Dáil Éireann debate -
Wednesday, 23 Oct 1929

Vol. 32 No. 1

Public Business. - National Health Insurance Bill, 1929—Second Stage.

Order for Second Reading read.

Minister for local Government and Public Health (General Mulcahy)

The object of this Bill is to introduce certain changes into the code of National Health Insurance which will make for simplification and economy. There is rather a large background to the proposals made in this Bill going back to a Committee dealing with the matter of National Health Insurance and Medical Services which sat in 1924 but did not definitely report until 1927. The Committee was appointed by the Minister for Finance and its terms of reference were (1) to inquire into and report on the advisability of the continued maintenance of the system of National Health Insurance in its present form and to make any recommendations which the Committee consider proper in that connection. (2) To consider whether it is desirable to institute a system of medical treatment on a contributory basis, and if so, to advise as to the form which that system should take. (3) To examine into and report on the question whether the Medical Services at present assisted and maintained out of State or local funds can be improved as respects efficiency and economy, and if so, in what manner, due regard being had to any recommendations made under the preceeding paragraph. Two reports have been published. On the general question of the continued maintenance of National Health Insurance the Committee reported that an overwhelming body of evidence was in favour of its continuance. The approved societies, the employers' representatives, the Labour representatives, the General Council of County Councils, and the medical profession, were all of opinion that Health Insurance had proved a real benefit to the working classes in the Saorstát. The Committee, however, recommended that certain changes could be advantageously made in regard to particular features of the Act, and the main object of this Bill is to give effect to these changes. It may be recalled that the effect of the Insurance Act has proved a real benefit to the working classes as borne out by statistics. The average weekly number of insured persons receiving sickness and disablement benefit during the year 1928 was 21,250, and the amount expended on these benefits during the year was £563,000. The amount expended on maternity benefit was £54,000. In addition, these societies which had surpluses at the last valuation were providing additional benefits such as dental benefit, hospital benefit, etc., involving expenditure of about £34,000 per annum.

In the Bill the first matter dealt with is that of exempt persons. It is necessary at the outset to distinguish between excepted persons arid exempt persons. Excepted persons are completely outside the scope of the Acts, while exempt persons are only partly out; they pay no contributions themselves but the employer has to pay the ordinary employer's portion of the contribution. The exempt class is composed of persons who are given a statutory right on certain conditions to apply for exemption, a right which they may or may not exercise at their own discretion. There are various conditions set out in the Acts which confer this right but the main grounds upon which exemptions are obtained arc (1) that the claimant has a pension or income of £26 per annum derived from sources other than his employment, or (2) that he is depending on some other person for his livelihood. Those who apply for exemption are in fact small in number — there were 726 exempt persons in 1928 — but they constitute a highly favoured class as they pay nothing themselves and yet they are provided with benefits out of the money provided by their employers and by the State.

As is usual in dealing with small classes of this nature the administration expenses involved are much higher than can be justified by the small amount of good effected. The Committee recommend that the right to claim exemption should be withdrawn and it is proposed to give effect to this recommendation, in the present Bill. Adjustments will be necessary so that such persons as are exempt at the present moment will not lose the rights they are entitled to as exempt persons until they become persons in ordinary insurance. There are certain statutory provisions dealing with Irish migratory labourers. As a matter of fact only two persons in 1928 applied to be regarded as in the class of migratory labourers and in fact provision dealing with Irish migratory labourers are no longer required in the Act.

With regard to the deposit contributors, the Committee unanimously recommended that if at all possible the class of deposit contributors should be abolished, and that all existing deposit contributors should be transferred to approved societies. While insurance under the Acts is compulsory, an insured person is not compelled to join a society, nor is a society compelled to take him as a member, and those insured persons who, for one reason or another, do not become members of approved societies constitute a class known as deposit contributors. The general principle of deposit insurance is that the contributors' right to benefit is limited to the contributions paid in respect of him increased by the usual State grant. A separate account is kept in the Commission for each deposit contributor. The benefits are administered by the Insurance Committees and are paid by the Commission out of the sum standing to the credit of the individual accounts. Insurance of this nature is obviously of very little use to the contributor, and in case of prolonged or serious illness his account is soon exhausted and lie is left entirely unprovided for. The weakness of the whole position is that a scheme purporting to be a scheme for National Health Insurance fails to provide for the insured person whose health is so indifferent that he cannot obtain admission to an approved society. There are only between 3,000 and 4,000 deposit contributors. Concurrently with a provision, of this nature doing away with the deposit contributor us a type of person recognised under the Act, it is obviously necessary that the existing rights of societies to refuse admission to members and to expel them should be withdraws except in cases where the constitution of the society requires that its membership should be limited to persons of certain classes. For instance, some societies have special rules limiting membership to men or women only, and to persons of a particular religion, or to residents of a certain area or employed in a particular trade. Such societies will continue to be entitled to reject applications for membership from persons who do not come within such category. Provision is also made for the transfer of existing deposit contributors to approved societies. A suitable interval will be given after the passing of the Bill to enable them to choose their own societies, but any who have not done so at the end of the period will be transferred en bloc to certain societies which will be selected by the Commission as suitable for the acceptance of such members.

In the case of married women, at present an insured woman who marries and remains in employment continues to pay the ordinary contributions and to be entitled to the ordinary benefit. If, however, being a member of a society, she ceases to be employed for a certain period she is transferred to a special class, called Class K, in which no contributions are required and benefits are payable on a special scale. The transfer takes place at the date of unemployment, that is, at the end of eight consecutive weeks of unemployment, excluding unemployment due to incapacity for work, terminating within twelve months of her marriage. If, however, she had completed eight consecutive weeks unemployment on or before the date of the marriage the transfer takes place at that date. The special scale of benefits applicable to Class K is:—(a) sickness or disablement benefit of 7/6 a week for a maximum period of eight weeks in the period between the date of unemployment and the date of the completion of the second year of marriage (not subject to reduction for arrears): (b) maternity benefit of £2 in respect of the first confinement after the date of unemployment and within two years of the date of her marriage (subject to reduction for arrears, but not below one pound); and (c) sanatorium benefit until the end of the half-year next following the completion of a year from the termination of eight weeks unemployment.

At the end of two years from the date of her marriage a Class K member ceases to be insured and her membership of a society ends. If she again becomes unemployed while still a member, that is, before the end of two years from the date of marriage, she is treated as a new entrant into insurance and is required to requalify for benefit, retaining the right to any Class K benefit to which she would otherwise have been entitled until she requalifies. Administration of the insurance of this particular class, which came into existence in July, 1918, has proved to be troublesome and difficult, and the Committee recommended a simpler method. namely, that marriage should terminate the woman's insurance and that if she continued to be or again became insured after marriage she should be treated as a new entrant and, further, that in lieu of the present benefit a cash endowment should he paid to insured women on on marriage. The Bill makes provision for this. The matters of the greatest importance arc the abolition of sanatorium benefits and the abolition of insurance committees. Both of these changes have been unanimously recommended by the Committee of Inquiry. The Insurance Act of 1911 set aside 1/3 per insured person out of insurance funds for the treatment of tuberculous insured persons, and the administration of the scheme for such treatment was entrusted to the County and County Borough Insurance Committees. In 1912 grants became available which enabled local authorities to obtain recoupment from State funds of one-half of their net expenditure on the treatment of tuberculosis. There is, therefore, in existence a dual system by which responsibility for treatment rests partly on insurance committees and partly on the local authorities. In actual fact what has happened is that the great majority of insurance committees have entered into agreements with the local authorities by which they transfer their funds to such authorities in return for treatment for their insured persons so far as moneys are available for the purpose. In all these cases the work of the insurance committees is mainly limited to recommending certain insured persons for treatment to the local authorities.

The system gives rise to two serious complaints, firstly, that insured persons not only have to pay for sanatorium benefit under the Insurance Acts but have also to contribute is taxpayers and ratepayers for the moneys expended on tuberculosis under the local authorities schemes; secondly, that in some areas the money available for insurance funds is not sufficient to meet the number of cases requiring treatment with the result that insured persons although they have already contributed for sanatorium benefit are sometimes called on to pay part of the actual cost of treatment provided by the local authorities if their means enable them to do so. On these grounds the Committee recommended the abolition of sanatorium benefit and suggested that the treatment of tuberculosis should be left entirely in the hands of local authorities. As deposit contributors whose benefits were administered by insurance committees are also being abolished there is no further work for these committees to do and their abolition is consequently also recommended. The abolition has been recommended unanimously by the Committee and provision is now being made to deal with it.

On the financial side the Bill provides that 1/3 per insured person hitherto available for sanatorium benefit and the 4d. per insured person available for the administration of insurance committees should now be diverted to meet the cost of medical certification. This amount of 1/7 together with the 5d. already contributed by approved societies will provide the 2/- per insured person which is required to meet the cost of obtaining medical certificates for insurance purposes. Local authorities will be compensated for the loss of 1/3d. per insured person which they had been getting from insurance funds by an annual grant from State sources of £27,750. which will be provided for in the Vote for Local Government and Public Health. As the State has hitherto been contributing 1/7d. per head to the Medical Certification Fund which will now cease, there will be a net saving to the State of 4d. per insured person, the estimated figure being £7,400 per annum. These arrangements put on a permanent basis the provision of money for medical certification and Acts of a temporary nature such as have been passed each year since 1924 will be no longer necessary. The Medical Referee Service will still be provided from State funds.

A number of smaller matters are dealt with in the Bill. There has been difficulty in getting the terms of the Act carried out in regard to the stamping of cards for junior assistant mistresses. That has been due to the fact that while the Minister for Education was responsible For the payment of the employer's share of the contributions the manager was supposed to stamp the cards. It is proposed that in future the Minister for education will be regarded as the employer. That arrangement will save the trouble hitherto experienced both by the managers and the Commissioners. In accordance with the further recommendation of the committee an amendment is made in Section 112 of the Act of 1911 which will enable inspectors of the Commission to enter private dwelling houses, if necessary, at reasonable times to investigate cases of non-compliance with the provisions of the Act. There has been a rather widespread non-compliance on the part of persons employing domestic servants in respect of the Act. While inspectors have had statutory powers to approach employers in workshops and other places other than private dwellings, they had no power to approach private dwellings. It is now proposed to give them such powers.

It is proposed to extend the period within which an insured person is required to give notice of illness to his approved society from the present figure of three to seven days. A system existed up to now by which if it was found that a person was not complying with the Act the Commissioners took steps to get him to comply with it. They have no statutory powers to get arrears paid up except in respect of arrears for a period of twelve months. It is proposed to amend the position by which the Commissioners can recover all arrears outstanding. The National Health Insurance auditors are given a power of surcharge in regard to the accounts of approved societies similar to that which they already possessed in the case of insurance committees.

At present their power is limited to disallowing improper payments or payments for which there is no legal authority. The sums are not charted against any individual, and after investigation they are recharged to the societies' benefit fund or the administration account on instructions from the Commission. It is proposed to take stops to enable such surcharge to be levied against the particular individual who was responsible in the matter. The Bill also contains a clause which limits the rights of insured person to pay contributions in respect of periods of unemployment. Under the existing law they are not ordinarily allowed to stamp their cards themselves, but in the 1918 Act they were given a limited right to pay contributions in respect of periods of unemployment due to incapacity or inability to obtain work, in order to bring their total contributions up to the number of 104. This gave an opportunity to an insured person who fell ill or who became unemployed during the early part of his insurance and in respect of whom contributions consequently ceased to be paid, to pay contributions himself for the purpose of making up the number of contributions required before benefit became payable. Some limitation of this right now becomes necessary having regard to the fact that all insured persons will in future be members of approved societies, and if the existing provisions were not altered unscrupulous persons could become entitled to substantial benefit by entering into employment for a short period with the collusion of an employer — even a week or a fortnight would be sufficient — and then paying a comparatively small sum in contributions themselves.

The point involved will be made clear if we consider that a person going into employment gets a card stamped for three or four weeks and then leaves employment. He would have the right to pay contributions himself to bring the total number up to 104 and he would then become entitled to a payment of 7/6 a week disablement benefit which might last for the rest of his life. If we consider the liability involved in that way as distinct from a liability which would arise in a bona fide way it will be realised that some provision must be made to prevent fraud. Such persons, who would not ordinarily lie insured persons at could, if they found themselves in bad health or suffering from a serious disease which was likely to lead to continued incapacity, secure employment for a short period, pay contributions themselves up to the qualifying number and become entitled to benefit which might last continuously during their lifetime.

The Bill, therefore, limits the existing rights as regards two classes — first, women, who have gone out of insurance on marriage and have re-entered employment within twelve months, and, second, employed contributors who are over eighteen years of age on entering insurance, and who fail to prove that they are normally insurable persons. The great majority of insured persons enter insurance before the age of eighteen, and if a society finds that the first insurable employment of an applicant for membership commences after that age, they will be entitled to satisfy themselves that such employment is genuine and not taken up for a short period merely for the purpose of being able to qualify for benefit before they allow him to pay contributions himself during periods of unemployment or incapacity. The Bill also contains provisions bringing the terms of National Health Insurance for soldiers more into accord with the present regulations for recruiting in the Army.

It will be seen from the terms of reference which I mentioned in the beginning that there were two matters of considerable importance which the Committee of Inquiry dealt with. One was the unification of societies. That does not appear in the terms of reference, but in fact the unification of societies and the introduction of medical benefits were two very important matters dealt with by the Commission. I did not introduce into this Bill anything dealing with medical benefits or the unification of societies. It was the opinion of the Commission that the unification of societies, that is, the bringing about of a condition of affairs in which the large number of approved societies that we have at the moment would be amalgamated into one unified society, was the most satisfactory way to deal with the National Health Insurance scheme, so that there might be a possibility of giving better benefit to insured persons and of economy in administration. At the time that the Committee was inquiring into the matter there were eighty separate approved societies and one approved society with twenty-five branches. At the present moment there are sixty-five approved societies and one approved society with nineteen branches, so that during the period that has elapsed from the time the Committee sat a reduction has taken, place in the number of societies.

