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Dáil Éireann debate -
Friday, 21 Apr 1939

Vol. 75 No. 7

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

I move:—

Go ndeontar suim ná raghaidh thar £195,258 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, 1940, chun Tuarastail agus Costaisí i dtaobh Riaracháin na nAchtanna um Arachas Sláinte Náisiúnta, 1911 go 1936, agus na nAchtanna um Pinsin do Bhaintreacha agus do Dhílleachtaithe, 1935 go 1937, agus chun Ilsíntiúisí agus Ildeontaisí, ar a n-áirmhítear Deontaisí áirithe i gCabhair mar gheall ar Chostas Sochar agus Costaisí Riaracháin fé sna hAchtanna um Arachas Sláinte Náisiúnta.

That a sum not exceeding £195,258 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, 1940, for Salaries and Expenses in connection with the Administration of the National Health Insurance Acts, 1911 to 1936 and the Widows' and Orphans' Pensions Acts, 1936 to 1937, and for sundry Contributions and Grants including certain Grants-in-Aid in respect of the Cost of Benefits and Expenses of Administration under the National Health Insurance Acts.

The sum now asked for is to complete the sum of £292,888 required under the National Health Insurance Vote for 1939-40. The figure covers the cost of central administration of National Health Insurance, and also the cost incurred for staff, etc., of the Department engaged in the administration of widows' and orphans' pensions. It also includes the amount required for the Statutory Exchequer Grants for National Health Insurance, and expenditure in connection with the District Medical Referee Service. There is a decrease of £7,400 in respect of the Statutory Exchequer Grants, due mainly to the drop in the expenditure on sickness benefit. There is an increase of £1,665 in respect of salaries, etc., due to increased cost-of-living bonus and increments. A small increase under sub-head B, Travelling Expenses, is also shown. There is an off-set of £1,442, being the increased amount under sub-head H— Appropriations-in-Aid. The net decrease in the Estimate as compared with the year 1938-39 is £7,236.

Two changes have taken place in the Committee of Management of the Society during the year. Mr. John O'Neill, one of the employers' representatives, retired on becoming a director of the new Amalgamated Assurance Company, and I have appointed in his stead Mr. John McKinley of 49 Castle Road, Dundalk. The other change was in the representatives of insured persons on the committee. An election takes place each year for five insured persons' representatives, and provision is made in the Acts for two being representative of the Province of Leinster, two of Munster, one of Connaught and part of Ulster. The persons elected in 1938 are residents of Kilkenny, Longford, Tralee, Mitchelstown and Westport, Mr. Michael Armstrong of Kilkenny having replaced Mr. Joseph Billings of Dublin. All members of the committee hold office until the 31st July, when new appointments and elections are necessary.

The membership of the society at the end of 1938 was about 586,000, being an increase of some 4,000 over the previous year, and the number of insured persons in receipt of sickness and disablement benefits at 31st December, 1938, was 25,200, which is about the average through the year. The value of the contributions from employers and employees collected in 1938 was £710,843. The expenditure on benefits during the year amounted to £684,704, showing a decrease from the previous year of £20,590. The accumulated funds forming the assets of National Health Insurance amounted to £4,490,690, showing an increase of £289,466 during the year. This sum, together with the unredeemed paper reserve values of £2,068,698, represents the sum required to meet the future liabilities of the fund in respect of the existing members.

The investigation which is being made by the Government Actuary into the experience of sickness and disablement having regard to the age, sex and marital condition of the insured persons, is now, I understand, almost complete. When the report is received the whole financial structure of the Acts as at present constituted will be reviewed for the purpose of determining what changes are necessary or desirable. Although the contribution income is still increasing, there are still employers who either deliberately or through negligence fail to comply with the provisions of the Acts. I would like to warn these people that the interests not only of insured persons themselves under the National Health Insurance Acts but also the interests of their widows under the Widows' and Orphans' Pensions Acts must be protected, and that non-compliance will entail prosecution. It was found necessary to bring 578 such prosecutions during 1938. In addition, a sum of £384 was recovered from employers in respect of benefit lost by employees owing to the employers' failure to pay contributions. I think it would be well, Sir, to take Vote 39, which covers widows' and orphans' pensions, with this Vote, which also includes widows' and orphans' pensions.

The Committee has no objection?

There is money for widows' and orphans' pensions included in this Vote as well.

I do not mind their being discussed together, provided that there can be a net decision on Vote 44.

I move that the Estimate be referred back for further consideration. I do so because I think this Estimate and the whole position in respect of National Health Insurance in this country reveals a very alarming and very disquieting condition of affairs from the point of view of the insured persons. In this Estimate there is a decrease of £7,000 in respect of benefits paid to insured persons during the year, and the total reduction in benefits for the year will amount to £27,000. It is rather significant, however, that while we are providing for a reduction in benefit to insured persons, and while the National Health Insurance Society, which has been created by legislation passed in this House, is also paying substantially less benefits than previously, the number of insured persons has risen rapidly during the past few years, so that on the one hand you have a rising membership of the National Health Insurance Society and on the other hand you have the society paying less in benefit, and the State making a lesser contribution to benefit than in former years.

I want to ascertain and to examine the causes which are leading up to the apparent saving by the State and by the National Health Insurance Society and, at the same time, to direct attention to a quite different tendency in respect of the administration of National Health Insurance in this country. In 1933, when the Bill to provide for the amalgamation of 65 National Health Insurance societies was passing through this House, the Government claimed that unification would result in a saving on administration, that there would be more efficient administration, and that there would be available for expenditure in the interests of insured persons money which, up to this, it was contended, was being wastefully spent on the separate administration of 65 separate societies. But we find that the opposite is, in fact, the case, and that, far from unification having brought down the cost of administration, the cost of administration has, in fact, substantially increased, although there is less justification now for such high expenditure on administration than there was when there were 65 separate societies functioning in the country.

I want, first of all, to give the House a picture of the National Health Insurance position in 1937, which is the last year for which I can get full details, and the position in 1933. In 1933, the membership of 65 separate societies amounted to 474,000. In 1937, the membership of the single National Health Insurance Society amounted to 583,000. In 1933, 104,000 persons received benefit from the National Health Insurance, from the 65 National Health Insurance societies, whereas, in 1937, although the membership had increased by 109,000 in the intervening four years, only 95,000 persons received benefit from the single National Health Insurance Society. So that you have a very substantial increase in the membership, on the one hand, represented by 109,000, and, on the other hand, you have 9,000 less persons receiving benefit in 1937, as compared with 1933.

I begin to ask myself whether that is due either to an excessive policing of the membership of the society by the administration of the new society, or whether it is due to improved national health. I think the report of the Minister's Department, published in the Press to-day, does not indicate that there has been any considerable improvement in the state of our national health. In many respects there is cause for quite considerable alarm in some of the figures issued. The reports of medical officers of health refute the suggestion that there has been any improvement in the national health. Many of the reports of the county medical officers of health indicate that children, in particular, are suffering from mal-nutrition in consequence of long-continued unemployment. The statistics prepared by boards of health, the reports prepared by county medical officers of health, all indicate that there has been no improvement whatever in national health, such as would justify a belief that the payment of less national health insurance benefits to day is in any way due to the fact that the health and physique of the nation has improved.

If you take the figures of infantile mortality you find that in 1934 there were 63 deaths per 1,000 births, and in 1937 there were 72 deaths per 1,000 births. You find too, that the position in respect of tuberculosis and cancer affords room still for grave concern. The position in that respect is such as to cause grave concern to the nation. Rheumatism has now become a national disease. The statistics available, official statistics, do not indicate that we are entitled to say that the reduction in benefits paid to insured persons is in any way attributable to an improvement in the health of the nation. I think the money saved on benefit has been saved as a result of excessive and unreasonable supervision of persons claiming National Health Insurance benefits.

