Dáil Éireann debate -
Thursday, 11 Apr 1935

Vol. 55 No. 17

In Committee on Finance. - Vote 44—National Health Insurance.

Minister for Local Government and Public Health (Mr. O Ceallaigh)

I move:—

Go ndeontar suim ná raghaidh thar £211,241 chun slánuithe na suime is gá chun íoctha an Mhuirir a thiocfaidh chun bheith iníoctha i rith na bliana dar críoch an 31adh lá de Mhárta, 1936, chun Tuarastail agus Costaisí Oifig an Aire Rialtais Aitiúla agus Sláinte Puiblí i dtaobh Riaracháin na nAchtanna um Arachas Sláinte Náisiúnta, 1911 go 1934, agus chun Ilsíntiúisí agus Ildeontaisí, ar a n-áirmhítear Deontaisí áirithe i gCabhair mar gheall ar Chostes Sochar agus Costaisí Riaracháin fé sna hAchtanna san.

That a sum not exceeding £211,241 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, 1936, for the Salaries and Expenses of the Office of the Minister for Local Government and Public Health in connection with the Administration of the National Health Insurance Acts, 1911 to 1934, and for sundry Contributions and Grants, including certain Grants-in-Aid in respect of the Cost of Benefits and Expenses of Administration under the said Acts.

During the last year the major part of the actual process of unification has been completed and the members of all the old approved societies and branches have now been merged in the unified society. The progress made in the matter has been more rapid than was anticipated. The society at first occupied temporary premises but in the early part of last year central premises of a suitable character were acquired in Upper O'Connell Street, which now form the head office of the society. Branch offices have been opened in Cork, Limerick and Waterford. The first transfer of societies was effected on 1st January, 1934, when 16 societies comprising 163,000 members were taken over. One society was taken over on the 30th April, and another on the 2nd June. This was followed by eight societies comprising 131,000 members at the end of June, and the remainder were taken over at various dates between that and the 15th December last when the transfers were completed. The total number of members transferred was approximately 483,000. The transfers were carried through with the least possible inconvenience to insured persons and continuity was preserved in the payment of benefits to those who were incapacitated at the time of transfer.

In selecting the staff of the society the Committee gave preference so far as efficiency permitted to the staffs of the old societies which had been displaced and apart from agents 188 members of such staffs have been given employment in the unified society including the secretary, treasurer, chief clerk and all the staff officers and deputy staff officers. Compensation has been paid by the society to 149 persons under Section 22, amounting to £93,970, and to 1,726 persons under Section 23 amounting to £12,730. The latter were mainly part-time agents. About 680 cases remain to be completed, making the estimated total compensation £128,750.

It is already apparent that the annual cost of administration by the unified society will be considerably less than that under the old scheme and the society estimate from the particulars now available that there will be a saving of 5d. per head on the capitation rate of 4/5 available for administration. This will amount to £10,000 per annum.

A certain amount of publicity has been given to alleged cases of delay or irregularity in the payment of benefits by the unified society. Any complaints of this kind which have reached the Department have been investigated, and in the great majority of them it is found that there is no genuine grievance and that they have arisen through erroneous ideas on the part of the insured persons themselves as to the benefits to which they were entitled. It is an essential feature of the scheme, as it is of every insurance scheme, that certain qualifying conditions must be fulfilled before the right to benefit accrues. Again, unless the number of contributions paid in a contribution year reaches the required number, benefits are reduced during the ensuing benefit year if arrears are not paid. This has been a very common form of complaint during the early months of the year. Although every individual insured person who was in arrears was notified before the 10th November last, and full instruction given as to the method of payment and the effect of non-payment, many of them ignored the instructions and then complained when their benefits were stopped or reduced. Some in claiming benefit have omitted to give particulars by which they could readily be identified, others have taken no trouble to have their cards stamped or to send them into the society at the proper time. All omissions or irregularities of this sort entail delay, but the delay is in no way attributable to the society.

There is one other point to which I would like to refer. Quite a number of insured persons have sent in one medical certificate and complained they have got no benefit. Benefit can only be paid when there is proved incapacity extending over a period. The first certificate merely proves that the person is ill on a particular day; there must be a second certificate proving a period of incapacity before benefit is payable.

It is not claimed that the society is infallible. It would be too much to expect that an occasional error would not arise in dealing with such a large volume of work—some 28,000 payments a week—but I am satisfied that the work is being well done, and that every possible effort is being made to consider the interests of the insured persons, and to give them the full advantage of the scheme even in cases where they themselves are slow to co-operate.