The Committee, while stating that unification of the societies would be the best possible way for organising the National Health Insurance system, were not prepared to say that that was feasible. The Executive Council, on considering the matter, were not prepared to say either that it was feasible, but I propose, on the Committee State, to put an amendment before the House that would provide an opportunity of discussing what can be done to improve the position from what it is at present. I said that the number of approved societies has been reduced from eighty to sixty-five. In my opinion, a very considerable reduction is desirable, and I propose to put before the House an amendment somewhat along these lines — giving the Commissioners power, in the case of voluntary amalgamations of societies during the next two years, the plan of amalgamation being subject to the Commissioners, to give a certain amount of compensation to those employees of the approved societies whose services will be dispensed with as a result. That is, in cases where voluntary amalgamation takes place within the next two years, provided that after two years the Commission may compulsorily bring about the amalgamation of societies down to a number not greater than twelve or fifteen, and giving, at the same time, a certain amount of compensation to the employees of the societies whose services will be dispensed with. When I say compensation, Deputies must put out of their minds that in such amalgamation as might take place in that particular way, anything like pensions will be available, because the organisation of the societies from a financial point of view would not make that in any way possible. There has been no compensation in any of the amalgamations that have taken place up to the present. The amalgamations have been amalgamations of weak societies, and in the great majority of cases the Commissioners had to step in and compulsorily carry out amalgamation. However, I will put an amendment before the House that will enable that matter to be discussed.

On the medical benefits aspect of the question, while the majority of the Committee considered that there should be a scheme of medical benefit and suggested that a medical benefit scheme could be arranged by increasing the contribution by twopence, nevertheless Deputies will find that there were three minority reports.

What, operated most in the minds of the minority reporters, and what operates in the minds of the Executive Council is the fact that it is shown that a very large proportion of insured persons are already treated free by the dispensary system throughout the country. It was felt, following the change that had taken place owing to the setting up of Boards of Health throughout the country — a change that had taken place comparatively recently — that we would require further time to judge what kind of a scheme of medical benefits should be introduced as well as to satisfy ourselves that the present system did not meet the needs of the situation. Personally, I am agreed that the system of medical benefits is very desirable, but we have not come to the time at which we can say what lines the finances or even the organisation for granting medical benefits to insured persons should take.

Mr. Seán T. O'Kelly

I move the following amendment:—

To delete all words after the word "That" and substitute therefor the words —"declines to give a Second Reading to the National Health Insurance Bill, 1929, until proposals have been laid before the Dáil providing for—

(1) The administration of National Health Insurance through one society, and

(2) Medical benefit."

In moving this amendment I wish to say, speaking generally and subject to certain amendments that we expect will be introduced at a later stage, that we do not desire to be taken as being opposed to the greater number of the amendments that are set out in this Bill to the National Health Insurance Acts. We have no desire whatever to oppose any amendments of these Acts that will tighten up and make more efficient the working of National Health Insurance. Above all, we have no desire to oppose any amendments that will lessen the cost, I should say the high cost, of administration of national health, both so far as the headquarters of the Insurance Commission and of the approved societies are concerned. As the Minister said, the amendments to the Acts that are set out in this Bill are the result, I think, in all cases of recommendation made by the Committee of Inquiry that was set up, as the Minister said, in 1924. With these recommendations, and the amendments that are based on them, there is, as I have said, fairly general agreement so far as we are concerned with perhaps two or three exceptions. There are minor amendments, however, that some of our friends would like to see made in the terms of the Bill.

As the House will understand from the amendment that I have on the Order Paper, our objection is not to the Bill. We do not wish to see the Bill defeated, and we would not like, even, to see it held up very long, except for the reason that, in my opinion, there are two grave omissions from the scope of it. These have been alluded to by the Minister. One is what is called in the report of the Committee of Inquiry, unification, and the other is the question of medical benefits. That Committee was set up at considerable expense, and I am sure it gave considerable time and consideration to the whole question of national health insurance. The Committee produced a report that made numerous recommendations. The Government has embodied the greater number of those recommendations in this Bill. We believe that the two principal outstanding recommendations contained in that report are ignored in this Bill, and that is the major fault that we have to find with it. The Bill has been expected for a long time. There has long been a promise that it would be brought in to amend the National Health Insurance Acts in the various ways which have been found necessary. It was generally expected by many insured persons and by approved societies that, when the National Health Insurance Acts were being amended, an attempt would be made under the Bill introduced for that purpose to bring in for consideration and legislation the subject of medical benefits. The fact that it has been ignored has led, as far as I have been able; to gather, to very grave disappointment.

The Committee of Inquiry, in their interim report, stated that there were 81 approved societies in existence at the time the inquiry was held. In the last report issued by the Commissioners it was stated that there were then 74 approved societies in existence, and the Minister tells us now that there are only 65 approved societies in operation in the Free State. Whether the number be 81, 74 or 65 it is our opinion that any such number is far too great to be in existence in the twenty-six counties. We believe, and I think anybody who has taken any time to consider this matter believes with us, that a drastic cutting down of the number under a scheme of unification of some kind is necessary, and that such a cutting down would redound to the benefit of all concerned. The Government would save money by it as well as the insured persons. The saving of this money would mean that there would be more money available for the insured persons in the matter of the medical attention they get at present, and that they would be likely to get as the result of the additional surpluses made available.

According to the last report of the Commissioners there arc at present 492,594 insured persons in the twenty-six counties. If there are 74 approved societies, that means there are, roughly, 6,500 members on the average in each society; if there are only 65 approved societies in existence — the Minister gave us that figure to-day — it means there would be between 7,000 and 7,500 members in each approved society. I imagine that in a certain number of the approved societies the number of members would be considerably greater than that, but, at all events, in a considerable number of the societies there must be 6,000 members or less. Every one of these approved societies has to have its own office its own committee of management, its own secretary, its own clerks and book-keepers, and all the other para phernalia required to run any properly organised office. The multiplication of these societies and the multiplication of officials leads to waste. I do not want to labour the question, but I think that the amendment that I have put down has already fructified to some extent by inducing the Minister to make the promise that he has made — that he will introduce an amendment which will seek to hurry up the question of the abolition of the number of these smaller societies.

We believe that the Government ought to have taken its courage in its hands and tackled this question in a bolder fashion. They could cut the losses at present being made by the Government itself and by the approved societies, losses which cost considerable sums annually to the insured persons. The amount of benefit they would get as a result of their payments would be very considerably increased if the whole organisation of national health were put oil a more efficient basis than that under which it is now operating. At present the societies are allowed 4/5d. per head per insured person per year for administration. That is a large sum out of the amounts paid by the insured person, and that could be considerably reduced if there were a more efficient scheme in operation. The report tells us that the cost of administration at headquarters is 3/8¼ per insured person, as against 1/4 per head in England. Of course it may not be quite fair to compare the cost of administration per head in the Free State with the cost of administration per head in England. We know that England is highly industrialised with a vast population, and the cost per head would be considerably lower than here. Nevertheless, 3/8¼ per head per insured person is a sum far above what it ought to cost to run National Health Insurance in Ireland, and above what it should cost if there were more efficient management. The interim report says on page 7, on the high cost of central administration:

"The Irish Commission submits that the method of calculating the expense at cost per head of the insured population is misleading and unfair; for it points out that there are over 12½ millions of insured persons in England compared with 450,000 in the Saorstát and that the overhead charges must be greater proportionately to numbers in the Saorstát than in Great Britain for administering the same type of machine. There are, the Commission states, other reasons why the cost of central administration is relatively higher in the Saorstát than in Great Britain."

There are reasons, but I think those reasons could be made to disappear to a large extent if the law were altered so as to enable more efficient management to be introduced. In giving evidence before the Committee of Inquiry the National Health Insurance Commission set out a number of reasons why some policy of unification ought to be adopted. Those interested will find them on page 6 of the interim report. I will refer to some of them. It gives a list which includes:

"(a) Inequality of benefits for members arising on a valuation because of the particular character of the society to which they belong. (b) Want of uniformity of administration. (c) Overlapping rival organisations, leading to disputes as to membership. (d) Inadequate agency system, and lack of supervision of sick members. (e) Number of transfers from one society to another and resulting disputes between societies as to membership. (f) Necessity for keeping on the deposit contributor class owing to expulsions from societies and to refusal of membership on account of health or other grounds. (g) Unfairness of the present arrears system, which is based on a higher average frequency of contribution payments than exists in the Saorstát. (h) Resulting high cost of central administration owing to (i) the necessity for keeping separate accounts for separate societies; (ii) constant supervision of societies by the Commission's indoor and outdoor staff; (iii) the large number of complaints, appeals and the like."

Again on page 32 there are set out what are, I think, more or less a duplication of what the National Health Insurance Commission sets out as objections to the present system.

"The Commission calculates that there would be a saving of about 45 per cent. on the present total cost of its administration, the accounting work would be reduced to a minimum and on the secretariat side would disappear most of the work of the Approved Societies' Branch."

That would be a considerable saving if it could be introduced at once and the Government had the courage to do what the Committee of Inquiry recommends. For these reasons we on these benches are of opinion that the Bill ought to be held up for some time to give the Ministry time to reconsider this matter, and to again read over the recommendations that have been made by the Committee of Inquiry and take into consideration the strong recommendations on these lines that are contained in the report. The personnel of the Committee was not one that to my mind was representative of the approved societies or of the opinion of the general run of insured persons. It was composed to a large extent of officials of one kind or another of the Government, and others, quite good enough people in their way no doubt, but not in as close touch as we would imagine persons inquiring into health insurance ought to be with ordinary insured persons and with approved societies. The Committee of Inquiry was: Professor William Magennis (Chairman), Sir Joseph A. Glynn, J. Hurson, James Gray Kyd, Canon MacHugh, P.P.; William J. Maguire, Robert J. Rowlette, Edward F. Stephenson, with Mr. Kavanagh as secretary.

In all probability if there had been on the Committee of Inquiry direct representatives of the insured persons, members of approved societies, and officials of approved societies who are in daily touch with insured persons, the recommendations in this report would have been somewhat different. I do not know that officials of approved societies would be in favour of unification, but they would certainly favour the cutting down of administration costs. They must approve of that, and such recommendations would have been put in, perhaps, even in stronger language than is to be found in the recommendations of this report. As it stands the recommendations are strongly put, and are such that greater notice ought to have been taken of them by the Ministry when considering the legislation they should bring with regard to this matter. As for the method of unification, we are not ourselves tied, and we do not wish to be taken as recommending any specific method of unifying or bringing into one body all the approved societies. Some would prefer nationalisation. From our point of view we do not mind what it is called, provided unification is brought about, and brought about in an efficient way, and that as a result the savings that must accrue will go to the benefit of the insured persons.

On page 14 there is one short paragraph of the report that summarises the views of the Committee of Inquiry. In paragraph 53 the Committee says: "We have carefully considered the three modes of simplification put before us, and we have come to the conclusion that unification— if feasible—affords the best method of simplifying National Health Insurance in the Saorstát and of effecting very considerable economies in the cost of its central administration." As we say, we are not tied to any particular method, call it simplification, unification or nationalisation, but we certainly are insistent on a more efficient and less costly management of National Health Insurance. I think it is worth while referring to some remarks made by Dr. Rowlette, who was one member of the Commission who added a note when signing the interim report. On page 22 of the interim report he says:—

"I agree in thinking that the method of administering National Health Insurance through approved societies is cumbersome under the conditions that are found in Ireland. The method was introduced to Ireland, merely to give uniformity to a system common to Great Britain and Ireland, but designed to meet English local conditions. It had no relation to Irish needs or customs, and with any re-casting of the insurance system in Ireland there appears to be no reason why the existing method of administration should be continued, if a better, or one more suitable, can be devised. The whole problem should be considered without prejudice.

The arguments put before us were convincing that a unification of society administration would lead to considerable saving, but the saving would, I believe, be greater, if the unification were carried a step further, and the entire administration committed to the care of a Department of Government, as is done in other countries where schemes of national insurance have been most highly developed. Such concentration in a Government Department would have the following advantages:—

(1) The direct responsibility of a Minister to Parliament for the entire adiministration of national health insurance;

(2) The co-ordination of national health insurance with the health policy of the country, and with the whole scheme of preventive medicine;

(3) The possibility of readily fitting in national health insurance with any other form of social insurance which the country may decide to adopt in the future;

(4) A greater immediate economy than can be attained, without loss of efficiency, by any other method."

That is the opinion of Dr. Rowlette, who, I understand, has given very considerable time and energy to studying this matter. With regard to the question of medical benefit, the second reason why we would like our amendment passed is because medical benefit has not been dealt with in this Bill. I think it will not be denied that it was the original intention, when the Bill was put into operation in Ireland, that at some time or another medical benefit would be given to the insured person in Ireland or in the Free State as was given to the English members of approved societies or English insured persons. Under the law as it stands the three main benefits granted to insured persons are sickness, disablement and maternity benefits. Certain approved societies, those that have surpluses for one reason or another have, as a result of those surpluses, been able in recent years to grant additional benefits. Some have granted dental benefits to a certain extent, and others optical benefits to their members, but there is no uniformity, and all or a great number of the approved societies are not in a position to grant these additional benefits. They have not all got surpluses available.

There is, therefore, as I say, a want of uniformity in the system, but outside that altogether we believe that the time has come when an effort should be made by the Ministry to introduce medical benefit. We believe there is a demand for it. We believe that it is just that it should be granted, and we believe that it is necessary if we take the state of public health into consideration. In Great Britain, and in the Six Counties medical benefit, consisting of medical treatment and attendance and the provision of proper and sufficient medicines and the medical and surgical appliances, with the free choice of a doctor, is also given to insured persons. I do not know if there is any doubt as to whether there is a persistent demand for the introduction of medical benefits, but in case anybody would have any doubts in their mind I think these doubts could be resolved by reference to the final report, where, on page 54 in Appendix 8, there is cited the opinion of the Approved Societies Association of Ireland on this particular question of medical benefit. I will not read it all; it is a long document. Anyone interested can see for himself. In paragraph 3 of Appendix 8 it says:

"It was the unanimous opinion that medical benefit should be a statutory benefit under the National Health Insurance Acts, and not an additional benefit."