At one time there were insurance commissioners functioning in this country and I will say for the insurance commissioners that, so far as the insured person was concerned, they were very much better guardians of his interest than the substituted machinery which is in existence to-day. The insurance commissioners always took the view, when a medical referee reported that a man was capable of light work, that it was not merely sufficient to say a man was capable of light work, but it was necessary for the light work to be available. To-day all the decisions given by the Minister or his arbitrator on this subject indicate that once a man is certified to be fit for light work there is an obligation on the man to try to get the light work, and if he cannot get the light work himself, then he loses benefit.

Apply that to the case of a man who is a docker or an agricultural labourer. In what phase of agriculture can you get light work? With so many agricultural labourers idle, any farmer seeking a man will obviously seek one who is able-bodied and capable of doing all kinds of work; he would have no use for a man who was not capable of doing all kinds of work and his circumstances would not enable him to take pity on a man capable only of light work. When you tell an agricultural labourer that he is capable of light work and he should get light work, what you are doing is you are offering to that man an excuse for depriving him of benefit in circumstances in which he was previously entitled to and received benefit. To tell a docker that he is fit for light work when everybody knows his occupation requires the possession of herculean strength, is merely to give him an excuse for depriving him of National Health Insurance benefit.

Those of us who have experience of the National Health Insurance Society's operations know well that the plea of light work is being utilised by district medical referees, by the society, by the arbitrator and by the Minister or his Department as an excuse for depriving persons of benefit which they would have got if the insurance commissioners were still functioning and exercising the same benevolent interest as they formerly did in respect of insured persons. I think the administration of the society in respect of light work is very unsatisfactory, and that the insured person is paying substantially in hardship and suffering and in want of money for the reduction of benefits recorded here in this Estimate and for the saving in benefits which the National Health Insurance Society now records.

As I said earlier, we were told in 1933 that a part from the actual financial structure of the 65 separate societies, that the amalgamation of them all and the creation of one society would confer substantial benefits on insured persons generally and that there would be a considerable saving in administration. What is the position? In 1933 we had 65 societies with separate offices, separate staffs, separate administration and with all the other kinds of duplication that inevitably goes hand-in-hand with a multiplicity of offices and societies. In 1933 the expenditure in the administration of the 65 societies was £162,000. In 1936, with one society, the expenditure was £186,000, so that as between 1933 and 1936 it cost £24,000 more to administer one society than it did to administer 65 societies in 1933. It is true that, for 1937, the expenditure on the Unified Society fell to £155,000, but even £155,000 expended on one society, particularly having regard to the expenditure in other years, is something which, I think, ought to be investigated in the light of the circumstances presented to us by the Minister in 1933.

One might understand if this increased expenditure was due to the payment of decent scales of salary to the employees of the society. I do not pretend to speak with any detailed accuracy on the salaries paid to the clerical staffs in the headquarters office of the society although I do not think that they are anything that can be described as princely or generous in any degree, but I do know of the salaries which are paid to the agents of the society throughout the country. While the society can apparently say that these are only part-time agencies, the fact remains that, from the point of view of ensuring compliance with the Act and from the point of view of efficient operation of the Act the agent of the society throughout the country is a very pivotal man and he renders excellent service to the society. The scale of wages paid to these men is simply intolerable. No private employer would dare to offer salaries of the amount these agents are now forced to accept. The rates of wages are very inadequate, notwithstanding the responsible nature of the agent's work. The agent is a man whose activities enable the society to run smoothly and satisfactorily. He has custody of a fair sum of negotiable securities and it is desirable that the agent of the National Health Insurance Society should be adequately paid, or reasonably remunerated for the responsible work which he performs on behalf of the society.

The expenditure, therefore, in so far as it is due to decent rates of wages, or salaries per head of the staff employed, is not explainable, but the Minister may be able to throw some light on how it comes about that 65 societies could be administered in 1933 for £162,000, while it cost £186,000 to administer the one society in 1936. The expenditure in 1937 on one society was almost the same as on 65 societies in 1933. Similarly, if we turn to administration, so far as the Department is concerned, we find and equally puzzling position. Departmentally, the expenditure on National Health Insurance has increased between 1933 and 1937, although, bear in mind, between those years there has been a very substantial reduction in the amout of benefit paid to insured persons. In 1933 the Departmental expenditure in respect of National Health Insurance was £268,000 and in 1937 £280,000. While the Departmental expenditure was going up, the administration of the National Health Society was such that the amount of benefit paid to insured persons was going down. In 1933, £318,000 was paid in benefit to insured persons. In 1937 the amount so paid was £264,000—a very substantial reduction in benefit to insured persons, while the cost of the society's administration and of the Departmental administration was rising. This year there will be a reduction of a further £27,000 in respect of the benefit paid to insured persons. The position up to date is that in 1939, £81,000 less than in 1933 is being paid to insured persons, notwithstanding the fact that in that period the membership of the society has increased by 120,000.

I should like if the Minister would give some indication as to what is causing the position whereby the Departmental and society expenditure on administration is rising. While the membership is rising, and has risen by 120,000 persons in the last five years, the amount paid in benefit has fallen by £81,000 in that period. Everybody seems to be able to get more money but the insured persons. When we look at what the doctors have got for certification during the period, we see that the payment to doctors in 1933 was £41,000, and in 1937 it was £51,000. Benefit between those years fell by £54,000, so that the doctors got £10,000 more in 1937 than in 1933 for certifying for payments of £54,000 less in 1937 than they did in 1933. The less we pay to the insured person the more we pay to the doctors and the more we spend on administration departmentally and from a society point of view. Everybody, as I have said, can get more money but the people who need it most.

Then we come to the question of the administration generally of National Health Insurance benefit in this country. An examination which I have made of the figures of expenditure on administration shows a very serious position. My examination indicates that it is costing 5/10 to administer every £1 paid in National Health Insurance benefit. If you make a similar comparison in respect of widows' and orphans' pensions, you find that it costs 3/- to administer £1 of benefit. If you look at the unemployment insurance and unemployment assistance, you find that it costs 2/8 to administer £1 of benefit, so that while it is costing 2/8 to administer £1 of unemployment assistance benefit, it is costing over 100 per cent. more to administer £1 of National Health Insurance benefit.

I do not think any Minister or any Department can pretend to be satisfied with the extravagance which these figures reveal. The insured person can hardly be expected calmly to tolerate a condition of affairs whereby well over 25 per cent. of the fund created for his benefit is being spent on administration and he is apparently finding it harder than ever to get the benefits to which he is statutorily entitled. It seems to me nothing short of an outrage, nothing short of a classic example of waste, that we should be spending 5/10 to administer £1 of National Health Insurance benefit, while it takes only 2/8 to administer £1 of unemployment assistance benefit or unemployment insurance benefit. That is a state of affairs which ought to give the Minister cause for grave concern and certainly is a matter which ought to be inquired into with a view to cheapening the administration and bringing it substantially down from its present inflated level.

When originally conceived, the National Health Insurance scheme was regarded by many social reformers as something which was going to pave the way for a correction of the former attitude of the State in remaining indifferent to the standard of public health or to the hardships and miseries which sick people suffered, particularly in the industrial world. The purpose of National Health Insurance, as originally declared, was to prevent sickness and to cure disease. That was a very laudable objective and in England some effort has been made to keep the primary purpose in view. Efforts have been made there to provide sickness benefit in other than cash form. On the continent, of course, schemes of social insurance and for dealing with the health of the people are very much in advance of anything we know here.

