Dáil Éireann debate -
Thursday, 22 May 1930

Vol. 34 No. 19

In Committee on Finance. - Vote 43—National Health Insurance.

Minister for Local Government and Public Health (General Mulcahy)

I move:—

Go ndeontar suim ná raghaidh thar £201,505 chun slánuithe na suime is gá chun íoctha an Mhuirir a thiocfidh chun bheith iníoctha i rith na bliana dar críoch an 31adh lá de Mhárta, 1931, chun Tuarastail agus Costaisí an Choimisiúin Arachais agus chun Ilsíntiúisí agus Ildeontaisí mar gheall ar chostas Sochar agus Costaisí Riaracháin fé sna hAchtanna um Arachas Sláinte Náisiúnta, 1911 go 1929 (maraon le Deontaisí áirithe i gCabhair).

That a sum not exceeding £201,505 be granted to complete the sum necessary to defray the Charge which will come in course of payment during the year ending on the 31st day of March, 1931, for the salaries and expenses of the Insurance Commission and for Sundry Contributions and Grants in respect of the cost of Benefits and Expenses of Administration under the National Health Insurance Acts, 1911 to 1929 (including certain Grants-in-Aid).

The increase under the headings Salaries, Wages and Allowances and Travelling Expenses shown in this Estimate is apparent rather than real. The figures when the Estimate was before the House last year were under sub-head A, £75,780, and under Travelling £6,570. During the year certain officers retired, and it was necessary to fill their places by officers seconded from other Departments. The cost of these officers was on the Estimate of the other Departments last year, and now the cost appears back. The figures were changed to the reduced figures here only when the Supplementary Estimate was introduced in the early part of this year and when it was clear that the money would not be expended. There is an error in printing in sub-head F.2, where the increase should read £6,600 and not £16,600.

Mr. O'Kelly

Last year, and the year before, I and other Deputies raised a question on this Vote as to the expense of the head office, and in particular in regard to the number of Commissioners. The Minister, who appeared to appreciate the fact that the office, from that point of view, was probably a bit top-heavy, agreed that something might be done to find another post for one, or maybe even two, of the Commissioners. I wonder if the Minister has given any consideration to that matter during the last twelve months, and if he now sees any way of reducing the overhead cost, which is very heavy. In my opinion, it is too heavy for the services the Department gives. I believe that one Commissioner would be sufficient. Even though one of the other two Commissioners is what might be described as a technical Commissioner, being a medical officer, I believe work might be found for him in some other Department. I think the Department could be run without such a technical adviser. There are other medical men in the service who, when a medical question arises, could be got to give advice to the Department. I should like to call the Minister's attention to this matter once more, as I think two of the three Commissioners could be dispensed with. We do not want to incur the extra expense of sending them out on pension, but it should be possible for the Minister, in consultation with other members of the Ministry, to find in some other Department, perhaps in his own Department, employment that would be suitable for one, if not two, of what might be called the junior Commissioners, or even perhaps for some of the other officials who, in my opinion, are too numerous.

[An Leas-Cheann Comhairle took the Chair.]

Mr. G. Wolfe

There is a matter I should like to bring to the Minister's attention. There must be, all over the country, a very large number of people who have been contributing to national health insurance since it was established, and who never had anything from it. I know quite a number of such people who have never got any benefit, and probably never will. I am sure that a good many of the societies must have a very large sum of money accumulating owing to cases of that kind. It seems to me that when these people arrive at the age of seventy, and no longer have to contribute to national health insurance, and, in a great many cases, are more or less compelled to take the old age pension, it would be a very good thing if some bonus were paid to them. The State contributes to this.

An Leas-Cheann Comhairle

That would require legislation.

Mr. Wolfe

I am only suggesting it.

An Leas-Cheann Comhairle

The Deputy cannot do that on the Estimates.

Mr. Wolfe

The State contributes to the insurance fund.

An Leas-Cheann Comhairle

Even so, that does not put the Deputy in order.

Mr. Wolfe

I hope the Minister will think over the matter.

Mr. O'Kelly

Could the Minister tell us what is the total number of approved societies in existence at present as compared with last year?