The total Estimate of £316,841 compares with a figure of £311,376 for the preceding year, but the items in the latter figure have been altered from those in the original Estimate owing to the changes effected when the Supplementary Estimate was introduced. In dealing with salaries for instance, the amount now appearing for last year is £62,341, but the amount in the original Estimate was £64,641. The difference of £2,300, which represented savings on the salaries sub-head as originally estimated was used in the Supplementary Estimate to meet deficiencies on other sub-heads of the Vote. The actual increase in the Estimate for salaries as compared with the Estimate made at the corresponding period last year is £420 and not £2,720, and this increase is more than accounted for by the ordinary incremental (and bonus) increases.

The increase in State grant is due to increased expenditure on benefits and to the increased number of contributions which, it is estimated, will be paid in 1935. There has been a steady increase in the annual contribution income of the Health Insurance Fund which, in 1934, is estimated to have reached £628,000. The expenditure on benefits has, however, also increased and, in 1934, is estimated to have been £782,000. The number of medical certificates issued under the medical certification scheme to insured persons increased from 1,339,000 in 1933 to 1,410,000 in 1934. The average number of persons in receipt of benefits weekly through the year was 27,330.

Under the provisions of the National Health Insurance Act, 1929, during the 12 months ended 31st December, 1934, sums totalling £484 16s. 11d. were recovered for insured persons by the Department from employers in respect of benefits lost through neglect to pay contributions. The accumulated funds forming the assets of National Health Insurance amounted to £3,646,320 at the end of 1934, indicating an increase of £94,540 during the year. As the annual income derived from dividends and interest, etc., however, is £183,670, it is evident that the income from other sources, i.e., contribution and State grant, is about £89,130 short of the expenditure.

Mr. Morrissey

It was rather difficult to follow the figures as read out by the Minister. The Minister, apparently, is satisfied that there are not many complaints and that so far as there are complaints, in nearly all cases any delays that take place are due to the members themselves rather than to the administration of the unified society. I want to say that so far as I am personally concerned, and speaking only for myself in this matter, there are far fewer complaints reaching me than I anticipated, and I can say that a very fair number of the complaints which did reach me, I found on investigation, were due to delay in contributing and in some cases, non-payment on the part of the members themselves. That is not to say that everything is perfect. It would be too much to expect that, but, on the whole, speaking as one who had some experience of the working of one of the societies, and as one who was opposed to the unification scheme, both inside and outside this House, the transfer from the societies throughout the country to the unified society has been carried out much more expeditiously than I ever anticipated.

Of course, it was only to be expected that there would be certain delays. I believe that those delays would be absolutely unavoidable, because, I take it, the unified society was largely occupied during the last 12 months in, so to speak, creating the machine for the running of the unified society. There are, of course, complaints and there are delays and there are bound to be delays, in respect of a centre in Dublin, that would not occur in a local society. When dealing, as naturally you must deal, in many cases with men down the country, agricultural labourers and others, who are not accustomed to writing and filling in forms, delays must occur in having these forms properly completed which did not occur when members merely walked into the office of the local society and had the matter fixed there and then. If there is any necessity for it, I would ask the Minister to urge on those who are in charge of the unified society to do all that is possible to avoid delay in dealing with these matters.

As the Minister, I am sure, is aware, in the case of benefit for sickness, and, perhaps even more so where the claims are maternity claims, it is all important that the money should be forthcoming as soon as possible. Very often, it makes a great difference to the mother and to the baby if the money is available to provide nourishment at the proper time. There is another matter to which I want to refer and I should like the Minister when he is replying to deal with it a little more fully than he dealt with it in his opening statement. That is the question of the income and expenditure. The position is serious and has been serious for a number of years. The whole financial basis of national health insurance in this country is being eaten away. There is a wide difference year after year between income and expenditure and I want the Minister to inform the House, if he is in a position to do so when he is replying, whether he proposes to take any steps to bring income and expenditure closer together, because it seems to me that you cannot continue indefinitely having a difference of £250,000 or £300,000 a year—I think it is roughly £300,000, taking a round figure—on the wrong side. The reserves are being slowly eaten into. It must be remembered, of course, that the reserves which are there to the credit of the unified society consist of money which is held in trust for those who have been contributing over a number of years and who, fortunately for themselves, have not had to call on that money so far.

I should also like the Minister to tell us whether any additional steps have been taken to deal with malingering and, perhaps, what is more important, with compliance and whether he is satisfied that he has reached a fairly high percentage of compliance with the Act. I am very doubtful in regard to that. What is the position in regard to malingering? We know that when you have economic stress, when wages are being reduced and being forced down and when men are being thrown out of employment, an added strain comes on the funds of the National Health Insurance Society. Men who are ill and have no work to return to are naturally inclined to remain longer on the books of the society—and I suppose it is hard to blame them—than they otherwise would.