If you were to take the position in Great Britain and in a dozen progressive countries in Europe you would find that our National Health Insurance scheme was merely an institution that gave a person a few shillings a week, and told him to get better as best he could; whereas in Great Britain and in progressive countries on the Continent the whole conception of National Health Insurance is on a much higher plane than it is in this country. We are doing nothing in the way of preventing sickness; we are doing nothing in the way of curing disease. What happens is that an insured person when he gets sick gets a certificate from a medical officer, who gives it to him after a most perfunctory examination and wishes him luck with the society. He makes application to the society and gets 15/- a week benefit. His wages may be £3, £3 10s., or £4 Let us say it is £3 per week. That man, who finds that £3 per week is necessary to sustain his family when he is in good health, submits his certificate to the society and in return gets 25 per cent. of his salary to keep his family and to meet the same expenses, although he himself probably needs the expenditure of more money than when he was in good health in order to cure his illness.

That is the position into which we have allowed National Health Insurance to drift. Its primary object was to prevent sickness and to cure disease. Our translation of that high concept into practice is to give a man 15/- a week and tell him to get better as quickly as he can and any way he can. No effort is made to treat a person under the scheme and no effort is made to advise him. All he may do is to call on the medical officer and get a certificate and wait until the 15/- comes to him. The State is not concerned under the scheme with curing the man. The dispensary medical officer may take him in hands and he may send him to hospital, but that is not part of the scheme envisaged when National Health Insurance was introduced. The State remains passively indifferent as to whether the man gets well or passes away. The concern of the society is to ensure that he does not draw too much benefit and does not stay too long on the books. If he does, the kind of person they send to have a look at him is the district medical referee, who will look at him occasionally and put him through the hoops. If he gives a certificate that the man is fit for light work, the man must try to find work, and if he fails, he loses his benefit. The very lofty purpose of our National Health Insurance legislation has descended to a very low level indeed. The wider purpose of the legislation has been completely forgotten. We are carrying on to-day simply, one might say, as a dole-paying institution, giving a man a few shillings a week, telling him to get better as well as he can. We are doing that at a cost which baffles any attempt to understand. It is costing 100 per cent. more than the administration of the unemployment assistance scheme to administer National Health Insurance. I should like to know whether the Minister has any plans for dealing with that position; whether he has any intention of expanding our legislation to deal with these grave defects in the scheme.

But even the sufferings of the insured person do not end there. In 1933, on the coming into operation of the Unified Society, certain additional benefits were being paid by certain societies. I agree that the position of all of them did not allow of their paying these additional benefits, but at least some of them were able to pay these additional benefits owing to the fact that they had good economic units for the purpose of insurance. Some of these societies, in addition to the cash benefits, paid dental benefits, provided hospital treatment, optical treatment, and surgical treatment, and some of them paid much more than the statutory benefit of 15/- per week to insured persons. I know of one society in fact that paid 19/- per week instead of the statutory 15/-. In the case of that particular society, which then went into the unified scheme, its members have lost dental benefit, hospital benefit, optical benefit, surgical treatment, convalescent home treatment, tuberculosis treatment, and the benefit is down from 19/- to 15/-.

I can understand that if you have a scramble for members for the purposes of National Health Insurance that some society because of the avocations of a particular class of members, will be able to get good economic units, and that some other societies will have to take the units which are not so good economically for insurance purposes, and that inevitably you will have inequalities of that kind resulting in the position that one class of member will be able to get benefits substantially higher than another class of member who pays precisely the same rate of contribution. I do not attach so much importance, therefore, to the dissimilarity in the benefits paid by one society as compared with another, but I do say that after six years of unification we ought to see some attempt by the Unified Society to level up the position. Instead of that, there has been a process of levelling down. Everybody has been pushed back to the statutory limit of benefit. There has been no improvement whatever for anybody. Although the good units made sacrifices, the units which are not so good for insurance purposes have got no extra benefits. I can understand a position whereby individual societies would give big benefits and there would be then a steep curve down to the general level of the statutory benefits. What has happened is that the curve has gone off and there has been no rise whatever in what was formerly the statutory level of benefits for the other members. The whole process which has gone on in the past six years has been one of levelling down and doing nothing whatever to improve the benefits in respect of the insured members generally.

The reason for this levelling down, and the plea which has been made as to the society's inability to provide additional benefit, has been that the insurance fund is not in a solvent actuarial position to provide additional benefit. Some expert said that the fund is insolvent. I do not know whether it is insolvent or not. I do not know whether the Minister knows the basis of valuation of the insurance fund, or understands the basis of its valuation. It has baffled many people who tried to take an interest in the matter to ascertain the basis of valuation. I think I am right in saying that the British people had the same basis of valuation as here, but they have since revised their valuation and found a new type of valuation. Apparently, that has not in any way caused a very serious dislocation of National Health Insurance legislation or benefits in England. What is the position of this fund, which is supposed to be insolvent? My inquiries into the matter show that the credit balance in the fund in 1937 was £4,000,000. My calculation was that that was increasing at the rate of £250,000 a year. The Minister, in fact, has put the rate of increase higher in the statement he read this morning, because, I think, he said that during the past year it increased by £289,000, so that this insolvent fund, consisting in 1937 of £4,000,000, has probably assets to-day to the extent of £4,500,000. Many undertakings in this country, commercial and industrial, would regard themselves in a very good position if they had assets to the extent of £4,500,000 and saw no likelihood, at the present rate of benefit, of having to draw on them, when they ascertained, from the current year's trading, that, in fact, that fund was increasing from £250,000 to £290,000 a year.

I should like if the Minister could tell us whether it is intended to revise the basis of valuation, and whether it is intended to release some of the accumulated assets for the benefit of insured persons. I know that the actuarial theory will be, bearing in mind the ages of members, and the expectation of life, that you have to budget for the possibility of what will be done for the last man left in the society. That always seems to be so remote, and so far removed from more pressing problems, that we can allow provision of that kind to become almost a fetish, if we allow ourselves to develop a state of mind where we proceed to do on the 1st of January something which was due to be done on the 31st of the following December. Whether that philosophy will be accepted or not is another matter.

The Deputy does not accept it himself.

One thing we ought to know, and that is the basis of valuation, to know whether we are going to maintain the present basis of valuation, and continue a position whereby insured members will be kept merely to statutory benefits; and whether an effort will be made to level up the rate of benefit, and try to implement the real purpose of National Health Insurance, which was to prevent sickness and to cure disease. I should like to know whether there will be any effort to create here a medical benefit scheme in connection with the National Health Insurance Society which exists in Britain and Northern Ireland, and whether any effort will be made to extend National Health Insurance to produce real National Health Insurance, instead of the very small tontine society which the present National Health Insurance scheme is. Normally, I think a valuation was due in 1935. When the Minister is replying, I should like to know if there has been any valuation since 1933. I should also like to know if the 1935 valuation was undertaken, and if the Minister has received any report, and, if so, when it will be circulated so that it can be perused by those interested in National Health Insurance.

I want to say again that there were many reasons for amalgamation of National Health Insurance societies into one society, just as there were many reasons for railway amalgamation, for trade union amalgamation, and for amalgamation to get rid of the waste and cut-throat competition of a half-dozen people seeking the privilege of paying benefit to a person. Of course, if there had not been amalgamation, some of the societies, whose assets were in a parlous condition, who were paying a very high rate of benefit; at least, substantial benefit, from the point of view of the aggregate total, which they could not continue, in that way were saved from what one might describe as bankruptcy, by being lumped into the general amalgamation scheme. I know societies whose income per member was 22/- and whose out going per member was 34/- a year. Obviously conditions like that could not possibly continue. Amalgamation, therefore, probably saved a number of these societies from ruin, and the members from considerable losses. My complaint is that the whole purpose of National Health Insurance was forgotten in the amalgamation scheme. Since 1933 nothing has happened under the present society except a levelling down of benefits. There has been no levelling up. After six years we are still in doubt as to what the future of National Health Insurance will be. We do not know whether it will continue on the present basis, or whether it will expand to satisfy the purpose of those who conceived it, and be a real National Health Insurance society, taking an interest, not merely in the health of the persons insured but to assure them of a reasonable standard of income to sustain them during periods of illness.