General Mulcahy

On the question of the Commissioners, the Deputy, I think, understands that I am quite at one with him on that matter. The matter did get my further consideration recently. It will be remembered that when dealing with the National Health Insurance Act of 1929 I gave some kind of undertaking with regard to legislation for the amalgamation of approved societies. That matter has been engaging my attention since, and I was rather unwilling to tamper with the present form of the Commission until we had arrived at some definite conclusion in regard to the lines on which the amalgamation of the societies might go. The question of the amalgamation of societies is under consideration between myself and the Commissioners, and certain interchanges of opinion and discussions have taken place between the Commissioners and the advisory committee representing the approved societies. I am not able to say that it has gone beyond that stage at present, because there are a limited number of ways in which we can bring about a certain amount of amalgamation of societies, and the selection of one or other of these ways will require a certain amount of further thought before we can venture to say that any one of them would be the best. I have been delayed in dealing with the question of the Commissioners for the reason that I do not like to tamper with them until we have come to some conclusion on the other matter.

With regard to the general overhead cost of the National Health Insurance Department it has to be borne in mind that the Department performs outdoor inspection for the Department of Industry and Commerce in connection with unemployment insurance, and that the cost of that work is estimated to be about £13,000. A further reduction of staff will, I think, be possible when presenting the estimates next year, arising out of the passing of the National Health Insurance Act of 1929. It may be possible to reduce the staff by about thirteen in different classes. As to the number of societies, I think I gave the figure before as sixty-six. However, I have not the figure in mind just now, but I could have it conveyed to the Deputy.

While the proposal that Deputy Wolfe makes is outside the present scheme, we have to bear in mind that if anything has to be introduced like that it means legislation, and it means reviewing the finances of the whole scheme. It is worth while remarking that the contributions paid by employers and employees for the year 1923 amounted to £425,017, and that for the year 1929 the partly estimated figure is £552,000, an increase of approximately 29.7. When we come to consider the benefits paid, we find that the total expenditure on benefits in 1923 was £439,337, and that the estimated expenditure for the year 1929 is £716,000, or an increase of 62.7 per cent. over 1923 as compared with an increase of 29.7 in respect of contributions from employers and employees. So that if there was at any particular time a margin in the insurance fund for giving gratuities to persons at 70 years of age, it is clear that there is no such margin now.

Sir James Craig

I am very glad to find that the Minister has seen it right to endeavour to reduce administration expenses. Attention has been repeatedly called to the very high administration expenses of this office compared with the amount of money that goes through the office. The figures at the present moment are over £83,000 spent in administration, and the Government part of the money that they put through their hands is only £225,000. Of course, I admit there is a great deal more money to be dealt with than appears there. I want to know if the Minister will kindly tell me whether there is any improvement as far as approved societies are concerned, in making hospital treatment an additional benefit. I have complained here on several occasions in connection with approved societies, that while some of them were quite willing and had adopted this method of paying hospitals for treatment at least 25/- a week, which covers half of the total expenses, some of the larger ones and the ones that seem to be very well off indeed refuse to make hospital treatment an additional benefit. I want to know from the Minister if there has been any improvement in the past year in that respect.

There is another point which is rather confusing, namely, medical certification and district medical referees. The amount is £4,600 for the present year, and £36,872 for the previous year. I have not been able to satisfy myself as to why this great reduction has occurred. If one looks one finds the explanation in item G: "The expenses of providing medical certificates of sickness owing to the absence of medical benefit in Saorstát Eireann in accordance with a scheme prepared by the Insurance Commission with the approval of the Minister for Finance." There was an Estimate of £13,000 for the previous year. I take it that amount was not used. I think the Minister ought to explain to us what is the meaning of that great reduction.