That is the opinion of the Executive of the Approved Societies' Association of Ireland on the question of a medical benefit scheme. I read somewhere, I think it was in this report, that the approved societies represented could speak for about 70 per cent. of the insured persons in the country. The trade union approved societies represent also a considerable percentage of the insured persons in the country. They gave evidence before this Committee of Inquiry. In Appendix 9 there is printed here in this report a statement from them dealing with this question of medical benefit. It says:

"The Association of Trade Union Approved Societies believe that a national scheme of Medical Service is preferable to any other scheme that can be suggested, and they claim a scheme of this kind must be introduced without delay. They believe that medical benefit for the working-class, whether insured or not, is absolutely essential in the national interest and is their absolute right. It appears to them that the worker's claim to medical service should not depend entirely on his ability to find an employer. The system responsible for the slums, the disease and the wreckage of human life should pay for its ravages.

"Meantime, as it appears unlikely that a national scheme of Medical Service unassociated with the contributory insurance scheme will be forthcoming in the immediate future the Association favours the extension of medical benefit under the Insurance Acts on a contributory basis, as a temporary expedient.

"Medical benefit, however, in our view cannot be provided as an additional benefit, but so long as it forms part and parcel of the insurance machinery must be a statutory benefit guaranteed to the insured persons.

"The Association is further of opinion that the scheme should embrace both the insured persons and their direct dependants.

"We believe the total cost of such benefits should not exceed 3d. per week, and we are of opinion that the State should assume responsibility for a substantial proportion of that contribution."

These two organisations speak for the vast body, perhaps for 90 per cent., of the insured persons. Such bodies as the Dublin Chamber of Commerce have also given evidence in favour of medical benefit. On page 27 of the final report, in a minority report appended to the final report by Mr. J.J. McElligott and Mr. J. Hurson, they quote the opinion of the late Mr. William Martin Murphy. Giving evidence before some previous committee, and speaking in regard to the extension of medical benefit, Mr. Murphy is reported as saying:

"The witness said that the Chamber (meaning Chamber of Commerce) advocates the extension of medical benefit to insured persons, and that the views given by the late Mr. William Martin Murphy before the Medical Benefit Committee in 1913 are still the views of the Chamber on the question of medical benefit."

He goes on to qualify that to some extent. Anybody who is interested will find it on page 27 of the final report. There was one section of the community that sent witnesses to give evidence before the Committee of Inquiry with regard to the value of health insurance itself, particularly with regard to the value of health insurance so far as it affected their members. That organisation was the Irish Farmers' Union.

In paragraph 19 of the Interim Report this appears:—

"The representatives of the Irish Farmers' Union and some country witnesses contended that agricultural labourers did not derive much benefit from the Act. When, however, figures submitted to the Committee by the Insurance Commission were placed before the witnesses they frankly confessed that the case made on behalf of the farmers was not borne out by the results."

So I think it can be fairly said of all classes of the community to whom health insurance has been of benefit. The Minister himself quoted the opinion of the Committee—their final opinion, having heard witnesses of all classes, of all kinds, and representative of every shade of opinion, I suppose, in the community—that the overwhelming body of opinion was in favour of the retention of health insurance. I think it is equally true that all classes are in favour of the extension of medical benefit. You have had the opinions of such widely divergent classes as the employers and the trade unions. You have, in between, the opinion of a body speaking for insured persons in general, people belonging to different classes of the community, organisations of one kind or another that have added to their work insurance work. The organisation of approved societies have unanimously and in the strongest terms recommended the adoption of medical benefit. The opinions of these bodies naturally would carry much greater weight than anything I could say in the matter. That is why I have gone to the trouble of quoting their opinions. The opinion of the Committee of Inquiry itself on the subject is to be found in paragraphs 67 and 70 of the Interim Report. I would like to refer you to these. Paragraph 67 states:

"The evidence submitted to the Committee shows that the majority of insured persons would welcome the introduction of a system of medical benefit on a contributory basis. Only 9 approved societies do not favour the extension of medical benefit to insured persons. The membership of these societies is about 12,600; and it is worth noting that some among them are already provided with medical treatment schemes of their own. Eight other approved societies— with a membership of nearly 12,000—would not favour the introduction of this benefit if it involved any increase in the present contribution under the Insurance Acts."

Paragraph 70 states:

"Medical treatment on a contributory basis should form part of National Health Insurance. Most of the witnesses examined as to medical benefit were of opinion that a proper system of medical treatment for the insured persons on a contributory basis is the main reform requisite. There is no doubt that National Health Insurance in Ireland has suffered from the absence of medical treatment as part of the statutory scheme of benefits. This was felt from the inception of the system of National Health Insurance. In the preamble to the original National Insurance Act, 1911, the Act is described as insurance against loss of health `and for the prevention and cure of sickness.' In 1913 the Committee appointed `to consider the extension of medical benefit under the National Insurance Act to Ireland' reported in favour of the immediate extension of such benefit to the county boroughs. That Committee did not see its way to recommend any further extension at the moment owing to being unable to arrange terms between the approved societies and the medical profession as to the inclusion of the dependants of insured persons which the societies demanded. That Committee also stated that the British system was unsuitable to rural Ireland and that the extension of medical benefit to areas outside the county boroughs should await the comprehensive reform of the Poor Law and the creation of a State medical service. No action was taken on this Report owing to the World War of 1914-18.

"The Irish Public Health Council considered the question of the extension of medical benefit and in paragraph 11 of its Report stated `that the absence of any provision for medical treatment of insured persons has an injurious effect on the health of the working classes, and we feel that some system such as we indicate in Part III. should be made operative as soon as possible.' The system referred to was the proposed creation of a medical service as set out in paragraphs 40 to 56 of that Report.

"It will be seen, therefore, that the two Committees which considered the question of medical benefit were of opinion that medical treatment on a contributory basis should form part of National Health Insurance. With that opinion the Committee is in agreement."

In several paragraphs of the Final Report a similar opinion is reiterated. I will only refer to one or two of them. Paragraph 1 states:

"In the Interim Report which this Committee had the honour to furnish you (paragraph 70) agreement is expressed with the verdict of the Medical Benefit Committee in 1913 and of the Irish Public Health Council in 1920, that medical treatment on a contributory basis should form part of National Health Insurance."

Paragraph 3 states:

"It now appears to this Committee that such a comprehensive scheme as that discussed in the Sub-Committee's Report, whereby medical treatment of every description would be available for the working classes and their dependants whether insured persons or otherwise—is the ideal solution of the problems proposed in the second and third of the terms of reference. For various reasons, however, and particularly on account of the estimate of expense prepared by the Sub-Committee, the members of this Committee, while regarding it as otherwise providing a solution of all the problems involved, are not unanimous in recommending it for immediate adoption. Disappointed in the expectation of the immediate establishment of a medical service of national scope, embracing, that is, both the insured and `poor persons,' this Committee turned its attention to the one practicable alternative, a scheme not so comprehensive, but providing a solution of the lesser—yet, perhaps, more urgent—problem of how to secure medical treatment for insured persons.

"The weight of the evidence submitted to this Committee, as indicated in Part II of the Interim Report, has been overwhelmingly in favour of the instant introduction of an adequate system of medical treatment for the insured population on a contributory basis."

There are other places in the report where that opinion is stressed. Paragraph 8 is one of them. It goes into detail in paragraph 8, giving the opinions of the Approved Societies Association and the Trade Union Association, and the opinions of other societies like the Prudential Health Insurance Society and the Irish Amalgamated Health Insurance Society, all in favour of the introduction of medical benefit. The heading of paragraph 18 says:

"Medical benefit would provide a natural check on irregular certification." It goes on to give its reasons for that in the paragraph. The heading to paragraph 19 states:

"The necessity for separate expenditure on certification would disappear on the introduction of medical benefit."

Paragraph 20 says medical benefit would effect a large saving in sickness benefit expenditure. There are arguments adduced to prove these contentions which perhaps Deputies interested will read for themselves. It says in paragraph 21: "Accordingly this report recommends that medical benefit be extended to insured persons in the Saorstát through some such scheme as is therein outlined." That is the scheme drawn up and submitted by and on behalf of the Insurance Commission. I do not think that there can be any doubt in anyone's mind as to the fairly unanimous demand there is for medical benefit. If there is one reason that appeals to me more than another why I would like to see medical benefit secured and extended to the insured persons, it is because of the backward position-of public health in this country. I will not go into it now, but I would like to see a total reorganisation of the medical services, somewhat on the lines of the schemes mentioned in the report and recommended under the third heading of the terms of reference given to the Committee of inquiry. But as there is no suggestion that any scheme of that kind is going to be put into operation in the near future, I would like to see the additional benefit that would accrue from the extension of medical benefit to insured persons given to those people who have paid and are paying, and who would be, I submit, prepared to pay whatever additional sum would be demanded of them—2d. is suggested—for the medical treatment now denied them.

I would like to refer to one or two remarks of Dr. Rowlette in the letter he sent in when giving adherence to the Final Report of the Committee. He stated:—

"The majority of the Committee state in paragraph 3 of this report that the ideal solution of the problems set in the second and third of the terms of reference is to be found in the immediate establishment of a medical service of national scope, on some such lines as the scheme discussed in the report of the sub-committee.

"For `various reasons,' however, and particularly on the ground of expense, this ideal solution is not recommended for immediate adoption. In my opinion a comprehensive scheme of this kind is not only the ideal but by far the best practical solution of the problems before the Committee. Moreover, it is the only solution which shows any fulfilment of the hope expressed by the Minister for Finance at the first meeting of the Committee, that the Committee would be able to recommend cooperation between the National Health Insurance and Poor Law systems.

"In postponing the solution that they regard as ideal, my colleagues seem to have lost sight of the general principle to which they commit themselves in the closing words of the report (paragraph 47):—`The health of the people is a prime consideration; economy secured at the expense of the people's health is prodigal waste of a national asset.'

"The almost unique position held by the Irish Free State as regards population makes the danger of subordinating health to pecuniary considerations greater here than in other countries. The Irish Free State is losing its population at a more rapid rate than any country in the world except one. The following figures taken from the Preliminary Report of the recent Census (p. 6) show the average annual increase or decrease of population per thousand of the several countries for which figures are available, based on the most recent Census returns:—

He quotes figures and points out that France tops the list in the way of losing population, and that Saorstát Eireann comes next. The average annual decrease per thousand in the case of France is 5.6 and, in the case of the Saorstát 3.7. There are two other countries, Austria and Belgium, losing population to a less extent than. France and the Saorstát. All the other countries—I suppose about 20 are quoted here—are to a greater or less extent, increasing in population. That makes me feel that anything we can do to help to improve public health, to help to stop the wastage of human life that goes on all over the Saorstát, we should do, and it appeals to me especially with regard to the city of Dublin, where, on the north side, the population is so dense and overcrowding so common that infants under 12 months old die at the rate of 170 per 1,000. That condition of affairs should not be allowed to continue and if we can help to improve it by the introduction of medical benefits into the insurance scheme the sooner we do so the better.

I am not going to deal with the other items in the Bill, or the various suggested amendments that are set out. On one or two there will probably be from our side at any rate a fair amount of discussion and a number of amendments submitted. The two big things that appeal to us, and on which we would like to do all we could to impress on the Ministry the desirability of holding back this Bill for the purpose of reconsideration, are the questions of simplification of the organisation—unification if you like or nationalisation—but simplification with a reduction of the cost of administration and the inclusion of medical benefit. The other matters are, I think, less important. They are perhaps important so far as the daily routine working of the societies and the Commission are concerned, but the matters of big national import that we think ought to have been dealt with courageously by the Executive are the two I mentioned. They have been ignored; the Executive for one reason or another decided not to legislate upon them, but to ignore the recommendations of the Committee, and the clamant demand that, I think, we have evidence of from insured persons—the inclusion of medical benefit. Because these two things have been ignored, because the Government for the time being has not thought fit to deal with them we ask that the amendment be adopted, that the Government be asked to reconsider the Bill, and bring it in later, including in it some scheme of simplification or unification, but certainly medical benefit.

Mr. T.J. O'Connell

This Bill is rather a difficult one to discuss on Second Reading, because it consists of a series of reforms or amendments of the existing Acts, and each section is more or less independent in itself, so that it is difficult to say what is the general principle running through the Bill that one could address oneself to at this stage. It is not a very easy Bill to understand or to follow. I was looking forward anxiously to the Minister's explanation of it, but he got through it so rapidly that it was not easy even to follow that. This is an exceedingly bad example of legislation by reference, as anyone can see who looks for a moment at paragraphs 2 and 3. There are numerous references there to old Acts which one would require to look up and study very carefully before he could form a definite opinion on the matter.

Undoubtedly, as Deputy O'Kelly said, the Bill does contain some administrative reforms that are, I think, generally accepted by the approved societies and by most people as being improvements on the present system of administration. The Minister mentioned some of them. There was, for instance, the question of the deposit contributors. That clause is being removed, and I think it is generally admitted that that will be an improvement. So far as the Bill facilitates general compliance with the Act in giving a right to insurance inspectors even to enter dwelling-houses at reasonable times, I think that that, too, will be approved, because the more general the compliance, the better it will be for all, concerned, and there is no doubt that this disability in the Act did have the effect of increasing non-compliance with the law.

There is the question of the abolition of exemption certificates, there is the question of specially giving power to follow up defaulters and to get them to pay up arrears, and there is the extension of the time for lodging claims from three days to seven days. All these, as I say, are generally taken to be improvements. But then again, there are some things to which serious objection is taken. For instance, serious objection is taken to the abolition of the insurance committees, and some of my colleagues who are more intimately associated with the work of these committees will perhaps have something to say on that aspect of the Bill. The question of the limitation of the rights of insured persons particularly in the matter of sanatorium benefit, and the question of the transfer of that to the boards of health are also objected to, and likewise there is objection to the fact that no provision seems to have been made in the Bill for the officers of the committees that are about to be abolished.