I have put down a motion directing attention to these serious defects in National Health Insurance, defects which are not generally appreciated by the Department. I am sure the Minister has considerable sympathy with every effort to promote social legislation and to improve our existing social legislation, but I am not satisfied that, as Minister in charge of a very big Department like the Department of Local Government, with its widespread activities, he can properly devote time to the consideration of such a pressing problem as this is. I should like to see social services such as National Health Insurance, old age pensions, widows' and orphans' pensions and unemployment assistance co-ordinated under the administration of a department of social services, collecting the contributions for these services by means of a single stamp or in the same way as income-tax can be collected from citizens. Of course, that is outside the ambit of this Estimate, and I do not propose to deal with the matter now. I think there is need for radical reform in respect to National Health Insurance. There is need for concentration on the problem and, in his reply, I hope the Minister will give an assurance that if he cannot definitely supervise the matter, at least, he will give directions that steps should be taken as soon as possible to improve the whole standard of National Health Insurance, and to provide for insured persons much better benefits than the level of the statutory scale in operation to-day.

Deputy Norton has covered the field of this Estimate very fully, and has made use of many figures, with most of which I find myself absolutely in agreement. I do not, however, agree with some of the conclusions he has drawn from the figures he put before the House. It seems to me that there are many factors concerned, and for the past few years we have to keep in mind, when talking about National Health Insurance, the changes that have taken place since the unification scheme came into being. As far as members are concerned there has not been any change for the better. So far as the majority of insured members are concerned, their position to-day is considerably worse than it was before the unification system. I am not saying, of course, that if we had not the unification scheme, or some similar scheme, the position of some of the societies might not be infinitely worse, or that, probably, a great number of them would not have gone out of existence, or that the position of the members would be very bad. Talking of the general run of the societies which were, I think, admittedly, well run, the members who were fortunate enough to belong to the well-run societies have very definitely suffered. I shall give a typical example of a society with which I was connected myself. It was an ordinary agricultural society, as I might call it. What I mean is that we had not any sheltered class of workers; they were drawn from agricultural labourers, general workers, domestic workers, and so on; and we were able to pay a cash benefit of 18/- a week, or 3/- a week more than the statutory benefit. If we had thought it advisable we could have paid a much higher cash benefit, but we decided to give what I would call very extensive non-cash benefits, such as optical treatment, dental treatment, and so on. Now, all that, so far as those members are concerned, has gone by the board, and the position is that all the good societies and all the members of the good societies are being brought down to the level of all the bad societies and the members of the bad societies.

There is, however, something worse than that. It is much more than a question of the mere reduction of 3/- a week or merely reducing them down to the statutory cash benefit; because we have got to remember this: that 15/- to-day—even 15/—has not the purchasing power that 15/- had even in 1933. Therefore, the actual reduction in the value of the benefit is more considerable than it would appear to be on the surface. One of the great difficulties in connection with the provision of benefit during illness, so far as workers are concerned, has been to get over this difficulty. Deputy Norton gave the case of a man who is in receipt of £3 a week, but he was able to work and immediately he became ill and his expenses became greater he was reduced to 15/- a week. I prefer to take a different case, and this is a difficulty that I see and have always seen in connection with this matter. Take the case of an agricultural labourer working for £1 or 25/- or 27/- a week. He becomes ill, and your cash benefit is £1 a week. That is bringing you down to the present day. Let us take the case of a married man, unemployed, who has nothing to hope for except rotational work at 4/- or 4/6 a day. Your cash benefit need not be very great to be more than he will get in wages under the rotational scheme, and there you are up against the temptation for that man to remain out of work longer than he would ordinarily remain out of work, and the more you increase the cash benefit the more you increase that temptation. That is one of the difficulties.

Now, one of the reasons why I personally would be rather slow to draw apparent conclusions from the figures is that the whole position has completely and absolutely changed. We cannot ignore the fact that the vast numbers of unemployed that we have in this country have a very big effect upon National Health Insurance, a tremendously big effect. Now, I am not blaming these people in the slightest, because I know that man in that position will do these things, and it cannot be helped. Men who, in ordinary conditions, if they were in a good job, would carry on and work and would only go to the doctor when it was absolutely necessary, but men who have practically no means, or very little means, will go to the doctor and get a certificate and draw benefit. That brings me to another point. We all know that the big trouble with National Health Insurance in this country has always been the question of certification. That may not be a popular thing to say, but one of the principal reasons for whatever abuses there have been in connection with National Health Insurance has been loose certification. Anybody who has had anything to do with a society knows—and I do not suggest for a moment that the doctors are dishonest, but I do know this from my own personal experience as a member of the committee of a society—that certificates were very often given to people to draw benefits from a society, which people the doctor had never seen. Once a certificate is issued in the first week to a person whom the doctor has seen and examined, and to whom he has given a certificate, the subsequent certificates are very often issued and continue to be issued with out any further examination by the doctor or with examinations only at very long intervals. Some people, of course, are inclined to take a rather lenient view of those who obtain benefit to which they are not properly entitled, and they seem to take the view that it is all right—you are only putting a quick one across the Government—but what we have to remember is that, when a person who is not entitled to benefit gets it, he is taking from the pool that is there for his fellow-workers and for his fellow-workers alone. I know that the question of certification has been one that has given a great deal of worry and has been the cause of a good deal of thought and planning not only since 1933 but prior to 1933, and I have been informed recently that there has been considerable improvement in the matter.

One of the biggest drains upon National Health Insurance is disablement benefit. Now, disablement benefit is perhaps one of the most valuable benefits that a broken worker has to get, but unfortunately it is the particular class of benefit that is most open to abuse or that can be most easily abused. I am afraid that it is going to be very difficult, without perhaps doing injustice to people, to check that and to deal with whatever malingerers there may be. I had hoped that the Minister's statement would have taken a rather different line. I should have liked to have heard a report from him on the work of the unified societies: whether he is satisfied that they are working along the right lines; whether there are any new departures; whether he has had any reports from them as to what action should be taken, in the light of their experience of the last year, to improve the system and make it more watertight and to reduce and, if it were possible, to eradicate whatever abuses there are; and what proposals they have made, if any, to bring the benefits to the members at least to the standard they enjoyed prior to the unification of National Health Insurance in this country. I should be very, very sorry indeed to think that the Minister or any member of this House would be satisfied to look upon the present National Health Insurance system as that which is going to be a permanent system for this country. It is merely a stop-gap.

One has only to think of the position of a workingman earning £2 a week. He has a wife and six or seven children. He has no spare money. If stricken down with illness he is at least two or three weeks without getting a penny. He is lucky if he gets something at the end of three weeks, and then all he receives is 15/- a week. What use is that for a man in his circumstances with so many to support? He has nothing to enable him to repair his health unless the children are to be allowed to go hungry. It seems to me that the health of a man in his position is bound to get worse. I do not want to overstate the case in any way. I have an appreciation of the difficulties that there are in this particular service. I took a fairly keen interest in the working of a society for a long number of years. While I appreciate the difficulties, I think it ought not to be outside the wit of those who are charged with dealing with the service to bring before the Government, the Minister and the House a scheme which would be an improvement on the existing position. If my memory serves me, I do not think that the Minister in the discussions that we had on the Bill when it was going through in 1933 indicated in any way that he was altogether in love with unification. He did not expect, I believe, any more than anybody else, that unification was going to end the trouble. It is safe to say that unification was introduced as something likely to save certain societies from going out of existence altogether. It was looked upon by those interested in the matter as a temporary measure which would secure at least the statutory benefits to members, pending the bringing forward of a more comprehensive scheme, one which would improve rather than disimprove the benefits which insured members would expect to get when stricken down with illness.