The Minister referred to compensation for the officials of other societies. I should be glad if he could tell us whether any of the former card collectors have been compensated, and, if so, how many, and how long it will take until the matter is completed. I mentioned those particular classes of men because, in many cases, they are men who are very badly off and the compensation, whatever it may be, to which they would be entitled would be very welcome, and I would suggest to the Minister that that might be speeded up and that the compensation to which they are entitled might be determined at the earliest possible moment.

Now I come to a matter that I have been trying to get at year after year in this House on this Vote—the costs of central administration. Strange as it may seem, instead of reducing, the cost of central administration is going up. I used to have to draw attention to the fact before the Unified Society came into being that they had one commissioner in England and, I think, one in Scotland, while we could not do with less than three in the Free State. I cannot for the life of me see why central administration should cost over £65,000. It seems to me that it is a sum out of all proportion to the cost, and I am satisfied that a substantial reduction could be made in that figure. I ask the Minister and his principal officials to give their attention to the matter because it seems to me, as I say, that while there is a reduction of one in the staff, there is an increase of over £5,000 in the cost. I think it will be very hard to justify that increase. We were told that when we got unification we were going to have a big reduction, to have a less costly service all round, and so on. I cannot understand why we cannot have an immediate reduction following the transfer of title, but the Minister did not hold out even a prospect, and are we going to take it that this is to be looked upon as the normal cost of administration under the Unified Society?

Those are really the only points I have got to make, but I would like to say that as one who is opposed and has yet to be convinced that the Unified Society is a better system than the old system, I was more than pleasantly surprised at the efficient and expeditious way in which the transfer was completed, and having regard to all the difficulties, completed without undue hardship to the vast number of applicants for benefit. I would suggest, however, that the officials of the Unified Society ought to strive to bring the matter as near to perfection as possible, because in times of illness it is vitally necessary that whatever money an applicant is entitled to should be made available as early as possible.

Mr. T.J. Murphy

I think it proper to offer some observations in an entirely different strain from that of Deputy Morrissey's speech. Before I come to the principal subject I have to speak of, I want to refer to a growing source of complaint in the portion of the country I come from. That is the clash between local medical opinion and the opinion of the medical referee. This has happened very frequently in what seemed to me to be rather striking cases. The referee pronounces somebody fit to work and local medical opinion is flatly contradictory, and on appeal the opinion of the local medical attendant has been invariably confirmed. I do not propose to offer an opinion in this matter except to suggest that the Minister might find an opportunity of inquiring as to how this system of medical referees is working and whether there is any substance in the feeling of dissatisfaction and discontent with the results of the examination of sick persons by the medical referee.

Speaking here this evening on the Local Government Estimate, I was in the position of being able to say some pleasant things about the officers of the Local Government Department— things, I think, which were entirely deserved. I wish I could take the same line in connection with the society responsible in this State at present for the management of the affairs of insured persons. I am afraid that the story, as far as my experience and knowledge goes, is an entirely different one. I have not had the happy experience which Deputy Morrissey seems to have had and I must say a very big portion of the work I had to do for several months past was endeavouring to remedy complaints that have arisen in connection with benefit, the payment of benefit and the rights of insured persons generally. There is no question about it, there has been considerable delay in a very large number of cases and there is, further, what seems to me to be very strange, and I am quite fair in saying so, a feeling in the headquarters of the unified society that complaints should not be made. I had a letter from the secretary in which he stated that it seemed to be my business to collect complaints. It is not my business, but it does not need any collection of grievances to get complaints, because they are coming in frequently. As one very directly in touch with a large number of workers, I can tell the Minister that the complaints are very general and, from my knowledge, all the blame is not on the insured persons. It is easy to talk about semi-illiterate labourers and to say that they do not know how to fill forms. Of course, they do not conform to the standards that those new managers of insurance would like, but they have rights and, in my opinion, their rights have not been given the consideration they were entitled to on a number of occasions. Perhaps that arises out of different sets of circumstances. It is a fact that a number of persons who had experience of the working of national health insurance were ignored and passed over when appointments had to be made in connection with the unified society. I am referring principally to agents and I do not want to dwell on that matter unduly for in many ways it was an extremely unpleasant business, and I prefer to say no more than that it was inevitable, when people with no knowledge of insurance were absorbed, that they could not give anything like the service of the experienced officials if their services had been utilised. There has been delay in issuing cards to members, and workers coming into employment or resuming employment after long delays have found it difficult to obtain cards in a reasonable time. There has been some improvement lately. Some time ago, the position was very bad and, of course, there was a stock answer for all complaints of this kind, namely, that the fault lies mainly with the insured persons. Occasionally, but very rarely, the infallible authorities of the unified society do admit they made some small mistake, but those admissions are very rare indeed and I think it is about time that we had a stocktaking as to the results that this much-vaunted unification system has brought to the insured persons in the country. That is the real test.

