 1945 allowed the Department to build new hospitals for tuberculosis patients. The 1947 Act provided for free treatment in sanatoria for tuberculosis patients. Tuberculosis was made a notifiable disease.

Noel Browne drove the fight against tuberculosis during his short tenure as Minister. Significant amounts of new beds were made available, and the death rate from tuberculosis halved within the three-year period.

This White Paper set the scene for the famous mother and child controversy, which ultimately lead to the resignation of Dr Noel Browne as Minister for Health in the 1948 to 1951 Inter-Party government.

Basic Services

Part III of the Health Act 1947 dealing with mother and child services was not commenced. Dr Browne could not secure the support of the inter-party government to proceed with his scheme in the famous mother and childcare controversy.

A White Paper on health services in 1952 was the precursor to the Health Act 1953 Act. That Act repealed the principle of the maternity and infant care scheme. It provided child welfare clinic services and school health examinations.

The proposal for universal GP services for children under 16 was drafted, and the Act extended eligibility for hospital services to most of the population. Despite an accommodation with the medical profession and the Catholic Church, the Health Act largely maintained the principles of a mother and child service. The universal free care for children under 16 was dropped as a proposal in 1952. The provisions finally came into full effect in 1956.

Health authorities were obliged to provide child welfare and clinic services. The mother and child service allowed for persons in the four groups of eligibility mentioned above to have a full maternity service, choice of doctor and mid-wife medical and nursing care for infants together with a maternity cash grant.

Public Health

The law in relation to food safety and infectious disease was modernized in the Health Act 1947. The Food Hygiene Regulations 1950 represented the first comprehensive food safety regulations and endured for over 50 years.

Public health functions remained with the Department of Local Government. The Health Department took over functions in relation to

• prevention,
• cure of disease,
• treatment and care of persons suffering from physical and mental illness,
• training and registration of persons employed in the health services,
• control over appointments of officers,
• research
• food hygiene
• control of medicines.

The 1947 Health Act transferred responsibility for preventative services such as food hygiene, infectious disease, immunization from urban districts to county councils.

Health Act 1953

The Health Act 1953 provided for hospital services for a number of categories, including persons insured for social welfare;

• Persons with family income less than certain thresholds;
• farms with rateable valuation less than certain thresholds and
• others who could demonstrate hardship.

Some were entitled to the services free, and others had to pay charges at varying rates. Similar provisions applied to outpatient services. Ultimately, 85% of the population were eligible for services.

Entitlement to general practitioner services was narrower than entitlement to hospital services. Eligibility was specified by regulation.

Medical cards were introduced in place of the previous method of proving eligibility. Eligibility had been administered by Councils, and the terms varied considerably, suggesting inconsistency.

Other Reform

A significant program of hospital building reconstruction took place in the post-war period. Significant numbers of new posts were created in regional and county hospitals.

A report from the 1950s recommended that the county homes that had replaced the poor law workhouses in the 1920s should be limited to aged and ill persons and that others should be accommodated elsewhere.

The late 1950s and early 1960s saw the establishment of the Voluntary Health Insurance Board as well as some structural reform. under the Health Authorities Act 1960 and the Health (Corporate Bodies) Act 1961. The Health (Fluoridation of Water Supply) Act 1961 provided for the fluoridation of public water.

The functions of the former public assistance authorities were transferred to the health authorities under the 1953 Act. Consultative health committees were established under the 1953 Act to advise councils in relation to health services. The Health Authorities Act established a unified health authority for the major cities.

The net result was that the council was the health authority administering all health services except mental treatment services, which is under the auspices of joint boards established under the Mental Treatment Act 1945.

1960-1973

The 1960 saw a range of medical discoveries, innovations and a change of emphasis for the health service from some of the acute problems of earlier years with a refocus on heart diseases, cancer, aging, psychiatric illness. The financial costs of bringing modern medicine to the general population raised significant issues in relation to priorities in government expenditure.