Dr. Hennessy

I would like to know if the Minister, following the example of Northern Ireland, has any intention of including medical benefit under the Insurance Acts. There is a Bill at present going through the Northern Parliament making provision for medical benefits. Dispensary doctors are not adversely affected by that Bill. They retain their present salaries and their pension rights are not interfered with at all. Here in the Saorstát there are the same reasons for medical benefits, and the only justification for keeping them out is the alleged medical service we have—the Poor Law Medical Service—which caters for insured people. A very large proportion of insured people who receive medical treatment under the Medical Charities Act receive it by the abuse of the Medical Charities Act. They have also in Northern Ireland changed the whole face of it by defining what a poor person is under the Medical Charities Act. In Northern Ireland a servant in receipt of £20 a year, with board and lodgings, is not considered eligible for treatment under the Medical Charities Act. It is different in the Free State, where we have workers who could easily pay 1d. a week for medical benefits, treated as poor persons. Moreover, the whole thing is aggravated by the very bad treatment poor law medical officers receive, especially in the cities. In Dublin they are amongst the worst paid in Ireland, and the Poor Law Commissioners who have received applications to improve their position have turned them down.

I should also like to ask the Minister, in connection with the reduction on the administration side of the Insurance Acts, why he allowed the reduction in the certification grant last year to be put to the credit of this reduction. That was taken out of the pockets of the Poor Law Medical Officers in rural Ireland, who are only receiving a capitation fee of 2/- and 2/6 for that certification, varying according to density of population. That already has proved a very small remuneration, and a justification, it appears, for the reduction in the certification grant was that the cost of administration of medical certification in accordance with the dispensary area instead of the county area was more expensive. Anybody who knows anything about medical certification knows the county area is simply quite an impossible basis on which to distribute certification money. The Minister knows all about that already. I hope he will give instructions to the National Health Commissioners to cease making the reductions that they made last year. It is a thoroughly dishonest proceeding, and I can characterise it by no other term.

General Mulcahy

In reply to Deputy Sir James Craig, I should point out that under the National Health Insurance Act, 1929, Insurance Committees dealing with sanatorium benefit are abolished. Sanatorium benefit was taken off as a charge from National Insurance funds, and medical certification was made a charge upon the funds of the societies instead of voting money from the State. So that medical certification proper will be a charge in future upon National Health Approved Societies' funds. The figure of £4,600 is the figure for the getting of second medical opinion, which will continue to be borne as a State charge.

In reply to what Deputy Hennessy said, the deduction of £800 is a deduction under, I think, Section 22 or 29 of the National Health Insurance Act of 1929, whereby the Minister is empowered to make this deduction. I do not think the Deputy will ask me to argue the case of the distribution of the certification money on a dispensary basis as against a county basis.

Dr. Hennessy

That is the reduction that I am concerned with.

General Mulcahy

It costs more to distribute these moneys in accordance with the wishes of the medical certifiers than it would cost if the money was distributed in the more equitable way that appeals to the Commissioners.

Dr. Hennessy

In a more iniquitous way.

General Mulcahy

We have undertaken to meet the wishes of the medical certifiers in the matter, but the National Health Insurance Act, 1929, gives authority for the recovery of the additional cost.

In reply to Deputy Sir James Craig on the question he asked in regard to hospital benefits, I have not yet come across the total number of societies. I think the figures are 65 societies and nineteen branches. Under the general heading of additional benefits there has been an increase. In cash value there has been an increase of from £3,315 in 1923 to £33,000 in 1929. As regards the form of these benefits, the non-cash additional benefits are as follows: dental benefit 47 societies. 19 branches; hospital, etc., benefits, 39 societies, 15 branches.

Sir. James Craig

That is still very bad.

General Mulcahy

You might say fifty per cent. of the societies and the great majority of the branches. Optical benefits 29 societies and 18 branches; for the provision of medical and surgical appliances, seven societies and sixteen branches. The granting of hospital benefits to members as well as the granting of additional benefits generally depends on the amount of surplus that each society has at the present moment. The third valuation of approved societies is being gone on with now. In view of the figures that I have quoted with regard to the increase in general expenditure on benefits, as compared with contributions, I do not know whether the next valuation will show that the societies are in a stronger position than they were when the second valuation was carried out. The extent to which they are weak or strong will depend on whether the additional societies can afford to give hospital benefits or not. It is a question of money. I take it the societies are rather willing to give all the benefit they can, but perhaps they concentrate more on the dental benefit, and I think there is something to be said for that.

Vote put and agreed to.