No amount of glorification over the wireless, no amount of elaborate newspaper articles containing very high-sounding phrases, no amount of well got out and highly-illustrated magazines will, in my opinion, justify the existence of this unified society to the average worker in the country except the members of the committee of management of that society are prepared to satisfy the test which the ordinary worker in the country will apply, and that is that the new service has to serve him as well as the one it replaced. In this country, for some years past, there are certain principles— if one could call them that—which have become stock principles, as it were. We have certain phrases to which, without at all inquiring into what they mean, we are inclined, and in some cases expected to pay allegiance and respect. Unification, centralisation and things like that sound extremely well. The poor law system afforded in some respects a striking example of how defective schemes of that kind can be in certain directions—I do not say altogether, but in certain respects. I say to the Minister in this connection that it would be well to realise that the simple people down the country have, in their own way, as I think he will find on examination, given service which was as least as good and I think in some cases better than the services which the insured persons have received since the change. At the risk of talking treason, I want to say I have yet to be convinced that unification in this or in any other service is the boon and the blessing that it is alleged to be to the parties concerned. I think it is time, as somebody else said earlier this evening, that we face up to realities in this connection, and see exactly how far there was foundation for the view that by just trotting out certain phrases we can impress everybody and convince ourselves that wonderful things are happening.

I had a letter from a constituent of mine a few days ago, who stated that she had been paying national health insurance contributions for a number of years; that she was a member of a certain society which was one of the first to be taken over; that she had furnished to the unified society her number in the society from which she was taken over, and that she was still awaiting payment of a claim for benefit made in December last. I asked the society to investigate that matter, and to investigate another case arising in the same district, where delay is said to have arisen because a card, the property of the insured person, was lost in the office of the society. I have had brought before me, over the last few months, at least a couple of cases a week arising out of the same kind of delay. I find further that much difficulty has arisen in connection with the demand of the unified society for the production of a certificate of age to ascertain that the person is eligible for benefit. I cannot complain of the society's asking for documentary proof of age, but I do complain that where that proof is furnished, and appears, from the point of the insured person, to be satisfactory, there still remains considerable delay in some cases.

Reference was made in this House some time ago, I understand, to alleged efforts on behalf of persons connected with the Unified Society to form within that society what would be known in the industrial world as a company union. There has grown up in certain parts of this country recently an ugly development, which finds expression in the formation inside certain industries of units controlled by the employers, where the members are supposed to exercise no other function and to be just yes-men for their employers. The Minister, as far as I know, was not aware that any such thing was happening in the unified society, but the rumour is very persistent, and I would ask the Minister to make further inquiries into that matter. I would also ask him to make further inquiries as to whether real difficulty exists in the matter of insured persons getting approach to the officers of the unified society in order that their claims should be investigated. I have here before me a copy of the instructions issued to the staff of the unified society, which seems to indicate that there must be, for the ordinary person, considerable difficulty in approaching the principal officers of that society. Paragraph 6 of the instructions goes to show that entry to the private rooms, save with permission, is prohibited. Green signal lights will give permission to enter the rooms. Entry is not permitted while a red signal light is showing. Some of us here have had experience in the last ten years of calling at the various departments of this State, from the offices of the President and the Ministers, down to those of the chief executive officers of the various departments. I must say that the formalities indicated in connection with the operations of the unified society show an entirely new and, I should say, undemocratic departure from what is the recognised practice in connection with Government offices. I am wondering whether the people who have been responsible for issuing ridiculous instructions of that kind, and for making what seem to me to be ridiculous arrangements, have been reading about the operations of certain people who control Italy and Germany at the present time, and whether they feel that, in a minor degree at least, the policy in certain countries of that kind ought to be adopted here. Why can there not be in the unified society—which after all is a collection of the societies which have been taken over to pay benefit honestly and deal fairly with insured persons all over the State—the same sort of democratic management that there is in the offices of the State?