The question that arises for consideration is what action should be taken. In a matter of this kind, one has to weigh up the reforms that seem to be of advantage against those to which objection may be taken and see whether it is worth while to go on with the Bill at all. I have a certain amount of sympathy with Deputy O'Kelly's point of view, although I am not quite sure what exactly would be the effect of carrying his amendment. It would send back the Bill to the Government, but, at the same time, would that commit them or commit the House to the administration of National Health Insurance through one society? I would not like to give a vote, here and now, that would commit me to that policy.

Deputy O'Kelly seemed to treat simplification, unification and nationalisation as if there were no great difference between them, but he must know that there is a very great difference indeed, and I am sure if he would proceed a little further and read the whole of Dr. Rowlette's note in the Interim Report he would see that the difference between nationalisation and unification was stressed there. Dr. Rowlette wound up his note by saying: "Administration by a Government Department is the natural, logical, and economic method for a National Health Insurance system, and is in accordance with the most successful precedents established by other countries, with the exception of Great Britain. I recommend the adoption of this method in the Saorstát." He says, of course, that if the Government were unwilling to adopt that method he would take unification as the next best thing. I would like to see an examination, not alone of the nationalisation of National Health Insurance, but of other insurances, as to why there could not, and should not be a national scheme for other types of insurance as well as this. For that reason, I would not like to give a vote that would commit me simply to the unification of National Health Insurance by itself.

On the question or medical benefit, I have much sympathy with Deputy O'Kelly's point, of view again, although what I would like to see would be what was recommended by the trade union society—a national scheme of medical service, which is not exactly the same as the extension of medical benefits to insured persons.

As I say, it is a question of what line ought to be taken with regard to this Bill. I do not know that anything would be gained by rejecting the Bill here and now. I feel that what ought to be done would be to allow it to get a Second Reading, and that we should then do what we could to amend it. I do not know that the extension of medical benefits might not even be brought in as an amendment to the Bill as it stands, and discussed by itself on the Committee Stage. Perhaps that is a matter of order, but I cannot see why it could not be done. But I feel that each one of these reforms ought to be discussed fully by itself and on its own merits, and for that reason I think that the Bill ought to get a Second Reading. Subject to that, and subject to how far certain amendments which will be submitted will be dealt with, I would hold myself free to vote against it when it has left Committee or on the Final Stage. Therefore, I think the wisest thing to do would be to let the Bill go to Committee and endeavour to amend it in accordance with what we believe to be the wishes of the approved societies and of the insured persons generally and what would be to their benefit. If we thought that the Bill, after it had left Committee was not worth going on with, we could then vote against it. But I think that nothing would be gained by simply putting aside now such reforms as are in it and waiting. Undoubtedly the two questions of unification or nationalisation and of medical benefits or medical services require very careful investigation, investigation even more careful. I would say, than what has been given by this Committee, the report of which Deputy O'Kelly quoted. I think that that would take a very considerable time, and I do not think we should wait to get such reforms as we are getting in this Bill until those questions were fully gone into. Therefore, I will vote for the Second Reading of the Bill.

Mr. G. Wolfe

I would like to say a few words in approval of this Bill dealing with the administration of National Health Insurance. It has been obvious to everybody for a very long time that the Act of 1911, passed eighteen years ago, requires amendment after those years. When it was introduced, I was a member of a county council which had more or less to deal with it, and of the Insurance Committee, and I was of the opinion that it was then very faulty and that many things had been forced on the country which, if it had been left to itself, it would not have agreed to.

There was a very strong attitude taken by certain people in power, and they expected that what they said should be done and nothing else. They listened to no amendment or change that other people thought might be an improvement. I think that was the generally accepted thing at the time. I think this Bill has great possibilities in it. It removes a great many anomalies which ought never to have been in the original Act that was passed in the year 1911. I think the abolition of certificates of exemption is a very excellent thing. It will work well. This ought never have been included in the Act, and the provision, has worked out, as the Minister mentioned himself, most unsatisfactorily. I think it will be a great improvement that all members entitled to enjoy National Insurance should belong to a society and be more or less under more control than they are simply as deposit contributors.

An Ceann Comhairle

took the Chair.

Mr. G. Wolfe

As regards leakages, there is no doubt that in the matter of domestic servants alone a very large number of people make it their business if possible to evade paying for their servants. More shame to them. The servants have not, in many cases, insisted on their rights. This is a matter that will be set right by this Bill. That is a very necessary thing too. I think it is very difficult to say what the leakage in regard to this particular point has been. I think it will be found to be a very large one when the matter is investigated. I do not think that anybody has a right to complain if an accredited officer comes into a house and asks to see the cards that the domestic servants have, and see if they are kept in proper order and that each one has a card. I found in my own experience that a great many have passed through my employment who have come to me with no cards whatever, but who have been in many employments before. These cases are not exceptions. That is one thing, and an important thing, that will be stopped right away by this Bill which the Minister has introduced. I have never been myself a very great admirer of Insurance Committees. I never thought they were very arduous, nor did I think that the results were commensurate with the amount of fuss created when they first came into being.

I think in many cases a very unwise choice was made of the places for the establishment of sanatoria. Certain strong-willed people selected these places and insisted that the sanatoria should be built on these particular sites and on no other. To my knowledge, most unsuitable places have been chosen for these buildings. At least to the ordinary lay mind sites have been chosen that ought not have been chosen. That is a matter that calls for considerable attention. There is no doubt that sanatoria treatment is necessary, and I believe it has done a certain amount of good. The exact amount of good or the exact number of cures I have never seen set out. The doctors, no doubt, can tell us that. I think that a great deal more might have been done with regard to making them more efficient, to make them work better, and to induce people to go to them, which is sometimes a very difficult business, and one that has been found so from the very commencement. Deputy O'Kelly has an amendment on the paper with the principle of which we would all agree more or less if the amendment were feasible. One would have thought at first that when the Bills dealing with insurance were introduced in 1911 that that should have been done. It might have been done more easily then than now. In principle we would all agree that one society would be the best. But against that we have got to consider what the expense of this amalgamation would be, as well as the cost of a new Ministry which would be involved and all the other necessary expenses in connection with the suggested change. After all, this is not a matter to be lightly regarded. But perhaps in time, as the Minister says, if it could be carried out, some sort of amalgamation might take place which, of course, will reduce the number of societies down to a very low point, if not into one. The Minister is evidently most friendly to the idea contained in the amendment.

Medical benefit is a thing that everybody would approve of if that also could be done. It was given in the English Act, but, of course, it was more expensive, and for that reason it was not adopted here. Of the usefulness of this provision no one could have any doubt, but its feasibility is another question. Whether it could be done at this time is also another question. The Minister expressed his approval of the idea, as we all do. I think it is a very good thing that the matter of medical certificates should be settled, because that, in my opinion, has always been the crux. One doctor says: "It is not my business to certify about this man; where am I to get my fee for doing so; who is to pay me for this?" That is a matter that will be set right, and it is not a small matter, for while doctors are differing patients are dying. I think this Bill is a very good one, and a great improvement on what has hitherto been the law. Altogether I feel that in this Bill there are great possibilities, and I have great hopes that when it passes on to the Statute Book the combined genius of the Dáil will have put into it certain necessary improvements which no doubt will meet the approval of the majority of us and possibly of the Minister, too. I am sure the country will welcome this Bill. The people have been looking for this Bill for a long time. I hope and believe it will work well and will offer benefit to the poor of the country and to the workers of this country for the betterment of whose position it has been introduced.

Mr. Lemass

I was very much surprised to hear Deputy O'Connell announce that he intended to vote for the Bill as against the amendment. I think that his decision to do so was possibly due to a misunderstanding of the amendment. Deputy O'Kelly moved his amendment because it was obvious that when a Bill to give effect to the recommendations of the Committee was introduced which omitted any reference to the recommendations dealing with medical benefit and the unification of approved societies, it was tantamount to a declaration by the Executive Council that they rejected the recommendations of the Committee in these matters. If Deputy O'Connell and his colleagues persist in their attitude towards this amendment they will, I think, appear to be supporting the Government in this matter. Of course Deputy O'Connell did not positively state that his Party favoured the institution of medical benefit or the unification of approved societies, but he said they were prepared to give these proposals sympathetic consideration. I think I can say, however, without appearing to be a carping critic, that one would have expected the leader of the Labour Party to have made up his mind upon questions of this kind before now. Whatever agitation there existed in this country in favour of the institution of medical benefits and the unification of approved societies, it was largely due to the efforts of persons associated with the present Labour Party. That fact makes it very difficult for me to understand Deputy O'Connell's attitude now.

Deputy O'Connell said one thing with which I am in complete agreement. He said that if we are going to amend the system of social insurance in this country we should go much further than a mere patching up of the existing law and should endeavour to embrace within its scope a number of services which are now excluded. I think it is possible, and not merely possible but obviously desirable, that a scheme of social insurance should be enacted that would include health insurance, industrial insurance, pensions for widows and orphans and compulsory insurance for employers against their liability under the Workmen's Compensation Acts. I can see no reason why it should not be possible to include in the one scheme provisions dealing with all these matters. If unemployment insurance could be included as well, although that would be very difficult, you would thus be guaranteeing the worker against any of the various evils that he will have to meet and that may bring poverty and destitution upon himself or upon his family—unemployment, sickness, accident, old age or, finally, death. In other countries they are working towards the establishment of comprehensive schemes of that nature. It is only here we appear to be content with mere patchwork legislation that seems to have no particular aim at all.

Even if we cannot get the Executive Council or a majority of the members of the Dáil to take the step I have suggested of embarking upon a thoroughly comprehensive scheme of social insurance, I think we should expect to receive at least the support of the members of the Labour Party and a large number of the members of the Cumann na nGaedheal Party in pressing for the enactment of the improvements in the National Insurance Acts which have been recently effected in Great Britain. The provision of additional facilities under these Acts, such as has been enacted in Great Britain, was recommended very strongly in the report of the Commission dealing with the relief of the sick and destitute poor which was published here in 1927. They point out in the report that for a combined contribution of 1/6d. for men and 1/1d, for women there would be provided sickness benefit for twenty-six weeks at 15/- a week (12/- to women); disablement benefit at the rate of 7/6d. a week for men and women up to the age of 65; an old age pension from 65 to 70 at 10/- a week. At 70 years the old age pension would be paid under the Old Age Pensions Act, but without any further inquiry. If a husband has been insured for 104 weeks and dies, leaving a widow, the widow would receive a pension of 10/- a week. If she has children she would receive an additional allowance for every child beginning with 5/- for the first child and 3/- for every subsequent child. The children's allowance would continue if the widow marries again. Each orphan would receive 7/6 per week until he or she would reach the specified age, which is 14 years.

That scheme is in operation in Great Britain and they were able to graft these additional benefits on to the existing Insurance Act which is now in operation in this country. There seems to be no administrative difficulty in adopting similar legislation here. We have constantly heard Ministers tell us that the way to have unification in this country is to make conditions so attractive here that the people of the Six Counties will be very anxious in their own interests to come in. Instead of moving in that direction, we are going actually in the opposite direction. The gap between the Free State and the Six Counties is widening to our detriment. In the Six Counties, social legislation is being enacted for the benefit of the people there, and here we do not appear to be moving in that direction at all. I admit that these things cannot be done without money, but money must be found for them. If the job of financing such schemes is properly undertaken, I have no doubt it would be possible to bring them to achievement.

That does not apply to the proposals made in this amendment. The recommendation of the Committee, that at least medical benefit should be given to Irish insured workers, is one that has received the consent of every Committee that examined this question since a scheme of National Health Insurance was first instituted. Committees or Commissions have been repeatedly examining this question since 1913 and every one of them recommended that some system of medical benefits should be instituted. The reason is quite obvious. The National Health Insurance Acts were not passed merely to provide insurance against the loss of employment through sickness, but that is all, in fact, that they are doing. These Acts were intended to operate for the prevention and cure of sickness, and in that respect they have been a complete failure in Ireland. Nothing has been done to prevent sickness, particularly industrial diseases. Nothing has been done to cure them. We merely provide a payment to the worker for twenty-six weeks while he is suffering from incapacity, or 7/6 a week for life if he is permanently disabled.

The case for instituting medical benefit is that the Acts are not fulfilling their main function without it. The main function of the Acts is to improve public health, to provide for the prevention and cure of sickness, and to enable the State to have information at its disposal which would enable it to trace the causes of diseases, particularly of industrial diseases, and enact legislation that would be directed against their removal. Of course, there are other arguments in favour of medical benefits besides that. I am prepared to admit that the arguments against medical benefits are very strong, and any person coming to an examination of this question with a purely financial outlook upon it will probably find himself influenced against the institution of any system of medical benefit here, on the ground that some percentage of the insured population have already medical services provided for them free of cost under the Medical Charities Act. I am not at all sure that the percentage is anything like as high as that stated by certain members of the Committee. They allege, I think, that it is 75 per cent. I do not think that it is anything as high as that. Undoubtedly, a very large percentage of insured persons are in a position to get free medical service under the poor law, but they object to doing so because of the taint of pauperism which attaches to all charitable provisions of that kind. The ideal solution of the problem is to provide free medical services for all. There is no doubt whatever that Deputy O'Connell is quite right when he said that. This Committee recommended it as the ideal solution, but also pointed out that it would cost something like one and a half million pounds a year in excess of what we are now paying for the dispensary system, and that they could hot see any possibility of getting this sum made available for the purpose of providing free medical service. But if we cannot have free medical service, we at least can devise some scheme of medical benefit which will meet the particular difficulties that exist in this country. I cannot see why it should not be possible at least to provide medical benefit for the workers in urban areas, or why any scheme devised must apply uniformly to them all. There may be administrative difficulties. In fact, the whole plea made by the Minister against medical benefit and unification was the fact that administrative difficulties would arise. I think we have heard the phrase, administrative difficulties, so often in relation to the work of the Department of Local Government that we are beginning to wonder if there is any difficulty which the Department is capable of overcoming. They always seem to take the line of least resistance when they come up against a difficulty. Undoubtedly, it is not going to be an easy matter to devise a system of medical benefit for insured workers that will fit in with the medical charities system without considerable overlapping, but it can be done, I believe, if a serious effort is made to do it by people who realise the necessity for some such provision being made.