With great respect to Deputy Norton, I think a great deal of his speech was positively shocking. When Deputy Norton proceeded to deal with the actuarial background of National Health Insurance in this country I must say that cold shivers went down my back. The actuarial aspect of National Health Insurance is an extremely complex and difficult question, one which it would not be reasonable to expect Deputy Norton to have an expert knowledge of, but a man in his responsible position should have sufficient information to realise the complexity of it and the reckless irresponsibility of talking about accumulated funds of £4,000,000, and the desirability of distributing these amongst insured persons. Of course you can distribute these funds amongst insured persons to-morrow morning if you want to and wreck the whole foundation of National Health Insurance in this country. But you have got to bear in mind that if you do that kind of thing once in respect of one fund, you not only wreck the National Health Insurance system but you wreck all prospect of carrying on similar schemes, of which there are legion and of which I hope there will be more, because you destroyed public confidence. If you establish a fund on a certain acturial basis and hold out to the persons entering that fund from time to time certain prospects founded on certain agreed actuarial calculations, and then halfway through uproot the whole thing, dissipate the assets and wreck the fund, you are simply robbing those who contributed their money in the earlier stages to the system.

I could not help thinking, as I listened to Deputy Norton, that before he was very long talking on the subject he himself began to realise the extravagances to which his line of thought was leading and he sheered away from it, but a person in the position of the Leader of the Labour Party ought to measure his words because when the Leader of the Labour Party speaks of distributing these moneys to the insured population, an accumulation of £4,000,000 sterling, he may proceed to qualify it in this House, but what the public will remember is that it is on record that he recommended that this vast accumulation of money should be forthwith distributed, and it is going to be extremely difficult to explain to people, who have heard that general suggestion, the actuarial reasons why it cannot be done. I, for instance, would not like to undertake the task of explaining the actuarial reasons why it should not be done to Deputies of this House who are supposed to devote a considerable part of their time to the study of such questions, much less to the many busy men earning their living up and down the country who have neither the time nor the inclination to go into elaborate actuarial calculations in order to clear their minds on this subject. Is it not an interesting thing to have heard the Leader of the Labour Party lamenting the unification of approved societies? I understood that the Labour Party was a Socialist Party.

I understood it believed in the State control of most of the sources of production.


And the nationalisation of most of the public services.

They surrendered all that this week.

Let us not jeer at them if they had the moral courage to abandon the workers' republic openly and above board because remember——

They did not do it openly. That is the point.

——there are those in this country who have abandoned the republic but who have not been open and above board about it. I admire a body of men who are prepared to say that the word "workers' republic" has come to have a certain meaning.

On a point of order. Is the Deputy in order in discussing this on the Estimate for National Health Insurance?

No. It has nothing whatever to do with National Health Insurance.

But I do not admire a body of men who say at their conventions that they believe in the nationalisation of everything that can be nationalised and then come into Dáil Eireann and lament loudly the nationalisation of National Health Insurance and the unification of all societies, and advance as one of their strongest arguments in condemnation of it that certain societies have lost their additional benefits and that all have been reducing the statutory benefits. There was only one good argument for unification, only one argument that I could not satisfactorily rebut on the unification Bill, and that was the argument based on the disparity of benefits.

There was one deplorable flaw in the system of approved societies at present functioning in England, and that was that you got a group of workers in special trades who withdrew themselves from the general framework of insurance and established an approved society to which they only admitted the members of their own trade such as bank clerks and persons in occupations of that kind. By withdrawing from the general community of insured persons they lumped their money together and enjoyed immense benefits, while the dock worker and labourer had to get into any society that would take them.

I myself had long experience of administering a society which catered principally for the Catholics of Northern Ireland who were very largely the hewers of wood and the drawers of water. They were people for whom we were striving night and day to get decent benefits. But as a result of unemployment and sickness arising from malnutrition and poverty, the rate of benefit which we could give them did not compare with the benefits that the Bank Clerks' Approved Society, the Engineers' Approved Society, or the skilled workers' approved society were giving. We could not get people with a law incidence of sickness to join our society because, reasonably enough, they said they could not by staying in our society get the benefits they could get in another society. They said by joining our society their money would go to provide benefit for the dock labourers and generally distressed persons. We had to spread the risk of sickness over employed persons; the moment you got employed persons to segregate themselves in a class you struck at the whole fundamentals of National Health Insurance.

In England you had an entirely different problem, because it is on an entirely different scale. You have an immense industrial population there. You had societies with an immense membership. Take the transport workers. They managed as a result of that immense membership to evade the evils which beset us here. The circumstances of the two countries are entirely different. National Health Insurance is a British concept devised for an industrial population. It is being worked in Ireland with the population 80 per cent. agricultural. The difficulties that beset us here are of the kind that Great Britain has never known.

I think that the amalgamation of the societies was a mistake. I said so five years ago, but there was no use in mentioning it then because the Labour Party at the time would have beaten anyone who spoke a word against it. Look at the position now. I was amused to hear Deputy Norton, who is a democratic Republican, proclaiming the virtues of the British people here to-day. The Deputy pointed out their virtuous outlook on National Health Insurance. He told us how much better they treated the working people of their country then we do. It is very refreshing to hear that this Republican has discovered that the "base, bloody and brutal Saxon" has some virtues. But I was shocked to hear a democratic Republican holding up the "base, bloody and brutal Saxon" as an example for us to follow.

I deplore the passing of the statutory benefit. I think we ought to do something to remedy that situation. I think we ought to do something along the lines of providing additional benefits of a prophylactic nature because I do not think that we can argue that the Treasury might profitably put its hands in its pockets and hand out additional money by way of supplement to the 15/- a week, unless we could go on and say that it would not be a continuing charge; because as a result of the additional expenditure we might anticipate a decrease in sickness amongst insured persons.

I think the Minister could make a good case for showing that we, looking forward, perceive an actuarial reason for what is burdening the funds of the unified society. We identify a considerable part of that reason as being the consequence of inadequate dental treatment in the early years of the insured person's life. We, therefore, propose in order to avoid a worse type of charge upon the funds—and that is the permanently incapacitated person, the 7/6 type of patient—to give the young members dental treatment in the early years of their lives so that in middle age they will not become 7/6 patients. The 7/6 patient is usually the rheumatic person or the person suffering from arthritis who breaks down and becomes incapable of work. The Parliamentary Secretary can correct me if I am wrong. I apprehend that directly or indirectly a great deal of that rheumatism and arthritis in middle age is due to the lack of dental treatment in youth. I believe that this poison from bad teeth passing into the people's system frequently eventuates in chronic disablement through rheumatism and arthritis when the person reaches the fifties or sixties. If we see after the people in their youth I believe that would reduce the actuarial burden on the funds of the society. That would reduce the number of crippled persons in middle age. I believe that could be done, and it is a thing that would be worth doing. I believe it is a speculation that the Minister would be justified in recommending. No one could say with certainty whether it would prove remunerative or not. We would all like to increase the benefits and this is the one economic increase that we could possibly make in the benefits with the hope of reducing later burdens.

I believe in controversy. I believe in saying quite openly what I say behind people's backs. Grave criticisms have been made to-day by the Labour Party with regard to the expenses of the administration of the Unified Society. Can the Minister for Local Government and Public Health put his hand upon his heart and say that in the appointment of the personnel of the headquarters staff of the Unified Society there was no patronage and no introduction into the staff of the Unified Society of persons but on merit alone? Were persons brought into that staff who on merit alone would never have got there? I have reason to believe that in the early stages of the Unified Society's history it was regarded more or less as a dumping ground for political hacks who had to be provided for. I recognise, and it is only honest to say so, that all of us in public life are menaced with that affliction. If there are any jobs or any preferments within the gifts of public men these men are afflicted with this sort of thing. They are pursued by their friends and by influential persons with the argument that after all this person may be the best person for the job, that he could do it and that it may be no harm to give him the job. That is very largely the usual argument in the case of decent people. I am not satisfied that in the Unified Society there were not people brought in to the general management or into the headquarters staff who were not the most efficient and the most competent persons that might have been put there. And, if the Minister now hears ferocious criticism of the expenses of administration, he ought to examine them in his own conscience and in the records of the Unified Society, to satisfy himself whether his influence or that of his Department was ever used to secure employment in the Unified Society for a person whom the Unified Society would not have employed on their own initiative; and if he finds that there are such cases, I submit that they ought to be examined with a view to determining whether such employment is in fact contributing to the unduly high ratio of expense which the leader of the Labour Party, in my opinion, fairly and reasonably complained of.