I am told further that the members of the staff in a good many cases are not very well paid. I think it would be much better if provision were made for reasonable remuneration for the junior members of the staff instead of having expensive devices of this kind, and ornamentation which, in the circumstances, does not seem at all warranted. It is a fact that numerous agents of the society are poorly paid. It is a fact, further, that the very small compensation to which a number of the agents are entitled has not yet been paid. Though at least some of the persons concerned have had no other occupation, they have told me that they found it difficult to get settlement of their claims made by the unified society. I notice further that members of the staff are prohibited from smoking during office hours. That is perhaps not a grievance but again I point out that in Government offices members of the staff are allowed to smoke during office hours and although perhaps the example is not a very good one members of this House know of numerous local bodies where, during the conduct of business, smoking is permissible. I do not know that I would definitely defend that. But I think that what obtains in the offices of this State generally ought to be good enough for a unified society. I should say that the instructions issued are so numerous, so varied and so full of commands that certain things are not to be done, that I am not surprised that the one complaint in Deputy Morrissey's speech in regard to the unlikelihood of costs being reduced in certain directions was made. I see one instruction issued that I think is extremely objectionable. This instruction has been issued to the female members of the staff and it contains a principle that is highly objectionable:—

"It is the wish of the committee of management that all women members of their staff should wear navy blue office coats. In order to facilitate the staff in the purchase of these coats, the committee is prepared to defray their initial cost and allow the staff to refund so much a week."

Mr. Everett

That is another body wearing blue.

Mr. T.J. Murphy

I do not know what power the Minister has to come into a matter of this kind. I think the Minister is a very sensible man. I pay him the compliment of realising, as some of us do on reading the instructions that I have read, that the gentlemen who were being put in charge in O'Connell Street have forgotten themselves and that it would appear they feel that their office is something approaching omni-potence. I think he ought to go and tell them to deal with the people around the country who are dissatisfied with them and that in meeting their obligations to the insured persons about the country they will be doing a good deal more to justify themselves than in piling up those regulations, piling up the creation of precedents and having all this routine business that is so very trifling and is doing so very little to justify the objects for which certain gentlemen were installed in the office in O'Connell Street.

I am not satisfied that the Unified Society has done as well as it ought to do. I do not share the view to which Deputy Morrissey gave expression—that he was surprised that things were going so well. I think the authors of the scheme ought to have been satisfied before they disturbed the existing scheme of insurance that before doing so they were going to put something in its place that would be superior. A considerable time after that change has been made there still remains numerous causes of complaint.

Mr. Morrissey

On a point of correction may I suggest to Deputy Murphy that I did not express the view he has attributed to me—that I was surprised that things were going so well. What I said was that I was pleased that the transfer had been carried out so expeditiously, but that I was still convinced that the unification was a mistake.

Mr. Murphy

I am sorry that I misquoted the Deputy. I do not want to condemn the society as being incapable of any good. I think there will be an improvement, but I believe there are just reasons and causes why the Minister should not feel that everything is quite all right. I assure the Minister that if he travelled over the country he would find very frequently numbers of people who have cause for complaint in this connection.

At a meeting of the workers in Cork City recently complaints by members of trade union bodies were voiced in connection with the working of the society in that city. I have found these complaints in various parts of the country with which I am in touch. I drew the attention of the Minister to the complaints, and at the risk of being told again as I was told some time ago on another matter—that I have a habit of collecting grievances against this society, I will continue to bring to the notice of this House when I get the opportunity and to the notice of the society when I do not get an opportunity in this House, cases of complaints that are, in my opinion, worthy of being inquired into. That is one of the functions of a member of this House. I am not going to divest myself of that right for anybody. The whole system of unification, in my opinion, is one that confers very questionable benefits on insured persons through the country. At the risk of being considered old-fashioned and out of date I do say that in my experience some of the societies that the new organisation replaced gave very much more satisfaction and much more prompt results and did more to maintain the confidence of their members to a much greater degree than this new institution has done. I think it is right when one feels that that is the case that that view should be expressed. The secretary of the society indicated recently over the wireless his hope that there should be a possibility of development along the lines of social insurances, which are very necessary and some of which are overdue. But one does not see much sign of an advance in that direction when one sees the Unified Society availing of a technicality to cut down to 3/- a week some claims for disablement benefit which runs at something like 7/- a week. Apart from the regulations in connection with national health services, there ought to be humanity and commonsense in any service. In no service are humanity and commonsense more needed than in this. If honest criticism of it uttered here and elsewhere helps to bring an increasing amount of humanity into the administration, I think we will have done well. I can assure the Minister that it is not a pleasant thing for anybody in this House to utter frequent criticisms on this or on any other matter. The only proof those citizens who are still unconvinced have that this Unified Society is going to improve along the lines that were marked out for it, when it was framed, is that these criticisms will continue.