I believe that if we had a system of medical benefit in operation it would be possible to reduce very considerably the claims made for sickness benefit upon the Insurance funds. There is no doubt that if workers were in a position to get, free of charge, medical advice, there would be much less illness and consequently a much smaller drain upon the funds of the societies, which would result in the societies being able to pay additional benefits to their members.

Medical benefit would also provide, as has been pointed out, a very valuable check upon irregular certification. It will be generally admitted that there is a very considerable amount of what is called irregular certification. It is noticeable that some 40 per cent. of the cases referred to the medical referees have been declared by these referees as being fit for work, and every approved society meeting in the country that is reported in the Press always contains some reference to irregular certification. I have here the annual report published this year of the G.S. & W.R. Health Insurance Employees' Benefit Fund, and they say: "We are of opinion that the cause of the excessive sickness claims is due to lax and indifferent medical certification. We have no reasonable complaint against a great number of medical certifiers whose certificates come before us, but there are several who require a little more backbone in the faithful discharge of their duties to approved societies." If a system of medical benefits were in operation, of course any necessity for a separate expenditure upon certification would not be necessary, and irregular certification would cease to be one of the evils attaching to National Health Insurance.

The Committee on National Health Insurance elaborate in great detail a scheme of medical benefits. I believe that that scheme was workable if it had been attempted; but if, for any reason, it does not appeal to the Minister, or to the Executive Council, surely they are not going to let the question stand at that? They should go ahead and work out some other scheme of a less elaborate nature, if they think it is so advisable, but, nevertheless, some scheme to provide medical benefit for those insured workers who need it. It is not every worker that likes to secure medical advice under the Medical Charities Act. In fact, it is well known that there are a large number of workers who insist on paying for medical advice, even though they are not in a position to do so, sooner than come under the Poor Law, and these workers would be very glad to be in a position, as a result of their own contributions, to be able to demand free medical attention and medicine as a right.

While I am on that, I would ask the Minister to explain to us what will be the position of insured persons with respect to sanatorium benefit. In the past, insured workers paid a contribution which entitled them to such benefit. In other words, they got sanatorium treatment as a right, free of charge. They will continue to pay the same contribution, and we are told they will get sanatorium treatment now as in the past, except that it will be administered by the Board of Health instead of the Insurance Committees. But will they be entitled to get it as a right, free of charge? That is an important point that should be made clear.

Mr. Everett

Section 22.

Mr. Lemass

Sanatorium benefit is abolished, but the local government bodies who were getting money out of insurance funds and in return giving free sanatorium treatment to insured workers will still be getting that money, except that it will come from the State instead of from insurance funds. The insurance money, however, will be used to pay the cost of medical certification, which was heretofore borne by the State. The State is being relieved of a great part of the cost of medical certification which it met, and in exchange is taking on a liability to pay a contribution in respect of the upkeep of sanatoria for the local government bodies. The worker's contribution is not being reduced. The State's contribution is not being increased. Somewhere somebody is making something if the workers are being deprived of the right, which they had heretofore, of free sanatorium treatment. I can see no reason why the local government bodies cannot continue to give the insured workers free sanatorium treatment, as in the past, even though the Bill as it stands becomes an Act.

I think also that the case for unification—I will use that word as the best one that comes to me—of approved societies is very strong. It has been stated, and not contradicted, that 40 per cent. of the total contributions under the Act is now spent in administration. If that is correct, it is an abnormally high proportion, and I think it is greater than in any form of commercial insurance with the possible exception of industrial insurance. It is also said that with the unification of approved societies the cost of administration would be reduced by some sixty per cent. If that is correct, and I believe it is, then the case for unification is overwhelming because it means that insured workers throughout the country are being deprived of increased sickness benefit, or dental benefit, or hospital benefit, or some other form of benefit which they could have, in order to keep those numerous societies with their numerous staffs in existence.

Apart altogether from the fact that unification would result in cheaper administration, I hold that the pooling of results over the entire population when insurance is compulsory is really fundamental. We have at present various societies. One society is composed of certain members in certain sheltered, well-paid, comfortable occupations—a society that caters for bank clerks, for instance. That society will have a very small number of claims in relation lo sickness. Their members are in continuous well-paid employment and they will have at every valuation a big disposable surplus, with which they can give additional benefits to their members. Another society caters for dock labourers, who are in casual and unhealthy and dangerous employment, and it will have a very much higher number of claims for sickness benefit; the regularity of the contributions will be less and there will not be any surplus when the valuation comes about, and they will find it difficult to pay the minimum statutory benefits to members. That is not right. If we are to have compulsory insurance for all workers as the term "worker" is defined under the Acts, the results should be spread over all and every single member of the society. Every single insured person who pays a contribution—and they all pay the same contribution—ought to be entitled with every other person to any increased benefits that may be possible in consequence of a reduced number of claims over the three-year period or should be compelled to bear the loss if there is no disposable surplus in consequence of an increased number of claims over the three-year period.

There is no country in the world except Great Britain that devised that extraordinary system of administering a social insurance scheme. Here we have sixty-five societies, with sixty-five staffs and sixty-five sets of agents, who are often in competition against each other for members—healthy members, of course—eating up the funds that should be made available for the payment of benefits to insured workers. I believe that if we were starting this health insurance scheme now there is no one in this Dáil would be mad enough to suggest that we should adopt the system adopted in 1911 in order to meet the conditions that existed in England at that time. Opinion in favour of unification throughout informed classes of the population is very strong and not confined to any one class. I have here a report of a lecture given by Mr. L.J. Duffy before the Statistical Society, in which he said, speaking as a representative of the workers: "In my opinion the outstanding defect in the National Health Insurance scheme as administered in this country, is the approved societies system," and, in elaborating that view, he described it as "wasteful, inequitable and inefficient." At the same meeting Mr. J.C.M. Eason expressed similar views on behalf of the Dublin Chamber of Commerce; so when we find representatives of employers and employed who are all of the opinion that the present system of administration is wrong, surely it is not right that it should be continued merely because the Department of Local Government sees certain administrative difficulties in changing it. It can be changed, I have no doubt.

The Minister in his speech gave me the impression that the only difficulty that was worrying him was the necessity of having to make certain provisions for redundant staffs of these approved societies. In other words, that they might possibly have to be supported out of the Exchequer for a period instead of being on the funds that should be available for the payment of benefit for the sick insured workers. The system is entirely wasteful. It could not be anything else when you have sixty-five societies very often in competition with one another. It is inequitable. The result of a compulsory insurance scheme should be spread over every person included in that system. It should not be possible for any one privileged section to cut themselves off from the rest and enjoy additional benefits. It is inefficient. There are, I am sure, a number of towns in this country with three or four hundred workers and twenty or twenty-five approved societies competing among themselves to get these three or four hundred workers included on their membership roll.

The Minister has informed us that he is going to put certain proposals before us at the Committee Stage. He is apparently under the impression from the figures relating to the number of approved societies that there is a tendency towards amalgamation. There is possibly a tendency towards amalgamation, although it is not unlikely that a number of those societies that disappeared, disappeared because they had not been properly managed, and the Insurance Commissioners wound them up when they found they were not able to carry on. The tendency, therefore, is bound to become less noticeable as the number of approved societies decreases. When we see a drop of ten or twelve societies at the end of the two or three years' period we think we are making fast progress, but as the number of societies grows less and less the tendency towards amalgamation will grow less. I do not think the proposals the Minister has put before us to give certain facilities for compensating redundant staffs is likely to help the process towards unification to any great extent. Even if it did, and if in five or six years' time we found there were eight or nine or ten or twelve approved societies I still think that there would be seven or nine or eleven too many. My view is that we should administer the National Health Insurance through one society. I am against nationalisation. Amongst the workers of Dublin with whom I discussed this matter the strongest argument they could advance against unification was that the ultimate result would be that National Health Insurance would be administered as Unemployment Insurance is administered. No one will say that the administration of the Unemployment Insurance is right. In Dublin at present it is administered very much as outdoor relief is administered. The workers are getting unemployment benefit not as a right for which they have contributed but as a form of charity, and they fear the same spirit would come into National Health Insurance if it was administered as a State Department.

Our view is that a new organisation should be started by the State with branches throughout the country, controlled by regional committees, to which there should be transferred all members of existing approved societies just as in this Bill you are proposing to transfer deposit contributors to approved societies. I cannot see any administrative difficulty in getting that done. There may be certain temporary provisions which will have to be made and certain precautions which will have to be taken to ensure that no insured person will suffer in consequence of the new arrangements. Certain provisions will have to be made to provide for the redundant staffs of approved societies. These things could and should be done. Even if a certain amount of expenditure may be involved at this stage to bring about that change it will more than repay itself in the saving in administrative costs which will result. If we can get down the administrative costs by 60 per cent. through unification then let us get unification. If the Ministry of Local Government see too many difficulties in the way I suggest that they should set up a Committee of the Dáil to show them how to do their work in that connection. The same remark applies to medical benefits. If they desired to set up a proper system in the Department of Local Government they would long since have got over the administrative difficulties about which the Minister talks. He tells us that the time has not come when we can come to a conclusion as to the most satisfactory method of administering or financing a system of medical benefits. If we wait for the Ministry of Local Government to come to a conclusion as to the most satisfactory system of administering medical benefits we will have to wait a long time. I believe that the Dáil should force them to take action by refusing to pass the Bill until they have made provision, as the amendment asks, for the administration of National Health Insurance through one society and for initiating a scheme of medical benefits for insured workers.

Mr. T. Murphy

In the statement made by the Minister he pointed out that the effect of the Bill would be to make certain economies. Certain economies are proposed under the Bill which would be desirable, but there are other economies which in my opinion would be very undesirable. I agree with what has been said in regard to getting rid of the term "exempted person." I believe that it is desirable that we should have unification in that respect at any rate. That would apply to people who are called deposit contributors. I want to touch on what I consider to be a very serious proposal, a proposal to confiscate the rights of insured persons in regard to sanatorium benefit. This is confiscation pure and simple, and it is entirely unjust. In so far as my view of that matter goes, I am opposed to that proposal anyway. It is also proposed that the work carried on by the insurance committees in the matter of administering sanatorium benefits is in future to be carried on otherwise. I heard with some surprise the statement made in the course of the debate that insurance committees did little good and that there was too much fuss about them. I do not think that that is a fair statement of the facts. I think that the major portion of the work to educate people in the matter or the treatment of tuberculosis and to eliminate tuberculosis has largely been carried on by insurance committees. From that point of view I feel that it is quite wrong that that work should be taken out of their hands. What are we going to get in return? Boards of Health will be asked to administer sanatorium benefits in addition to their ordinary work. Members of these boards are up to their eyes in work in connection with labourers' cottages and so forth, and cannot be expected to take on themselves this additional service. The service will be materially injured if that course is adopted.

Again, what right has the Department morally to steal from people who are paying National Health Insurance contributions for certain State benefits and to ask them to go to boards of health to receive treatment as if they were destitute persons? They are not destitute, because the Act of Parliament that provides benefits for them settles their rights. It is unfair to filch these rights from them and to put them into the category of people who are destitute and who have to receive treatment in that way. In some cases, at any rate, insurance committees have gone far in their efforts to treat cases of tuberculosis, even to the extent of sending people out of the country at considerable expense to get treatment. Does the Minister believe that the Boards of Health, having many other financial commitments and being mainly composed of people who are out to save money at any cost, will give the same facilities to insured persons as were given by insurance committees? I say that they will not. It will simply mean that consumptives will be dumped in the county home. That is a serious position, and I will oppose that proposal so far as I can. On the other hand, I am glad that there is a proposal in the Bill to enable Commissioners to recover all arrears of contributions.

While offences committed for retaining contributions of this kind might be met by a fine hitherto, the person who had to be insured would suffer, because all the contributions could not be recovered. In that connection, in my opinion, one of the reasons why there is such irregularity in the matter of paying insurance contributions is, to some extent, the manner in which the Commissioners deal with cases of this kind. Ordinary cases of non-compliance are dealt with in a too round-about way. In my opinion the interval that is allowed to elapse between the time when the inspector reports cases of non-compliance and when the file comes back from the Department is too long, much longer than is necessary and too much time is taken up in dealing with cases of that kind. I think that the National Health Commissioners have to shoulder a good deal of responsibility for that position, and I am glad to see that an effort is being made in this Bill to put an end to it. I think that a Bill of this kind should contain provisions for medical benefits, but I am quite clear that it is not the best way to secure that by simply rejecting this Bill. There are valuable provisions in the Bill, and I am not prepared to take the responsibility of voting for the rejection of the Bill because of the omission that has been referred to. I cannot see any reason why this whole matter could not be gone into on the Committee Stage by an amendment brought in on that stage. I remember when the National Health Insurance Act of 1911 was being passed a very strong demand was made in this country for the inclusion of medical benefit. One has only to remember what the position was then and how useless it was to criticise an Act that was brought in with the benediction of our own representatives at that time. I think the attitude taken up by Deputy O'Connell in this matter is the sensible attitude, because it permits of an examination of the whole question. While I am opposed to the elimination of insurance committees and the filching away of the rights of insured persons to sanatorium treatment, I am prepared to vote for the Second Reading of the Bill and to reserve my right to change my attitude on certain points on the subsequent stages of the Bill.

Mr. J.J. Byrne

As Deputy O'Connell has stated, this is a very difficult Bill for the ordinary individual to understand. The one thing that I am anxious to ascertain is whether insured persons enjoy under the Bill the same advantages they enjoy under the 1911 Act. I have been informed that the 1911 Act was not the perfect instrument that some of us here have been led to believe it was. I have been told that under the 1911 Act funds were frequently insufficient to give sanatorium treatment, and that under that Act it was a case of first come, first served. I am assured that under the present Act everybody is entitled to sanatorium treatment, and that the position of insured persons will be identical with the position they enjoyed under the 1911 Act, except for the difference that everybody suffering from the scourge of tuberculosis will receive treatment under the Act. Nobody will be neglected. It is a decided advantage to insured persons, and even to uninsured persons, that persons who are or are not insured under the Act will be entitled to this treatment.