A White Paper on health was published in 1966, which foreshadowed the changes in legislation and structure over the following years.

The Health Act 1970 was introduced by Erskine Childers. Under the original legislation, the County Councils were the health authorities for their respective areas. The County Council Health Authorities and  Health Districts were merged into eight Health Board in 1970. Ultimately, a single national Health Service Executive replaced the Health Boards in 2005.

Health Boards were established, and powers of local authorities and health matters were transferred to them. A choice of doctor scheme was introduced in place of the dispensary service. State resources were increased.

1970s & 80s

Brendan Corish, leader of the Labour Party, became Minister for Health in the 1973 to 1977 coalition government. The number of county hospitals giving full medical and surgical services was reduced from 24 to 14. The remaining 14 hospitals were to be expanded to provide a better service.

Charles Haughey became Minister for Health in 1977. The Tobacco Products (Control of Advertising Sponsorship and Sales Promotion) Act 1977 restricted the advertising of tobacco.

Eligibility for hospital services was extended in 1979 to the entire population. Consultants were permitted to charge fees to the estimated 15% of the population in the highest income bracket. This was complemented by voluntary health insurance coverage, which covered a quarter of the population.

The late 1970s and early 1980s saw a retrenchment in expenditure. The principal legislation from the covered the o registration and regulation of doctors and nurses as well as the modernization of family planning laws. The Health Education Bureau was established in 1975. The Misuse of Drugs Act was established to control the sale and supply of controlled drugs in 1977.

Health Boards Established

The county units were inappropriately small. The regional and teaching hospitals in the cities began treating the increasing number of patients. Local health authorities were partly responsible for the expense of patients sent to larger regional hospitals in which they had no input. These developments justified the reorganization of health services into a smaller number of larger entities.

The Health Act 1970 set up the hospitals and regional hospital boards. The Health boards were established in 1971. The existing bodies were dissolved and incorporated into the Health Boards. The administration of the health services was transferred to the eight Health Boards.

The Minister and Department’s role was primarily policymaking. It also played a coordination and supervisory role in relation to the appointment of personnel, remuneration, and other conditions of employment.

Several advisory bodies, including the National Drugs Advisory Board and the National Health Council, were appointed.

Health Board Organisation

The Health Boards comprised members appointed by Councils, medical practitioners, and representatives of other professions. The Health Boards organized themselves into a number of divisions comprising hospital services, community care and specialized hospital services. Each was administrated by program manager.

Each Health Board had a chief executive and staff. The powers of the chief executive were substantially less than those of the county manager in respect of county council matters. The Health Board itself retained significant power. The board itself would make directions and decisions in relation to general or particular matters. In practice, it was necessary to delegate a substantial portion of their functions to the executive staff.

• The Eastern Health Board included Dublin, Wicklow and Kildare.
• The Northeastern Health Board included Meade, Cavan, and Monaghan.
• The Southeastern Health Board included South Tipperary, Kilkenny, Wexford and Waterford.
• The Southern Health Board included Cork and Kerry.
• Mid-Western Health Board included Limerick, North Tipperary and Clare.
• The Western Health Board included Galway, Mayo and Roscommon.
• The Northwestern Health Board included Sligo, Leitrim and Donegal.

Funding

At the end of World War II, most of the rudimentary health services were financed by local authority rates. State grants played a relatively minor role, accounting for no more than one-sixth of total expenditure.

Under 1947 legislation, the State undertook to pay each health authority the increased cost and services. The State contribution was to be twice that of the local authorities in the base year. After that level, it was to be divided equally between the State and local authorities.

In the late 1960s, health expenditure constituted a substantial part of local authority outgoings. At that stage, the State’s contribution to health had substantially increased and was significantly greater than that of the local authorities due to developments in healthcare.

By 1970, the state contribution to health services exceeded 50%. It was recognized that the rate was not an appropriate source for the expansion of health service expenditure. The contribution from rates was ultimately phased out by the mid-1970s.