I realise that the Minister has no definite control over the internal working of the society except perhaps in the sense that he has accepted Parliamentary responsibility. But I do suggest to him that he ought to examine into the need for fixing the appointed day for the election of direct representatives of the insured persons on the committee of management at the earliest possible moment. That at least will put the onus on insured persons all over the country of approaching their own direct representatives in connection with grievances that may arise regarding their interests. I feel it would be a step that would remove a good many of the complaints and obviate a good deal of the discontent that exists at the present time in connection with the working of the society.

Dr. O'Dowd

I do not intend to enter into a discussion of the merits or demerits of the Unified Society in this Vote, but I should like to point out to Deputy Murphy and others, who have complained that there is delay in the payment of benefits by the society on receipt of the necessary medical certificate, that what really does happen in many of these cases is that the insured person puts on the medical certificate his or her old number; that is to say, the number that they had in their old society before unification took place. That has been brought to my notice several times recently. Each insured person has got a new number but in many cases they omit to put it on the certificate, and delay, in my opinion, is due in many cases to that error on the part of the insured person. I should like to pay a tribute to the courtesy of the medical referees in connection with national health insurance cases. The medical referees, as Deputy Murphy knows, perhaps, at all times inform the insured person's medical attendant of their intention to have that insured person called for examination, and they give the particulars to the insured person's own doctor as to the time and place of examination and invite him to be present if he so desires or to supply any information that may be of help to the insured person. Speaking personally, I must say that in 100 per cent. of the cases, I agree with the decision given by the medical referees.

Recently a circular was sent out to certain medical men and to certain medical certifiers by the Unified Society asking them for their opinion on the extension of social insurance. To my mind social insurance in the State will never reach anything like the degree of perfection which we all hope it will some day attain unless there is included, in addition to the ordinary national health insurance certification, etc., some scheme of medical benefits. We, in the Twenty-Six Counties, are far behind our brethren in the North in that respect. In the north-eastern portion of Ireland, and in England, you have, coupled with a scheme of national health insurance, a scheme of medical benefits, and until we have an extension of social insurance to include a scheme of medical benefits, then national health insurance and social insurance will never reach the state of perfection which we all hope it will some day attain. In connection with that matter, I should like to say that if at any time in the near future it is contemplated to have an extension of the scheme so as to include medical benefits for the insured persons, so far as I know the medical profession, who would have the administration of the scheme largely in their hands, are whole-heartedly unanimous in the suggestion that they made on several occasions, I think, to the Department and to the Unified Society, that that scheme should be in the hands of the Minister and the State Department and should not be left under the control and in the hands of any Department that is not directly responsible to the Minister. We believe that it would be more efficient to have the scheme under the direct control of the Minister and of his Department.

Dr. Rowlette

The Minister, in his interesting statement, made a remark which puzzled and somewhat disturbed me. In speaking of the complaints which were occasionally made as to delay in drawing benefit, he said that members were sometimes under the impression that they should get benefit on one certificate only, but that it was necessary to present a second certificate before benefit would be paid. If I heard the Minister's remark correctly, it seems to me that there is some possibility of considerable injustice to the insured person in that matter. Benefit is payable after, I think, three days of incapacity, on the society receiving evidence that the member is incapacitated from work and is incapable of work.

There is no provision in the statutes, so far as I am aware, as to the kind of evidence that is to be procured, but in practice the evidence is the medical certificate. There is no provision that two medical certificates are required before the member is entitled to benefit. If the sick member were sure to see a doctor on the second or third day of his illness no injustice would be done if he were not to receive benefit until he presented the second certificate a week later. In many cases, however, the sick person does not go to see a doctor immediately on the second or third or even the fourth day of illness, and it may be well on to the end of a week before he sees a doctor. If he has to wait another week in order to get a second certificate before he gets benefit, he is not getting his rights under the Insurance Acts. I do not know whether the Minister, or the society, has made any regulations which require a second certificate to be presented before a member can obtain his benefit, but if so, in the sort of case I have suggested, an injustice is done and a right of the member is taken from him. I do not think that it should go out that a second certificate is necessary before benefit is obtainable.