Two objections were made by the Opposition to the Second Reading of the Bill. The first was under the heading of unification, and the second on the question of medical benefit. I think the Minister has very effectively dealt with the first objection under the heading of unification. He has promised to introduce, on the Committee Stage, an amendment dealing with unification, first dealing with it on a voluntary basis and then, after a period of two years, dealing with it on a compulsory basis. I think that that is a very reasonable amendment and one that should meet the opinion of all sides of the House. A period of two years will not be very long to wait until we have compulsory unification introduced, if it has not been completed in that time. I think the attitude of the Minister on the question of medical benefit was eminently reasonable, because he pointed out that the whole question of medical benefit was an exceedingly difficult one, and that admission was made by those who spoke against the Second Reading of the Bill. He said that in his opinion it would be necessary to survey the whole question in conjunction with the Free State dispensary system. Much has been said against the Free State dispensary system, and suggestions have been made that the taint of pauperism is connected with it. In my experience of the City of Dublin, I know a great many people who avail themselves of the dispensary system who could afford to pay a doctor, and I do not agree with the contention that any taint of pauperism attaches to that particular system.

The one reason I rose to speak on the Bill was to ask what will be done for the redundant officials whose redundancy will arise under the abolition of the Insurance Committees. The Minister has promised compensation for disemploycd officials under the voluntary scheme of unification which he proposes to introduce on the Committee Stage of the Bill, but the Minister has said nothing at all as to what will be done for those disemployed under this Bill when it becomes law. These are difficult times, as everybody knows, for a person who becomes disemployed to endeavour to find any means of earning a subsistence. I ask the Minister will it be possible for him to introduce an amendment on the Committee Stage to give disemployed persons, who are disemployed owing to the passage of the Bill, some reasonable compensation for the loss of employment. I would urge that there have been many precedents for that, and I cannot see why these people should not receive the same treatment under this Bill as other officials have received in different places on similar occasions. In England compensation for displaced officials has been given under two Acts.

I understand that under the Transport Act of 1919, and also by Section 121 of the Local Government Act of 1898, such compensation is given. Under the latter Act, for an actual service of twenty years there was an addition of ten-sixtieths, and there was a graded scale of compensation for officials whose services ranged from twenty years down to five years. I would ask the Minister to incorporate a similar provision for the compensation of dismissed officials in this Bill. There is an analogous case and a Free State precedent for the incorporation of provisions for compensation such as I ask. Under the Railways Act of 1924 a similar basis was adopted in the case of displacement of officials, and those who had less than five years' service received a payment of one-sixth of the annual salary and emoluments for each completed year of service instead of an annual allowance. Why should officials who have rendered good and faithful service to the State on the Committees not receive the same compensation as has been meted out to other officials? I would strongly appeal to the Minister to give us a promise on the Second Reading of the Bill that he will at least mete out the same measure of justice to those who will be displaced by the passage of the Bill, as has been given to similar individuals on similar occasions.

Mr. Everett

I wish to support the plea of Deputy Byrne on behalf of the officials. The Insurance Committee formerly consisted of representatives of the Commissioners, representatives from the insured persons, and representatives from the contributing bodies. Under the 1911 Act an insured person was entitled to sanatorium treatment for either himself, his wife, or his dependants. Under the present Bill an insured person will continue to pay for sanatorium benefit, but he will be at the mercy of the Board of Health as to whether he will receive the treatment or not. At the present time non-insured persons are being given treatment under the county scheme. Non-insured persons, children and others, are entitled to receive sanatorium treatment, but no such treatment as insurance committees give will be given by the Board of Health. In the first place, a large number of the members of the Board of Health will have no experience of the administration of sanatorium treatment, and I doubt if many members of the Board of Health will sanction treatment in a sanatorium or treatment in a foreign country, or give treatment to dependants of an insured person, children and others, for two or three years in the various hospitals in Dublin.

I believe that this Bill has been brought in with a view to assisting ratepayers and with a view to assisting in reducing the cost for sanatorium treatment under your new county medical officers scheme. The Minister stated that nearly all the insurance committees had made agreements with county boards of health. I am aware that the Minister's Department sent out circulars to county boards of health urging them to endeavour to make agreements with county insurance committees—to get the insurance committees to make agreements with them so that the boards of health could use the funds of the insurance committees to give sanatorium treatment to non-insured persons. I am also aware that certain insurance committees refused to come to any agreement with the boards of health. They took up the attitude that as they were appointed to look solely after the interests of insured persons that their funds would be used solely in improving the health of the sick people insured with them. A number of county councils had a scheme for the treatment of people suffering from tuberculosis. Other county councils refused to provide anything of the kind. They took up the attitude: "Let the county insurance committees appoint persons." One Deputy said that he was not aware of any great fuss being made by the insurance committees. That, I suggest, shows a want of knowledge of the work done by insurance committees. Insurance committees desire to treat all their afflicted members in secret. They do not want the Press to be present, because reports might be published indicating that the number of afflicted people had increased within a certain period. The work is done quietly. I might say also that the work is being carried out at a very small cost to the Government. I should say that not 5 per cent. of the cost of the administration goes for sanatorium treatment. The proposal is to displace the existing officials.

If this Bill is passed the work will be under the control of the County Boards of Health, and you will have to appoint extra officials. Existing officials deprived of their positions will have to be pensioned. It will also mean the creation of new positions under the Boards of Health for the purpose of carrying out the Act. I appeal to the Minister to leave the administration of sanatorium benefit for insured persons as it is at present with the Insurance Committees. The insured persons have their representatives on those committees. The Government, through the Insurance Commission, have their representatives on them as well as the contributing body. But if the administration is to be carried out by the Boards of Health the insured persons will cease to be entitled to any benefit, because Section 22 of the Bill says that benefits in the matter of sanatorium treatment will cease after the 1st January. The result will be that the insured person will have no voice in the administration of the Act. Speaking from my experience of members of Boards of Health, the insured persons paying for benefits that they are now being deprived of by Act of Parliament will have my greatest sympathy. At present in my county the Board of Health is carrying on work that was formerly done by five rural district councils and four boards of guardians. That Board is obliged to hold two meetings in the month. When the work under this Act is added on the Board will have to hold an extra meeting each month. As it is, the members of the Board are overburdened with the amount of work they have to do. I defy any member of a Board of Health to say that all the work relating to the housing schemes, sanitation and various other matters connected with the social welfare of the people can be properly attended to in the few hours allotted each month for a Board meeting. The work is being rushed, and is not getting the attention that it received formerly when you had five district councils and four boards of guardians attending to it. I agree that some of the amendments proposed in this Bill are good. At the same time I would appeal to the Minister to bring in amendments to meet the points that have been put to him from these benches. If he is not prepared to do that, then we intend to bring in some amendments. I, like Deputy O'Connell, reserve to myself the right, if the amendments which we have indicated are not accepted by the Government, to vote against the Bill on the final stage.

I should like to say to Deputy Lemass that we are not out against medical benefits. Deputy O'Connell has clearly stated our position. We want to consider the matter carefully. Speaking for myself, I am not prepared to rush in and vote for a Bill to give medical benefits to men who are only in receipt of 30/- a week. At the present time 70 per cent. or 80 per cent. of the insured people in my constituency are entitled to free medical benefit. They avail of the Charities Act for their benefit. Therefore, I am not going to give any promise before I see the Minister's Bill, which may increase the contributions from those men who are only in receipt of 30/- a week merely for the sake of giving to 30 per cent. benefits that they can afford at the present time. An insured person getting medical benefit may have to pay an increased contribution. He cannot very well afford to do that out of a wage of 30/- a week. Until the Minister brings in a Bill, or until Deputy Lemass introduces an amendment giving an indication as to how the money is to be raised, I for one am not prepared to Support this Bill. On the Committee Stage, I propose to introduce amendments with a view to improving it. The Minister has made a promise as regards the voluntary winding-up of certain insurance societies that he will treat the officials by giving them compensation for loss of office. I say that the clerks engaged by insurance committees are entitled to no less generous treatment than officials received under the amalgamation scheme. I hope that the insured people throughout the country will realise the seriousness of this Bill. This Bill has been brought in for the purpose of dealing with insurance. It is good in some respects, but I certainly object to the section which proposes to deprive insured persons of rights and benefits for which they have been making provision by their contributions since 1911.

Mr. Derrig

I desire to support the amendment standing in the name of Deputy Seán T. O'Kelly. Some members of the Dáil seem to be prepared to take this Bill very easily. They know that when the Estimates are discussed here annually we are precluded from discussing matters upon them which should rightly be dealt with by legislation. The National Health Insurance question is one that has been considered by several Committees and Commissions. This is the first opportunity that this Party, at any rate, has had of discussing the question from the legislative point of view. We, therefore, are anxious to impress upon the Government the necessity for taking steps to reorganise the whole system, if possible, before this Bill passes through all its stages. The Minister's opening statement, in which he gave us a brief explanation of the different clauses in the Bill, was, to my mind, unsatisfying. I could not gather from him what are the ultimate intentions of the Government. The amendment of Deputy Seán T. O'Kelly has done good work in so far as it has forced from the Minister the promise that the question of unification will have to be considered, and that definite steps will have to be taken, to bring it about after two years, whether or not progress may be made before that time. But, I wonder why the Minister could not have taken steps before this, because the Commission which sat in 1924 recommended unification. Surely the National Health Insurance Commissioners, in collaboration with the Minister, must have discussed this question. It seems extraordinary that the only reply of the Minister to the question for or against unification is to rush along when he has failed to include it in the Bill in the first instance and to say, "I am going to bring in an amendment to deal with that." We want to know the arguments against unification. If there are such arguments I have not heard of them.

The only people opposed to unification, it would seem, are the approved societies. If that is clear we have advanced so far. The question is what are the arguments the approved societies are able to put forward? One of their arguments. I suppose, would be that in the future National Health Insurance was liable to be extended. "The system will expand," they say, "as in England, and if you want to expand and improve the system you will want us, the approved societies." The Minister has not given the faintest indication that there is going to be any extension of benefits, and, therefore, that makes the case in favour of unification very much stronger. I cannot for the life of me see why any member of the Dáil should not force the Government to take this question in hand now and not in two years time. As regards the question of medical benefit, it seems to me that if medical benefit is not in our National Health Insurance scheme why call it a health insurance scheme at all? As an English writer said recently, call it a burial insurance scheme if you like, or some other insurance scheme, but if you are not going to provide for the health and proper treatment of your contributors do not persist in calling it a National Health Insurance scheme.

Deputy Byrne says that the present scheme is not perfect. We know it is not perfect. It is almost twenty years in operation, and there is no reason why our Irish Government should not attempt to improve upon it drastically if they see fit. If the position is that they feel their difficulties are too great and they cannot overcome them; that the expense is too great, or that the trouble of organisation cannot be undertaken for some reason, let us know the reason. It may be the case, and I believe it is, that the Government have not been able to make up their minds on this matter, and that they are taking advantage of the fact that this whole question of national health insurance, which is a very technical question, as it is obscured in a maze of technicalities that the ordinary man in the street cannot understand, and I think that even the ordinary T.D. no matter how much he burrows will fail to get to the labyrinthian recesses of the operations of the approved societies; but no matter what the difficulties and technicalities are the fact is that the keystone of the are is not there —that is medical benefit. In my opinion the National Health Insurance scheme without medical benefit is like the famous canal we have in the west of Ireland which connects Lough Corrib with Lough Mask, and which like more of our canals is sadly in need of traffic and navigation, but it is also in need of water owing to the fact that it was made of porous limestone and the water could not be got to stay in it. The money for the National Health Insurance scheme seems to be going through some porous limestone or other represented by the central administration, the approved societies and the various other expenses of administration, and the thing that ought to be there as a very real safeguard for the people, the original idea of the whole system of national health insurance, the prevention of disease, is not there.

There are a number of arguments against medical benefit. The Labour Party have refused to support this amendment, but they have stated no arguments against medical benefit. I do not think they could very well do so. They say they are compelled to vote for the Bill as against the amendment. In doing so, in my opinion, they are putting back the question of medical benefit, and this is an opportunity for the Labour Party, as well as for any other members who are interested in this question, to take up the question of medical benefit and try to get the Government to do something, for goodness knows when legislation will be introduced again. Deputy Murphy says that valuable concessions have been given. I would like to know what the valuable concessions are. He seemed to be talking against them most of the time as if they were disadvantages. As far as I can gather from the trend of his remarks, he is highly dissatisfied with the idea of taking away sanatorium benefit. He thinks that is very bad, and he does not approve of the abolition of the Insurance Committees. How he can come around later on and say that the Bill gives valuable concessions while those two features are radical parts, and of which he disapproves, I cannot understand.

I fail to see how he can get in his amendments on the Committee Stage. The important points outside administrative changes are the abolition of insurance committees and the abolition of sanatorium benefit. I fail to see how any other question, although there are many bigger questions, can be brought in. The Second Beading is, to my mind, the time to point out what is not in the Bill, and not to be trying to get things in afterwards, as the Ceann Comhairle has often explained, that should be brought in on the Second Reading. It is going to be pretty difficult to do so later, if I know the Ceann Comhairle. There are a great number of arguments against medical benefit. The Local Government medical expert says that one argument against it is that we are very well provided with medical attendance at present. He says we have a perfect network of medical facilities in Dublin. I doubt that very much. You have facilities in Dublin because you have a large number of hospitals which look after the sick poor, but the Insurance Commissioners are not paying the hospitals for the treatment the hospitals are giving the sick poor. In any case, whatever treatment the poor people may happen to get gratis in hospitals has nothing to do with the question of dispensary service, which, in the opinion of this expert, is a thing that makes additional medical benefit under the Insurance Act unnecessary.