Reference has been made to the agents in the country and, in that connection, I wonder does that division of the Minister's Department charged with the provision of National Health Insurance ever inquire into the question of whether the agents in the country are located in the most convenient centres for the insured persons which they serve?

We have no control over the agents.

And no representations have been made? Let me put a case to the Minister. Suppose I am an insured person, and one of a considerable group in a district, and that we are the only insured group in that district —a large district with a very scattered insured population, except in the corner where we happen to be. We are informed that our agent lives seven miles away, at the other end of the district. Have we no right to go to the Minister and say that the Approved Society has appointed as agent a person who is in an unsuitable location, and who either ought to be made move in to where the bulk of his members are or resign and make way for a man who is prepared to live amongst the members?

It is not the Minister's responsibility. The Committee of Management deals with everything in connection with the staff and the salaries and wages of the staff.

Has the Minister no right of remonstrance?

He has no rights in the matter; in fact, he could be told to mind his own business.

Really? I should have thought that the Minister would have a right to say: "In my judgment, the insured persons are not getting the services they are entitled to demand."

If a member of the society makes a direct complaint we can investigate it.

I know cases in Monaghan—and I think the Parliamentary Secretary knows them too—where there are grave doubts as to whether the agents are properly located. In one case an agent is located in the country although there are one or two towns in his area. Naturally the bulk of the insured persons with whom he has to deal are living in the towns, yet the agent is a man living four or five miles out in the country and his area is very large—I think it is two areas. That is obviously unsuitable and is a matter that I would expect the Minister's Department would examine and remonstrate with the approved society regarding it. There is no necessity to make any concealment about it—the man is very well know. I do not propose to mention his name, and I am not asking the Minister to investigate the matter without full consideration. The man happens to be a strong supporter of the Parliamentary Secretary and a vigorous opponent of mine, and it may be that representation made to me could have been influenced by that fact. But the facts are certainly true, as they appear to me, looking at it in an ordinary way and not as a politician might look at it.

It must be very hard to do that.

The situation is not satisfactory. It would be reasonable if that man came into the centre of his district, dwelt there, and made himself available to the bulk of his members —and not live in the back of beyond where no one could reach him.

Which town would he come to?

Oh, to Castleblayney or Carrickmacross—whichever is the more convenient.

What would the people of the other towns say then? They might make representations that the district should be divided.

I sympathise with Deputy Smith for advancing that view. If he would recommend that this area be divided and direct the Minister's attention to that aspect of the question I have no doubt that the Minister would be glad to carefully consider Deputy Smith's recommendation that this area should be divided and two men established there.

I never knew the Deputy was so clever. He is a genius.

Now, Sir, the second point I want to make is this. I think the Minister ought to consider whether it is desirable that the unified society should adopt the Post Office system of having temporary employees as their agents. I am not sure if this is a matter for which the Minister is responsible at all.

He cannot make representations as to the terms of employment.

Very well. There is another matter which is very important. Do insured persons who are summoned before a medical board get a fair deal? I want to say at once that, in my experience, where these cases have been brought to my attention and where I have brought them before the Minister's Department, they have been very fairly dealt with at once, and I have no complaint to make on that score at all. But I cannot help thinking that there may be cases which never get to the Minister's Department. I came across the case of a man who I happened to know was a bit deaf—one of those stupid fellows who could not make themselves understood and could not make a case. He was obviously incapacitated for work, and he was called before the Medical Board of Referees and he was knocked off the benefit. It was perfectly manifest to me that there must have been some mistake about it, and I got into touch with the Minister's Department and, to make a long story short, a further examination was made on a subsequent application and the man was restored to benefit. It has got to be borne in mind that persons who are incapacitated under the National Health Insurance system are frequently very ill-equipped to make a case. I would like to think that you had insured persons on the one side, the society on the other side and the referee between them—and that the Minister's Department would be the protector of the rights of the insured persons. I am not altogether satisfied that that aspect of the thing is present to the minds of the insured persons or the Minister's Department, and I believe that that is something that ought to be watched, because it is not right that people should be deprived of their benefits simply because they are not able to make their own case.

All the matters to which I have referred are capable of wide elaboration. I do not propose to spend the Minister's time or that of the House elaborating them because they can do that for themselves.

But, there is a last point. I do not know if the Minister's attention has recently been directed to a decision of the appeal court in Great Britain. A man fell ill and was awarded 15/- a week. His employer, who did not wish to dismiss him, paid him the difference between his wages and the 15/- a week for the duration of his illness. Let us say the man was earning £3 a week. He got 15/- from the approved society and £2 5s. from his employer. When the man recovered, he went back to work and he sued his employer for the 15/- which the employer had deducted from his wages during the several weeks of his illness. A decision was given in the court, in the first instance, that the employer had no right to make that deduction. The case was brought, I think, to the court of appeal and they confirmed that decision. Now, the evil which will arise from that decision is this, that it places upon us all an obligation to dismiss a man the moment he falls ill. Most employers, when a man gets sick, would be anxious to make up his wages to what they were but they think it is only fair, when they themselves are contributing every week to the National Health Insurance fund, that they should be entitled to deduct the 15/-. This decision makes it clear, if the law is allowed to stand in its present form, that you must either dismiss a man, by giving him notice, or pay him his full wages in addition to the National Health Insurance benefit.

That is a matter on which the Labour Party must have some view and I think it would be of great value if the Labour Party would give us their view upon it. I am strongly of opinion that that attitude should not prevail in this country, because it would give rise to grave abuses and frequent dismissal of sick men in order to save that 15/-. I am satisfied that the majority of employers would give the difference between a man's wages and his National Health Insurance for a reasonable period of sickness. Therefore, I invite the Minister, by declaration or otherwise, to provide against litigation taking place in this country which would have a result similar to that of the decision in the British courts.

I only propose to advert to one or two points in connection with this Estimate, mainly on the question of the courts, which has been referred to. I think that, with a slight alteration, the present system could be made satisfactory. Where a member is given the right to have an appeal and lodges 5/- the case is tried in the head offices of the society in O'Connell Street, but that is very little use to a man or woman from a remote part of the country. they have got their powers and their authorities and rights and can send the 5/-, but the case is tried in absentia because, in most cases, they have no opportunity of being represented. In a very few, remote cases, perhaps, some Deputy will go in to represent them there, but, in the vast majority of cases the people have no direct representation. The case is tried in the head office of the society and, rightly or wrongly, in the country we have a kind of suspicion that when you go to law with the devil, the court being in his own region, you do not expect to get much satisfaction. When the results seem to justify that kind of premonition, it does not make for confidence in the administration of the courts. There is, of course, a further appeal to the Minister, if that one is unsatisfactory and, in that event, the case can be tried locally. I am suggesting that the system should be reversed completely. The original case should be tried in as near a place as possible to the residence of the applicant, similar to what is being done, for instance, by the labour exchanges. In local areas a professional man is appointed who will hear cases on stated days from the surrounding district. The whole County of Limerick, where I come from, for instance, and parts of County Clare have cases heard in the City of Limerick, which is quite convenient. On stated days, cases are heard there by a professional man acting as referee. I know that this thing happens in Cork under the National Health Insurance scheme but I do not know of it happening anywhere else except Cork.