I should like to hear from the Minister whether he can give the House any information as to when he may hope to have a fairly accurate and complete register of the insured persons in the country. I think it is common knowledge that the register has become somewhat stale and that it would require some little time, with the help of the Unified Society, to bring the register up-to-date and make it fairly accurate. No doubt, in that respect, unification should be a help in having an accurate register. The accuracy of the register is of very great importance to the medical men who work as certifiers by agreement with the Minister, because the distribution of the funds available between the several certifiers depends upon the accuracy of the register and the correct addresses of the insured members. A large number of complaints arise from medical men who feel that they are not justly treated because of inequalities of distribution which they do not understand, which are possibly due to an inaccurate register. It is quite possible that some of them will get a severe shock when the register becomes accurate, because if some have been underpaid some others must have been overpaid. Whether the register is accurate or inaccurate, I am afraid the Minister's officers are likely to hear complaints from time to time. Nevertheless, it is of importance that, as soon as possible, the register should be complete and accurate as regards the names and address of members.

I associate myself completely with what Deputy Dr. O'Dowd has said about the desirability of establishing medical treatment in connection with national health insurance. It is an absurdity on the face of it that a system calling itself national health insurance should really consist of nothing but a series of cash payments to people who are sick, because that is what it comes to in this country, and that no activity of the scheme is devoted to the treatment or prevention of disease. I notice in the Estimate that there is a considerable sum— £35,500—put down as medical benefits, which may mislead the unwary into thinking that there are medical benefits in existence in this country, while there are, of course, none. I do not understand how that item has got that name. It is only a name and has no reference to fact. There are no medical benefits administered under the national health insurance scheme.

I agree with what Deputy O'Dowd said as to the propriety of putting ourselves in a level with other civilised countries by adding medical treatment to our insurance scheme. A scheme has been introduced in Northern Ireland in recent years, which might not perhaps be suitable for this area. I do not wish to express the opinion that it would be suitable to this area; but medical benefits have been introduced in Northern Ireland and have, I think, worked pretty well. The Irish Free State is in the unhappy position of not being able to stand on the same level as other members of the League of Nations, because its insurance scheme differs from that of other nations in the absence of medical benefits.

I was interested to learn from the Minister that there has been some economy already assured through the process of unification, and it will be interesting, as time passes, to learn of further economy and to make some estimation in the course of a few years as to how many generations will have passed before we arrive at the degree of economy promised or hoped for before this unification was decided upon. I may say that I am not disappointed with the degree of economy reached, because I never shared in the optimistic hopes and promises made before and at the time that unification was decided upon.

The scheme of unification has come in for some criticism, particularly from Deputy Murphy. I do not think that there is any doubt, despite Deputy Murphy's opinion, that a unified society is able to give a better, a more efficient, and a more economical service than 50 or 60 scattered societies, some large and some small.

I was, however, rather disappointed that Deputy Murphy did not proceed a little further. I thought he was coming to the point on several occasions. I had hoped that he would urge on the Minister that he should take the step which was urged on the previous Government several years ago by the Labour Party of the time, that instead of stopping short at unification the Government should decide on having National Health Insurance as a State Service under the direct control of the Minister; that instead of farming out National Health Insurance to a society and giving such society a monopoly, the insurance scheme should be part of the Departmental work of the Minister himself. It appears to me that there still must be considerable duplication of work as between the Unified Society and the Minister's Department and that much greater economy could be made by abolishing that duplication; that more efficient service would be obtained and that less time would be lost. I hope the Minister will consider seriously, when opportunity occurs, taking the further step of passing from the single society to embracing National Health Insurance in the work of a Government Department.

It is by means of a Government Department that National Health Insurance is worked in several countries. The society scheme we have here is an outgrowth from the system imposed on this country 20 years ago—not because it was suitable to this country. Nobody ever suggested that it was suitable. It was undoubtedly suitable to the industrial population of a great part of Great Britain where the Friendly Society system was popular and fairly efficient. In this country the Friendly Society system was limited to a few of the large towns and was not in a position to undertake the whole work of National Health Insurance. Our present system is almost an accidental outgrowth of the Friendly Society system of the industrial towns in Great Britain and not anything that is particularly congenial to this country or suitable to the needs of this country.

I myself was of opinion, when it was decided to unify the various societies into one, that it was a step in the right direction, but it was only one step where two should have been taken. I would urge on the Minister to proceed to the second step as soon as he gets an opportunity. I would remind him too that his own policy as regards National Health Insurance, stated very clearly in this House a few years ago, was that two steps were necessary: (1) unification of societies, and (2) medical treatment. He has taken one of these steps, and I hope he will take the second in this direction also.

Mr. Everett

I should like to know from the Minister when the rules in connection with the society will be printed and circulated? I have written to the society for the rules for the guidance of insured members and I understand that up to the present they have not drafted any rules in connection with the society. I also wish to know when the insured members will have an opportunity of selecting their own committee of management, particularly after having heard the rules read out by Deputy Murphy. I do not think there is any other Government Department having a set of rules laid down by the committee of management which must be obeyed. I suggest to the Minister that the time has come when the three civil servants in charge of this society should be sent back to their own departments and that the insured members should be allowed to select their own committee of management, which will have some consideration both for the staff and for the insured persons.