He says we have three-fourths of our insured persons getting dispensary service free. Dispensary service, if I might say so without offence to those who practise it, very often consists of a bottle of medicine. What the bottle of medicine is nobody knows, least of all the people who are getting it. They have the idea that since they are entitled to free treatment and since there are bottles of medicine going, if they can get a bottle of medicine that is all right. That is the great idea with many people as regards free dispensary service. At its best dispensary service can hardly he said to be treatment for the prevention of disease. You want to carry on that treatment for a long period of time, and you want to have a place for hospitals in your scheme, so that people will not have to rely on a bottle of medicine and a few words from the doctor, but that they will have continuous visits from the doctor. If necessary the scheme should provide for the transfer of these people to the hospital. The dispensary system, in many places, is not satisfactory. I do not know whether the doctors or the patients are to blame, but I am sure every Deputy knows that the red ticket system is not operating as it was intended to operate, and that the sick poor are not getting the benefit of that red ticket system. In the west of Ireland it is well known that the dispensary doctors are paid, though the medical expert says that the dispensary doctors are giving free treatment. In the report of the Poor Law Commission, which has gone so far uncontradicted, you have evidence given that the poor people always pay the dispensary doctor when they get his advice and his bottle of medicine, but I am not concerned at the moment with whether they pay or not.

What I am concerned with is to try to build up a proper organisation under National Health Insurance. The National Health Insurance Commission themselves said that the dispensary system should be taken over; either transfer the whole thing to the Department of Local Government and make it a public health branch, or else abolish the dispensary system and create a new system on the lines of the panel, where you will not have the present system where the poor people are paying perhaps out of proportion to their means, and other people who can well afford it avail of the dispensaries and pay nothing. If that is the case in the city of Dublin it is not the case in the country. I know rich people, who can well afford it, come up to the city of Dublin hospitals and take advantage of whatever free treatment they can get there. We ought to try to distribute the expense. Our contributors have been paying the same as the English contributors for the past 20 years, and they have not got this medical benefit, and although sanatorium benefit was abandoned in England lately the English seem to have given a great number of additional benefits, so that nobody can say we are following the English example.

We are following the English example all right in cutting off sanatorium benefit, but we are not following the English example in trying to effect economies or give additional benefits. We have the position that our contributors at present are paying, I think, 7d. and 8d. per woman or man as against 4d., which was the cost to the contributor weekly originally, and there is no improvement practically in the value of the service given. At the same time the Minister for Local Government, when he sees fit, increases the salaries of dispensary doctors in Mayo without consulting anybody. Now I ask him to turn around and consider the condition of the people whom those doctors are supposed to look after, and if he is reorganising this scheme and wants to improve it, to weigh up the whole question of the dispensary system and try to put it on some basis such as the panel basis

It was mentioned by Deputy Sir James Craig last year in a debate here that some 18 out of 31 societies had some forms of medical benefit. They call it medical benefit, and the Minister told us in his opening speech that those societies which are giving extra benefits to their members are expending £34,000 yearly on that. Is not that an argument in favour of medical benefit? Certain societies have had to go out of their way and make special arrangements for hospitals and practitioners for giving extra treatment to their members, and other societies have no treatment whatever, and the position exists that a member of one society has certain extra benefits, dental treatment or some other medical benefit, and a member or members of some other society has no such benefit. The whole thing ought to be reorganised and uniformity enforced, so that people in the more distant country districts, who have to suffer heaviest in this particular case because they have not the facilities at their door and because the cost of administration is altogether too heavy to enable them to be catered for properly, would get as good treatment as the people in the cities.

The dispensary system is not enough to start with if we really want national health insurance, which means cutting out disease, reducing the number of deaths, and keeping the largest possible number of people in employment. As has been pointed out by other speakers, you have a system of medical certification. You are going to take this £36,000 from the tuberculosis people and leave them at the mercy of the County Boards of Health. The County Boards of Health are already grumbling about the unsatisfactory provision made for the tuberculosis patients they have to treat in the ordinary way. Only yesterday I received a letter from the Kilkenny Board of Health asking me to try to get the Government to increase the amount which is available per head for the treatment of tuberculosis patients from 1/2 to 2/6. In Kilkenny there are only a small number of tuberculosis cases. Perhaps that is the reason that there seems to be such disparity between the costs. They are only getting 1/2 and they have to pay 2/6. They complain that in other matters, such as mental homes, they are not getting the support, which is still based on pre-war, which they ought to get from the central Government, in view of the new conditions and the great increase in wages and the cost of living. Now we are going to hand over the tuberculosis patients, as Deputy Murphy pointed out, to the Boards of Health, who are concerned with reducing expenses, reducing the rates, and who feel that the eyes of the ratepayers are upon them at all times. As Deputy O'Kelly pointed out, in reading Dr. Rowlette's statement, you cannot carry on public health departments from the efficient point of view of maintaining the health of your population, of doing your utmost to preserve them in the healthiest condition possible, if you are going to be concerned in cutting down expenses at every turn.

You cannot therefore throw the whole responsibility for this work on the Boards of Health. In any case if the Boards of Health were experts in this matter and knew exactly how this whole question should be tackled in their respective areas they are too small in numbers to cover the areas. You cannot have tuberculosis patients going to the members, of the Boards of Health. On the other hand it extra provision will have to be made, as I am sure it will have to be made, how is the Minister going to get the Boards of Health to make it? They are already complaining everywhere that the cost of home assistance is too high. This, in my opinion, is a confession of failure, it is burking the issue. You are shifting on to the local bodies something you have not even attempted to solve yourself.

I hope Deputy Sir James Craig or somebody else who knows something about tuberculosis will tell us how tuberculosis should be tackled in a national way. Certainly that is not tackling it to put the whole onus as an additional side-show on the local bodies. You are taking, as I said, this £36,000 and you are no longer going to spend it on sanatorium buildings. Where are you going to put it? The approved societies say that this money is going to go into medical certification. While we are abolishing sanatorium benefit because we are told it is uneconomic and that the expense and trouble of the insurance committees is too much and should no longer be maintained, we are turning around and giving this £36,000 for medical certification. What use is medical certification without something following it? If it is part of medical benefit it is all right. If you are going to stop there, just paying a doctor for issuing these certificates, what on earth is the use of that to the nation? Let us for goodness sake increase that £36,000 and give an inducement to the doctors to give treatment. Let us try to build up a system whereby not alone the dispensary patient but any other patient can get, in the very beginning, a better system than they are getting at present, a better service than the ordinary dispensary and the bottle of medicine which they are so anxious to have, so that they will get proper diagnosis and proper treatment from the local practitioner. Let us try to build that up, giving them hospital treatment. Let us try to establish contact. That is the way in which I believe the Minister could save a great deal of his expenses when he does amalgamate all these societies. When he does make up his mind to establish medical benefit let him get into direct contact both with the doctors and the hospitals.

I have not a word to say against insurance committees. I believe that such bodies should be kept in existence where possible. It is a very bad thing to leave everything in the hands of paid officials, even if they are doctors. By all means, have nominated committees if you like. Not that these committees can control the doctors. If the doctors do not want to do the work properly no coercion will make them do it. Let us take them into our confidence and start this business of medical benefit properly.

I see in this an argument in addition to the argument that the dispensaries are already catering for the sick poor, that the cost of medical benefit would be too great— the case that is suggested by the insurance committees which, I think, lacks that special knowledge of the matter that Deputy O'Kelly referred to, special acquaintance with the details of administration that would make their estimate very valuable or would make it absolutely beyond question, the estimate that medical benefit would come to 2d. per week, a penny for the employed person and a penny for the employer. In England under this system of hospital treatment a patient can get treatment for a whole week in hospital for a contribution of 3d. per week. Of course, these hospitals work cheaply, and, in fact, one of the necessities of the scheme is to try to get, as I have been emphasising, as much voluntary labour as possible, and not to leave everything to paid officials. If in England the cost works out on an average at 3d. per week for medical treatment, surely the cost of contribution in this country ought not to work out at 2d. per week. There ought not to be such disparity, and I believe that that 2d., which undoubtedly would be a burden upon the population, could be reduced. It could be reduced very largely by unification of the societies, as has been suggested. It could be reduced very largely by including all the classes of the community that are still outside the national health insurance and who are getting less than £250 per annum in any kind of employment, as in England. To bring everybody in would bring in additional finance, and additional finance would mean additional economies in administration. You would have more money coming in and you could reduce your overhead expenses. As well as that I believe the Minister should have at his disposal men—medical men preferably—who know this business and who would organise a system of medical benefit and put it on a proper and up-to-date, basis, who would have direct contact with the hospitals and the local practitioners. At the same time, they should have advisory bodies, some such bodies as the organising committees which the Minister is now abolishing. A great many complaints have been levelled against these committees, that they never did their work. But, unfortunately, public opinion was not in touch with these committees. These societies, as Deputy Murphy said, worked in the dark. Nobody was interested in their work. That is the case of a great number of voluntary workers in this country. Before we scrap all the voluntary work that is being done—good work in connection with public health—and appoint paid officials, let us hear what these people have to say. Let us try to keep them on. They do not cost anything, and it is useful to have impartial people who have given their time to one branch or another of philanthropic work.

Dr. Hennessy

For personal reasons, I did not intend to take any part in this debate. I came in to listen, but I have heard so much that I feel forced to make some remarks. Deputy O'Kelly has dealt with two aspects of the Bill, or rather with two aspects that the Bill does not provide for, that is medical benefit and the unification of societies. Take the unification of societies. Like Deputy O'Connell, I would very much prefer nationalisation. I need not go into any details as to why I would prefer nationalisation to unification. Enough has been said in the debate to show that nationalisation is very much preferable to unification. Sanatorium benefit has come in for a good deal of criticism. Sanatorium benefit has been very unsatisfactory in the past, but I cannot conceive any change in this Bill that will put it in a worse position. Taking it merely from the Insurance Committee to the Health Board is not in itself a defect. We have too many local bodies administering health matters in this country with the result that it is nobody's business in the end. Sanatorium benefit had one great defect in the past. Even where a patient had too long to wait to get his treatment in a sanatorium, when he had made substantial progress in the sanatorium and when he came to be discharged he had to go back to very unsuitable and unhygienic surroundings. There was no suitable work provided for him, and it was a grim necessity for him if he was the father of a family to find something for his dependants. The work that should be provided should be suitable work for a convalescent from a sanatorium. The housing with which we are making considerable headway, but still comparatively slight, is a very important fact in combating and preventing tuberculosis. Sanatorium benefit, whether administered by the Insurance Committee or by the Health Board, should be purely dealt with as a question of contract. I believe that the Minister for Local Government will see that it is dealt with as a contract and that the insured people will get the benefit of the contract without any undue delay.

The question of medical benefits has been referred to. I think that Deputy O'Connell's attitude when he said that he would prefer a national medical service, was misunderstood. He and the Labour Party have been charged with being against medical benefit. The fact of being in favour of a national medical service is certainly in favour of medical benefit, but on a very much larger scale. A national medical service and the abolition of public health boards would not only provide medical benefit for the insured person but would also provide free services for the dependants of the insured person and for poor people generally.

The poor law medical service has come in for some criticism. I am thinking that Deputy Derrig's medical colleagues will resent or feel inclined to resent his description of the treatment given by dispensary doctors. I was a dispensary doctor myself for twenty years, and I consider it a slander on me and on most of the men I knew who did that work. I am not saying that the Poor Law medical service is an adequate service. I will give you some figures in a moment that will show you how it must fail in giving a proper medical service to the people, be they insured or be they poor persons.

I will take figures for the city of Dublin, and I will quote statistics from what I call a normal dispensary district. This district has two dispensary doctors who are euphemistically described as part-time officials. When you hear the work they have to do you will see what truth there is in that description. I admit they are part-time officials to the extent that they get miserable salaries. Taking the average for three years there were attended at the houses of the sick in one year by these two dispensary doctors—which I shall call domiciliary visits, meaning acute cases which were not fit to come to the dispensary—3,316 persons under the Medical Charities Act. At the dispensaries they attended 19,944 new cases. That makes a total between the domiciliary cases and the cases attending the dispensary of 23,260, persons. These were attended by two doctors, and taking the average attendance, which might mean anything from four to six visits for each person— in one case it might mean only one attendance, but in another case it might mean ten to twenty attendances—they had to give anything from 80,000 to 100,000 attendances. How could any two doctors do that? Two doctors were called to afford medical attendance to 23,260 persons. Under the Insurance Act in England you cannot have more than 3,000 persons on your panel, and I believe that is considered too many, and is about to be reduced. These two part-time officials get a salary of £260 a year each. I do not know if you will believe that these doctors applied for an increase of salary and that the Poor Law Commissioners turned them down and would not give it, notwithstanding all the work they had to do.

Fault has been found with the Minister for Local Government and Public Health because he increased the salaries of the Mayo doctors. I hope he will increase the salaries of the dispensary doctors in Dublin. If he does he will be doing not only justice to the dispensary doctors but, I believe, a great service to the poor people who are dependent on them for medical attendance. I cannot imagine how any doctors with that sense of ill-treatment, arising out of being paid so inadequately as they are, and being refused an increase of salary can give the best services that are within their command; it would be against human nature. It has been said of Mayo and the west of Ireland that the doctors there do not attend poor persons, that they charge fees, I have never heard of a doctor in the west of Ireland, any more than in the south of Ireland, who refused to attend on a ticket, where it did not mean very serious consequences to him.

Mr. Derrig

If Deputy Hennessy is referring to what I said, perhaps I may be allowed to explain. I did not say that any doctor refused to attend. I said that the red ticket system was a bad system. That is all.

Dr. Hennessy

The point I want to emphasise is that the wardens, in every instance where they consider a person is a poor person, issue a ticket, and I hold that no dispensary doctor dare refuse to attend. At that I will leave it. In the Free State the dispensary doctors are liable in the first instance for medical attendance on between 50 and 60 per cent. of the population, and for doing so they get £160,000 yearly. It does not cover the travelling expenses. That is the whole crux in this case—that the service is so cheap and is costing so little to the State. The same argument was made under the British Government, though the British Government were prepared to give medical benefits, but the Irish Party, under Irish duress, had to call for their deletion.