I would ask the Minister to look into the matter seriously, as I know from personal contact it will cause a feeling of confidence and change and satisfaction amongst most of the members. I do not think it would create any dislocation whatever in the affairs of the society to have the cases heard originally in the local venue. If an appeal has to lie, either by the society or by the applicant, let it be tried in Dublin or wherever the Minister likes to determine. I have been agitating for this for a considerable time and the longer I am meeting these cases the more I am convinced of the necessity to have that change brought about.

I was rather sorry to hear Deputy Morrissey speak this morning on the loose certification. I think we really should have got away from the time when there may have been some foundation for that statement. There was, perhaps, a time when the statement that there was loose certification may have had some basis or justification, but that was previous to the formation of this Unified Society. I do not think anybody could say at the moment that there is loose certification. When there was loose certification, prior to the formation of the amalgamated society, the circumstances in the country were of such an abnormal character that I think the medical profession were entitled to congratulation for having taken the humane stand of issuing certificates in what might have been called, in normal practice, a loose manner. I observe Deputy Dillon smiling. I appreciate his sense of humour.

It is a very dangerous doctrine if doctors are to betray their profession for a humane purpose.

I am still suggesting, Sir, that the certificates issued in what is being called a "loose" manner were eventually economical for the insurance societies, before or after amalgamation because, in many cases, the issue of a certificate by the doctor to a man for a couple of days saved him, perhaps, from falling into a long and serious illness.

He would get no benefit for a couple of days' absence.

A certificate issued in the preliminary stages would give a man a few days' rest and save him from what might have been a long illness and long absence from his work, even though that certificate might have been eventually tobooed by the medical referee. I suggest that, if there was ever looseness on the part of the certifying doctors, it would have been quite justified because the certifying doctors acting for the society felt they had a definite mandate for taking to the other side and doing rank injustice, in many cases, to some of the members.

Then we had the spectacle of having those cases tried. We had two, three, or may be more outside doctors with their certificates, 11 or 12 of them, held up and one certificate from the medical referee was supposed to outweigh and counter-balance the weight of evidence coming from all those professional men, all having degrees from the same university. I think it is a serious reflection to have it implied that we could not trust our medical doctors to do their duty by this country, and I am not speaking without some knowledge of this question. I have had many years' experience in the administration of a society and I have had many years' experience of the members, and I say it is nothing less than a misstatement to speak in this fashion of loose certification being a contributory factor to any extent in bringing about the insolvency of the societies, such of them as were insolvent, and it is much wider of the mark to talk about it at the present day.

I cannot see any great danger either of the abuse of disablement benefit. The disablement benefit is, to my mind, very well protected in the statute, and I do not at all see the danger that has been referred to by Deputy Morrissey in that respect. The disablement benefit is certainly one of the most useful items in the insurance code. Having got to run the gamut of the full period on full benefit and the remainder on reduced benefit, the machinery to safeguard against malingering is, I think, amply provided for in the Act. I have not the least fear that that particular section of the Act is likely to be abused. Having regard to the position which had been reached by the majority of the societies through difficult periods in the history of the country, many of them having provided those increased benefits—the sheltered societies of which Deputy Dillon speaks, people who had sheltered occupations, where they were in a position to improve the benefits of their members, as against what could be done by people in more hazardous occupations—and having regard also to the fact that there were comparatively very few failures in that great number of societies, I do believe that, with the unification which has taken place and the economical working which should have resulted, we have reached a position where an increase in the statutory benefits is more than overdue. It is certainly a great loss to the members and their dependents to have lost the optical, dental and other benefits provided for by their careful working of a few years. I do certainly believe that the time ought to have been reached when the Unified Society would seriously take up the matter as to whether they are in a position to increase the benefits—both the financial benefits and the optical and dental benefits—provided by the societies previous to being taken over. I am particularly anxious to stress again the point about the holding of the courts. I think it would make for great satisfaction among the members generally if my suggestion could be adopted.

The Minister to conclude.

I am always a keen listener to the discussion on this matter. I took an interest in the subject before I became Minister although I had no personal experience of societies. Before becoming Minister I was interested, just as a citizen and a public man, in social questions. This was one of them. I took an interest in it many years ago when the question of national health insurance was first introduced into this country. Perhaps Deputy Dillon is old enough to remember—I do not know whether he is or not—the great discussions which took place in the country as to whether the system which had been adopted in England, and to which he himself referred, was a suitable type of insurance for adoption in this country. There were many discussions and many debates, I think, in the British House of Commons, and certainly in local authorities and all sorts of societies, about its adoption here. It was generally felt here, at any rate, that it was not a suitable type of insurance for this country. It was felt that it was not the type of insurance that was best suited to secure what it was intended to secure for the working classes in this country. What was true then, when the system was first introduced, is to a large extent true to-day, and possibly the type, being such as it was, was responsible for the failure of many of the insurance societies, which if they had not failed were certain of failure in a brief time if they had been allowed to continue their administration as it had been carried on previous to amalgamation. There is no use in going into that story now. Everybody knows that there were good reasons—Deputy Dillon gave one, but there are more than one good reason— why amalgamation had to be adopted at that time. There is no use in debating that subject.

Deputy Norton speaks as if we had had plenty of time since amalgamation fully to investigate the whole system, its financial reactions, and the changes brought about by amalgamation, and ought to have, at any rate, brought forward suggestions for the necessary remedies. I think he suggested that we had had plenty of time to introduce the remedies which might be found necessary. As a matter of fact, amalgamation was not completed until late in 1935. The Bill was introduced in 1933. Late in 1935 the amalgamation was completed, and the least possible time that the actuary demands to get statistics to make the necessary actuarial investigations as to the condition of the society and its prospects in the future is three years. He has asked for three years' statistics of the working of the society as an amalgamated society, and all the statistics that he has asked for have, I think, been furnished to him. He has asked for at least three full years' experience of working as an amalgamated society, a unified society, before he can give us the necessary financial and other actuarial figures that are necessary for a proper examination of the basis on which we have been working and may be expected to work for the future, so that it is not right and it is not fair to say that the Minister has been negligent or lax in his duties. If it were Deputy Norton himself who had been here—and I know that he is a much more active and perhaps a more enthusiastic social reformer than I am—he could not have done it one day earlier. I thought we would have had the actuary's report before now. We have not got it. We are expecting it any minute now. If we had had it before the Estimate, as I had hoped, we might have had, not a chance to examine it thoroughly, but a chance to look over it and outline the suggestions that might be made. We have not had the report. It is not possible to make any suggestions for the future, to make any observations on what the three years' working has shown us, or the defects or other matters of interest that the examination of the three years' working as a unified society will bring forth. We have not had an opportunity of seeing them; we do not know what is likely to appear from them except in a very general way; but we do know from short interim reports which we have had, and from correspondence with the actuary, that there will have to be very serious consideration of the whole national health insurance organisation in this country, that the financial basis is not what it ought to be, and that the draws on the fund have been much heavier than anticipated—much heavier.

Correspondence with the valuer drew attention in the case of insured men to the high rate of disablement benefit, which he stated had been double the provision which had been made in the insurance scheme as originally drafted, and in the case of women to the excess of 15 per cent. over the provision made with regard to sickness benefit. The excessive rate of disablement benefit was anticipated to work out at nearly four times the provision, when the final figures are available. We have not got the figures yet, and I am just giving that as a suggestion of what we are likely to get from the actuary. That being so, and knowing we are going to get a report that is going to show a very serious situation of a fundamental kind that will have to be examined very thoroughly, and time will have to be given to its consideration, it is not fair, I suggest, to say that any time is being lost by the Government or by the Minister, and that there has been neglect on anybody's part in doing things for the improvement of the present national health insurance system that ought to have been done. That, I certainly say, is not a charge that can justly be made, or that can be substantiated.