I raised a question in the House some time ago in connection with the formation of a union. I am fully aware of the Minister's sympathy with workers. A room was placed at the disposal of the members, as it was not the wish that the members should become trade unionists. It was suggested that there should be a company union. The Minister stated that that was not so. We are not in a position to produce members of the staff, but we know what happened. I can assure the House that members were anxious to become trade unionists, but were told that there could be a company union. The late President Wilson and also President Roosevelt had to bring in legislation to abolish company unions in America because they were making profits out of the workers. I suggest to the Minister that he will have to do as President Roosevelt did, to bring in a Bill to prevent the management of the Unified Society exploiting the underpaid workers. The Minister may be surprised to know that one of the rules provides that members are not to be allowed to join trade unions; that no member of the staff has a right to subscribe 6d. a week without the authority and the sanction of the secretary; that before any collection or subscription is invited from members of the staff the permission of the secretary must be obtained. In large State Departments like the Department of Finance or the Department of Local Government there is no rule preventing members of the staff contributing to their own unions. I should like to know from the Minister how many of the staff have been recruited from persons outside Ireland: how many of the staff were brought from Belfast to work here, where we had a large number of our own people unemployed.

Mr. O Ceallaigh

Is that outside Ireland?

Mr. Everett

At the present time, it is not under our jurisdiction and very few Free State nationals get employment in Belfast. Yet we have members of the Government claiming that people from Belfast, who rendered service in the north are to be brought back here and given good positions. Was it necessary to bring a person who had no previous experience back from England to carry on insurance work here while we had a large number of people who had worked in insurance offices unemployed? I suggest to the Minister that much of the discontent would be removed if he saw that the rules of this society were circulated and that the insured members got an opportunity of electing their own committee of management. I am certain that if the insured persons got the right to select the committee of management the staff need have no terror about subscribing 6d. a week to a trade union. The insured members would then have the right to decide who should be the governors of the society. I guarantee to the Minister that if the insured members had the opportunity of directly complaining there would be very little discontent amongst the staff, and that that would prevent Mussolini tactics on the part of the committee of management. I am expressing that opinion on behalf of the underpaid workers.

Mr. O Ceallaigh

I note that there did not seem to be unanimity amongst those who spoke on the tribute that Deputy Morrissey paid to the expeditious manner in which unification was carried through, and the satisfactory nature of the work done. Of course, it is to be expected that this very big organisation recently established to deal with National Health Insurance could not run altogether smoothly in the first few months of its existence. I discount very largely the complaints made by Deputy Murphy and one or two other Deputies. I have a list of 23 complaints from Deputy Murphy, and of the 23 there were 17 for which the society was in no way responsible, and of the other complaints they were not wholly responsible. They were responsible to some extent, but not wholly. Taking that list of complaints from Deputy Murphy alone, I think what I have said shows a fairly good record of work for a society which has been in existence only a few months, and that covers nearly half a million insured persons. Some of the rules and regulations of the society do not seem to have met with the cordial approval of Deputy Everett and Deputy Murphy.

Mr. Everett

Not the rules of the society, but the rules of the staff.

Mr. O Ceallaigh

The rules of the staff I am not going to interfere with. There is a committee of management and that is their job. As the Act lays down that committee will go out of existence within a period of three years, and I take it that Deputy Everett and Deputy Murphy will not be sorry.

Mr. Everett

I will not be sorry.

Mr. O Ceallaigh

I can say this, that I doubt if any other three men could have brought about unification so expeditiously and so satisfactorily as these three men did in their period of office, and they deserve every credit for what they did. Deputy O'Dowd and Deputy Rowlette raised the important question of medical benefit again. That is a question that was often discussed before and will probably be discussed again. What I said about medical benefit I adhere to. I hope to see the day when national health insurance, as it is called, will be really national health insurance and not what it is in practice at the present time. The rules of the society are available. I think Deputy Everett asked that he should be provided with a copy. One or two other points were raised by Deputy Murphy and by Deputy Everett as to expenditure. There is not a loss, as Deputy Murphy suggested, on the present working of the organisation. There is a credit rather than a deficit for the end of the year. For the last few years there has been a very considerable increase in revenue, due to the very efficient working of the national health insurance organisation.

Question put and agreed to.

Progress reported; Committee to sit again.