The medical profession favour a national medical service in preference to medical benefits. They are not going to make very much profit out of one service or the other, but a national medical service, as I said before—and I think it will bear repetition—gives not only medical treatment to the insured person, but also gives it to the dependants of the insured, and to numbers of other poor persons. There was a very valuable scheme of national medical service drafted which would have conferred a great national benefit, but, while not of great profit to medical men, it was undoubtedly expensive, because it provided for proper institutional and preventive treatment from the public health point of view. It has been often stated that we need no national medical service and no medical benefits. We have already a dispensary medical service. While a dispensary medical service is, I believe, adequate for rural areas, it is a lamentable failure to cope with the work it has to do in the larger urban areas. I have given figures that are incontrovertible. There might be some chance for it if those doctors were whole-time officials and had nothing to do but to treat the poor. But a man with £260 yearly is expected to do some private practice, and I do not know how he manages it. However, you have a discontented service, and a discontented medical service is not a great asset. You have a dispensary medical service that is giving free treatment to between 50 and 60 per cent. of the population. I say if it is giving that medical treatment it is owing to abuse of the Medical Charities Act. The Medical Charities Act was only intended for poor persons. If a person were called a pauper—and that is only the Latin for a poor person— it would be very offensive, but, nevertheless, that is what the Act was for—to afford medical treatment to poor persons and paupers. At the time the Medical Charities Act was instituted in Ireland wage-earners had only 15/- or £1 a quarter, and were destitute enough for anything.

I am not asking, as Deputy Everett suggested, that a man in receipt of 30/- a week should pay 1½d. or even 2d. a week for his medical treatment, but I believe that a service should be found to give proper medical treatment to a wage-earner of that kind without any contribution from him. It would not be so expensive. Of course, I know that the Minister is afraid of the expense, and very reasonably afraid of it, because the commitments of a national service, though necessary if it is to deal with the question properly, are very expensive.

An inquiry was held in Northern Ireland, and for the first time an effort was made to define a "poor person." In Southern Ireland, and when Ireland was a unit, the great fall-back was not to define the term "poor person" so that it might be more freely abused and so that 50 per cent or 60 per cent. of the people would be treated free. The Northern Ireland Committee was, to some certain extent, a Departmental Committee, but it had extern representation of all interests. It defined a "poor person," and amongst the classes that it stated were not poor persons was the case of a man or a woman-servant in receipt of £50 a year wages, with board and lodgings, that such a person was not entitled to be treated under the Medical Charities Act. You know that these persons are very freely treated under the Medical Charities Act in the Free State. Of course, it is an abuse of the Medical Charities Act that these people should be treated, but they have come in for want of a contributory scheme and have to be treated. The natural result that followed from the definition of a "poor person" in Northern Ireland is that the Northern Ireland people are now making provision for medical benefits.

Deputy Lemass made reference to the unsatisfactory and irregular way in which medical certification was done by doctors. Of course, that was meant as a reflection, although he did not stress the point, from the Report quoted. He quoted the number of insured persons whom the ordinary medical attendant certified as unfit for work, but who were sent back to work by the referees. The difference between the medical referee and the medical practitioner is this: The medical practitioner adheres to the professional interpretation of unfitness for work. The statutory definition which more or less governs the medical referee is a different thing; it means: "Is the man fit to do any work"; not his ordinary work, but any work. That is how there is often such a discrepancy between the medical practitioner as a certifier and the medical referee. It is a matter of statutory definition.

Mr. O'Kelly

Would the Deputy say that there is no evidence of the fact that medical certification has been most unsatisfactory?

Dr. Hennessy

Yes, in a general way, but I am telling the House that that is accounted for in a number of ways. I know medical men who might even be statutorily bound to certify in accordance with the definition in the Act, but who ignore it and only consider if the man is fit or unfit to follow his ordinary occupation. Sometimes there are doctors, possibly soft-hearted, possibly careless, who do not make an examination sufficiently extensive, and some cases will go in that should not.

Mr. O'Kelly

Did the Deputy ever hear of a circular issued on the 2nd May, 1929, to the dispensary doctors by the Insurance Commission?

Dr. Hennessy

I am explaining that. The National Health Commission will naturally—and there are many other explanations—uphold the attitude of the medical referee, and the medical referee may be as fallible as the medical practitioner. Approved societies will find fault with legitimate certification and refuse to pay sickness benefit on legitimate certification until compelled by the National Health Commission. I will leave it at that. I do not say that there are not faults, but taking the thing as a whole, it is as I have explained.

Mention has been made of displaced officials. They are mostly clerical officers, and I have a good deal of sympathy with the claim made by the Labour Party that they should be compensated. They are losing their employment, and if they cannot be absorbed into another service, I think the Minister should give them some consideration, because it is a very serious thing for a number of these men. They have given ten or twelve of the best years of their lives to uphill work, and I think they are entitled to some consideration.

Mr. Corish

Deputy O'Connell's attitude seems to have been misunderstood by Deputy Lemass, who professed to express surprise that the Labour Party are against medical benefits. I think I am right in assuring Deputy Lemass that the Labour Party are not what might be called against medical benefits, but favour a greater scheme than medical benefits which could be derived from a State Insurance Act, that is, by a national medical service, because no matter how tight the Commissioners endeavour to make the Insurance Acts a certain number of people will be left outside of them who will require medical attention. I believe that a State medical service is the proper institution to set up in order to deal equitably and properly with the poor.

The dispensary service has been mentioned. At present it is almost impossible to define the persons who are entitled to be treated by a dispensary doctor because of the fact that the value of money is different now from what it was some years ago, and guardians and wardens are sometimes asked to discriminate as to whether a person should receive a ticket or not, with the result that on a great many occasions people do not get the benefits to which they are entitled.

There are certain provisions in the Bill which go to strengthen the Insurance Acts and to ensure that a greater amount of money will be made available for insurance purposes. There are certain clauses for tightening up insurance. But like my colleagues and others who have spoken, I want to protest strongly against the abolition of insurance committees. According to statements made here, a great many Deputies are of opinion that insurance committees have not been used for anything but to see that people suffering from tuberculosis are placed in sanatoria. As far as the County Wexford Committee is concerned, they do a great deal more than that. When they come across an insured person who suffers from tuberculosis they are able to provide him or her with milk, butter and eggs as nourishment in the home.

Deputy Hennessy referred to what has undoubtedly been a fact—that the difficulty about sanatorium treatment up to this has been the period of waiting. Patients were allowed to suffer on account of the waiting period, but in my opinion patients will suffer still more if you do away with the insurance committee, because they had these patients under their supervision; they saw to it that they were provided with proper nourishment before admission, and when a patient left the sanatorium they made it their business not alone to get the doctor and the nurse attached to the committee to visit the patient but members of the committee themselves visited him.

As Deputy Derrig has pointed out, to hand over sanatorium treatment to county boards of health is a ridiculous proposition. Since the abolition of the boards of guardians and district councils, the county boards of health find themselves unable to cope with the amount of work they have to do in the time at their disposal. Immediately after the amalgamation scheme was brought into operation, county boards of health used to meet once a month.

Now they find it impossible to do the work which they are called upon to do during one day in the month, and in many cases they have to meet three times during the month in order to do the work they are called upon to do. To my mind tuberculosis cases will be neglected if they are to be left to the county boards of health. In that event very deserving cases would be neglected, because the county boards of health who are to deal with tuberculosis cases will not have the time to deal with them in the way in which they should be dealt with. I think what I stated is true, and that committees in the past saw to it that when patients were sent to a sanatorium the patients were kept under constant supervision and on their return from the sanatorium they provided them with nourishment and looked after them when they came back. In that way an earnest effort was made to have proper surroundings for the patient. In many cases I have known committees, in the case of patients who were living in bad houses, approached people who had better houses and tried to secure for the patient better housing accommodation. That is a very important thing, to see that when a person does go to a sanatorium and is sent back that proper accommodation is provided for him. That is what these committees have been doing in the past. If these committees are abolished tuberculosis cases which are decreasing will increase.

Mr. Kennedy

Deputy Dr. Hennessy said there were too many local bodies administering public health. That is a very wrong statement. The one body dealing with public health since the amalgamation of our unions is the board of health. The only portion of public health work which they did not take over was that in regard to the tuberculosis scheme of insurance connected therewith. Now we find that the insurance committees take up this part of the work once a month and deal with the subject. If this extra work is given to the board of health, it will be neglected. The committee with which I am connected has been constituted of people who have not been elected. This committee is largely composed of many charitable ladies who, as Deputy Corish said, administer the Act and make it a point to visit the homes. Through schemes like the Jubilee Nurses centred in Athlone and other places they have done immense work in the home in the way of cleanliness and other measures to prevent tuberculosis. In a quiet way they have done Trojan work. You are going to take away the services of these people who devote practically all their time to this kind of work and you are going to throw it in at the end of the monthly board of health meetings, at perhaps 7 o'clock in the evening and ask the members to deal with this matter of tuberculosis.

If you do that you will find before long that that arrangement will not work at all. The amendment put down by Deputy O'Kelly dealt with unification. As far as I am aware, if other Deputies' duties are like mine I should say that half the time of a representative is taken up getting the Insurance Commissioners to run after the various societies and get them to do their work. Repeatedly after medical certification, some of these societies have refused again and again to pay benefits. In that way they have caused great trouble and privation to the people. You would have unification with one society not out to make money. Most of the small societies are out to get the most money out of the scheme. You would have one insurance society which would be better looked after by the Insurance Commissioners. Personally, if I were asked what would be the best scheme and I advocated it last year On the Vote, it would be nationalisation. The next best thing is unification. The worst thing is to leave the matter as it is.

I cannot understand the attitude of the Labour Party in choosing to leave the thing as it is instead of taking up a scheme of unification. We heard the defence here of dispensary work and sanatorium benefit. My idea of dispensary work is "Come in, come on, put out your tongue, have you a bottle?" The bottle is generally a bottle of cod liver oil. Until you find some other way of dealing with tuberculosis there is nothing very much to be said in favour of the dispensary scheme. There is one point here in the Report which was quoted by Deputy O'Kelly previously. There is no harm in emphasising it. I quote from Dr. Rowlette when he said: "I agree in thinking that the methods of administering National Health Insurance through approved societies is cumbersome under the conditions that are found in Ireland. The method was introduced into Ireland merely to give uniformity to a system common to a different island, but designed to meet English local needs. It had no relation to Irish needs or customs, and with any recasting of the insurance system, there appears to be no reason why the existing method of administration should be continued if a better or one more suitable can be devised."

One could not emphasise half enough the cumbersome way that the National Health Insurance is administered in Ireland, particularly in rural districts. There is a network of by-laws in the administration of insurance which would suit a big industrial centre. But you find in the rural parts of Ireland that a man has to walk ten miles to the nearest centre of his society. He is told when he goes there that he is a fortnight late with his card, and that even if it is stamped he cannot get sickness benefit out of it. One begins to realise that what Dr. Rowlette said is not over-exaggerated when one considers what has been happening. I could give numerous instances of cases of little technicalities like that in the administration of health insurance. I know of cases where persons, were it not for home help, would, during sickness, he destitute because of these matters. The whole thing needs to be simplified. These technical regulations which were intended for industrial centres need to be done away with as regards this country, and especially as regards the rural parts. I do not think that there is much fear, as the Minister for Local Government and Public Health indicated, that an insured person here, because he or she has two or three stamps on his card, will come in and stamp up the card so as to draw benefit. There are very few in this country in a position to do that. On the Second Reading of this Bill I want to protest against the idea of abolishing local committees, and to appeal for a simplification of the rules of health insurance as applied to Ireland, so as to make it more in keeping with the needs of the insured.

An Ceann Comhairle

took the Chair.

Dr. O'Dowd

I merely intervene in this debate because it seems that some speakers on this side have got a wrong conception of the work of dispensary medical officers. I want to say that those who speak as some speakers have spoken on the work of dispensary doctors do not seem to know what they are saying, nor did the last speaker either. I would suggest to Deputy Kennedy, who is, I understand, chairman of a local board of health, that it is his duty to see that the dispensary doctors in the county of Westmeath do more than ask the patients to put out their tongues, and give them cod liver oil. The statement was made here that there was no attempt at the prevention of disease and no attempt at real treatment; that bottles were given indiscriminately to people who came into the dispensary. I wish to place on record my emphatic protest against such a statement. Such a slander should not be used without proof. It was also said that red tickets were a failure. They did not say what the alternative is. I am sure that there is no one interested in the poor law medical service who would not be glad to see a better system than the system at present in operation, but for want of a better system the present system is the only system by which the poor can be treated. Figures have been given to show that all this talk about the work of dispensary doctors is moonshine.

It was also suggested that there was a certain looseness in medical certification. If there are one or two medical certifiers who have been loose and who have given certificates when they should not be given, the whole body of medical certifiers should not be slandered. One may as well say that it is dishonesty on the part of the insured person to come for a certificate. Does anybody in his sane moments dream that a person will seek 7/6 disablement benefit and get certificates in order to do so, when he can obtain 35/- or 40/- a week working?

As regards the medical referee, I would like to point out that generally he is called in at the end of an illness. He is not called in by some societies for six or twelve months but other societies call him in after six or seven weeks. As far as the society for which I do a good deal of certification is concerned, the referee is hardly ever called in. I will quote the A.O.H. as a case in point. It is one of the biggest societies in this country. As a rule that society calls in the medical referee after four or five weeks. I suggest that where the referee is called in after four or five weeks, and where the certifiers know that he will be called in, it is wrong to think that there is any looseness in regard to medical certification, and Deputies should not think otherwise. I feel that I could not allow those statements to pass unchallenged and that is the reason that I intervene.

General Mulcahy

I beg to move the adjournment of the debate.

Debate adjourned.