Deputy Norton spoke at length on the reduction in benefits. I need not say much more with regard to that. Deputy Norton and the House generally know the reason as well as I do for the reduction in benefits. The reductions that have taken place are to some extent due to the tightening up of administration. Though it may not be humane in some respects, if we take the standard Deputy Keyes was recommending to us—though it may be not humane from that point of view— I would say that the management of the Unified Society is probably technically better all round than the management of any of the societies that were in existence previous to the amalgamation. It is not the society's duty and it is not its job—it would be a breach of trust on its part—if it paid benefit of any kind to people not entitled to it. Deputy Norton and Deputy Keyes know that the management of the society is largely in the hands of people representing the working classes; it is largely in the hands of Labour people at the present time. I think they will agree that Labour is well represented there.

They take no part in the administration.

They control the administration and direct the officials.

I would like the Minister to hear them on that.

Are they not the majority? I think they probably are. If they are not, there are at least 50 per cent. or so representatives of the working classes. They have at least 50 if not 51 per cent. of the Committee of Management and I take it the officials act under the instructions of the Committee of Management. Members of the committee, even those who do not directly represent the working classes, would probably, some of them, resent very much if I said they were not representative of the workers. Some of them would be what we would not regard generally as the working classes, but they would be sympathetic in their administration. Take the chairman, for example. I take it you could not get a more sympathetic person to any of the complaints that might be made by the working class people as to inhuman treatment from the point of view of the society. If there is any complaint about the administration, I think that ought properly to be made to the committee. I am not saying that it is improper to make it to me, but it is in the hands of the committee to deal with matters affecting the administration. If there is any complaint of injustice to any member of the society, the complaint would be properly made to the Minister and the Minister will have it investigated.

As to the costs of administration, I think that Deputy Norton, before he makes the wild charges that he made to-day about cost of administration, ought to have examined the figures. He ought to remember that there have been changes of a substantial kind in the treatment of the staff and that these changes in the treatment of the staff have added to the administration costs. He recommended to-day increases of salary and better treatment for certain types of officials on the staff and he knows that every recommendation he makes will add to the cost of administration. The fact of the matter is that the cost of administration has gone down year after year considerably, even though we have put on to the cost of administration a considerable sum to provide a superannuation fund for the staff, a thing that did not exist before. Also in the figures for administration you have to take into account the cost of compensation to the officials dismissed from the old staffs of the unified societies.

I have here the figures relating to administration. Deputy Norton gave the figure £162,000 for 1933. It was £125,000 for 1934. That included £18,000 by way of transitional expenditure, partly due to the compensation to outgoing officials. The figure in 1935 was £110,000, and in 1936 it was £144,941. That included £31,000 of a fund put up for the superannuation of the staff. In 1937 it was £108,707, and in 1938 it was £113,551. That knocks the bottom completely out of the statement made by Deputy Norton as to the growing cost of administration.

I do not agree with the Minister's full cost of administration.

The Deputy will have to look into the figures again and get better informed.

And so will the Minister.

These are figures which I defy the Deputy to say are incorrect.

I question them.

There was a good deal of talk about loss of benefits to various classes of insured persons. The reason for that is obvious. Deputy Morrissey talked on it; Deputy Dillon knows it as well as I do and I think Deputy Norton and Deputy Keyes also know it. That had to be. There has been no opportunity since the amalgamation to do anything to increase the benefits. Our first endeavour is to try to get the National Health Insurance, even as it stands at present, put on a safe, sound financial basis. Then the next step will be to see what we can do to improve matters. It would be the ambition of everybody, of every Party in this House, to try to make National Health insurance a real national health insurance organisation, which it is not at present. That is our ideal. It will take time.

We have to have a thorough examination of the structure. We will have to see that the finances of it, even as it stands at present, with the very limited and restricted benefits that are there, are on a sound basis. Medical benefits are things that we want to look into. They do not exist in reality at present. We will not be able to get these things unless we build on a sure foundation. We will not do that, as Deputy Dillon said, if we start by throwing out the £4,000,000 assets or the odd millions of pounds that are there as a foundation on which to build national health insurance in this country.

I do not agree with Deputy Norton that there has been excessive and unnecessary supervision of insured persons. That is not so. The society and their officials are a sympathetic body of people. They are men who have a duty to perform and they are conscientious. I take it the Committee of Management are equally conscientious, and I take it the insured persons are not supervised or cross-questioned any more than is necessary to ensure that the people not entitled to benefit do not get it.

Is the Minister satisfied that the Act is adequately enforced?

They are trying hard to get it enforced. There are cases where employers do not pay—I think there are. Nearly every week I hear of a case or two where people have been found and the inspectorial staff is kept fully occupied. I am glad to say that we do hear from Deputies, and from others, of cases that have come to their knowledge of persons who have not been doing their duty and who have not been obeying the law, as far as National Health Insurance is concerned. In every case in which we get information such people are followed up. We had close on 600 prosecutions during the past year, and I believe we should have had more. However, there is much better compliance for the last four or five years than there used to be.

Deputy Morrissey complained that I had not said more about the working of the Unified Society and of the suggestions they have made for improvements in the Act. My hands are tied very largely until I get a report from the actuary. When I get that report, and when it is examined, I hope that advances may be made. On the point raised by Deputy Keyes as to arbitrations and appeals, that is a matter that is largely in the hands of the society. The manner in which these courts are to be held is governed by their rules. We have made suggestions to them from time to time, and sometimes they have been acted upon. We cannot do anything further than make suggestions. They have found there are various difficulties in the way. I know, and the society knows, that it would be more convenient for insured persons to have these courts held more frequently in various towns throughout the country. Whatever we can do to secure that object in future, to a great extent, we shall recommend to the society.

With regard to the staff, I think the concept of duty of the headquarters' staff, those for whom I am responsible, is to secure that the insured person gets his rights, so far as the law allows it. I think in carrying out that duty they are a sympathetic and kind-hearted body of men. In carrying out the law, if there is any doubt in their minds, they will give the benefit of that doubt to the sick and afflicted. That would be my recommendation to them, certainly, in carrying out their duty. I do not think they show any harshness, or that they put insured persons to unduly severe tests. From all I have heard about them—I do not know any one of them, I do not think I ever met one of them personally— from medical practitioners and from officials of my own staff, they say that they are absolutely satisfied that they are conscientious and kind-hearted men who would not inflict hardship or injustice on anybody.

I regret that I had not a fuller and more optimistic statement to make on this question of National Health Insurance. It is one in which I am completely interested and in which, I think, the House as a whole is interested. I know that all parts of the House would be sympathetic towards any progress that could be made in this humanitarian work of securing for the worker, and particularly the afflicted worker, the benefits which have been granted in many other countries. It is a very difficult and intricate problem here in this country. When we come to the question of medical benefits, if that is to be brought in here, we have to related it and to co-ordinate it with the question of dispensary medical services. I have given some consideration to that matter already, and I find it a very difficult and thorny problem, one that cannot be settled in a day. Some day it will have to be tackled— I hope soon. Certainly some day proposals for improving the present national health insurance system must be made. I feel from what I have heard in the House here, and at other times from representations made to me, that these proposals to improve the lot of the afflicted worker, when made, will receive sympathetic consideration in this House.

The Minister intimated that he expected to receive the report of the actuary at an early date. Would the Minister say when, approximately, he expects to receive it and whether, when it is received, it will be possible to circulate it without the delay inevitable if there has to be prior consideration before circulation?

I thought that I would have it before now. I thought that we would have it before the end of the financial year. We are expecting it any day. I shall have to consider the question of circulation.

Motion, by leave, withdrawn.
Vote put and agreed to.