Dáil Éireann debate -
Wednesday, 23 Apr 1941

Vol. 82 No. 12

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

Minister for Industry and Commerce (Mr. MacEntee)

I move:—

Go ndeontar suim ná raghaidh thar £208,121 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, 1942, chun Tuarastail agus Costaisí i dtaobh na nAchtanna um Arachas Sláinte Náisiúnta, 1911 go 1936, agus na nAchtanna um Pinsin do Bhaintreacha agus do Dhílleachtaithe, 1935 go 1940, do Riaradh, agus chun Ilsíntiúisí agus Ildeontaisí, ar a n-áirmhítear Deontaisí áirithe i gCabhair alos Costais Sochar agus Costaisí Riaracháin fé sna hAchtanna um Arachas Sláinte Náisiúnta.

That a sum, not exceeding £208,121, be granted to complete the sum necessary to defray the Charge which will come in course of payment during the year ending the 31st day of March, 1942, 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, 1935 to 1940, 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.

Parliamentary Secretary to the Minister for Local Government and Public Health (Dr. Ward)

The sum now asked for is to complete the sum of £311,121 required under the National Health Insurance Vote for 1941-42. The figure covers the cost of central administration of national health insurance and also the cost of staff, etc., engaged in the administration of widows' and orphans' pensions. In addition, it includes the amount of £250,000 required for statutory exchequer grants for national health insurance and a special grant of £1,400 expenditure in connection with travelling expenses of persons examined under the district medical referee scheme. There is an increase of £11,000 in respect of statutory exchequer grants due mainly to the increase in the armed forces in respect of which special grants to supplement contributions are made, and to an expected special repayment of a loan to the society for compensation purposes. The increase is partly offset by an expected decrease in benefits involving a corresponding decrease in State grant.

There is also an increase of £1,425 in salaries, due to increments. A decrease in the sub-head A A—Actuary—is due to the fact that it is unnecessary to make provision this year in connection with inquiries into the financial position. An increase of £1,742 under sub-head I—Appropriations-in-Aid—is an offset, leaving a net increase of £9,729 as compared with the year 1940-41.

Two changes took place during the past year in the composition of the Committee of Management of the National Health Insurance Society. One change took place in the representatives of insured persons on the committee of management. Each year, an election of five insured person's representatives takes place in accordance with the Acts, which provide for the election of two members of the committee as representatives of the insured persons in the Province of Leinster, two for the Province of Munster and one for Connaught and Ulster. The representatives elected in 1940 include two persons resident in Dublin, one in Tipperary, one in Cork and one in Mayo. Mr. T. Looney, of Blarney, replaced Mr. Horgan of Tralee. Amongst the representatives of insured persons nominated by the Irish Trades' Union Congress, Mr. T. Dunne, of Waterford, replaces Mr. J.J. Farrelly of Dublin. All members of the committee of management hold office until the 31st July next, when new appointments and elections will be necessary.

The estimated number of insured persons at the end of 1940 was about 581,000, being a decrease of 15,000, and there was a decrease in the contribution income of about £6,000 to £708,875. Part of the decrease in the value of the contributions is due to enlistment of civilian insured persons in the armed forces, the contributions payable for soldiers being 4½d. a week only, as compared with 8d. a week in civil life. The number of insured persons in receipt of sickness and disablement benefits at 31st December, 1940, was 25,180, which was approximately the weekly average throughout the year. During the year, the number of separate benefit payments including sickness, disablement, maternity and marriage amounted to 1,174,157. Maternity benefit was paid in respect of 25,738 confinements.

The cost of benefits at £695,000 shows an increase of £6,500. The accumulated funds forming the assets of National Health Insurance amounted to £5,013,688 at 31st December, 1940. This sum, together with the unredeemed paper reserve values of £1,945,213, represents the sum required to meet the future liabilities of the fund under the existing financial system.

During the year, it was necessary to bring legal proceedings in 910 cases against employers who had failed to comply with the provisions of the Acts as regards payment of contributions. I would like again to remind employers that default of this kind often leads to loss of benefits to insured people and of contributory pensions to the widows and orphans of deceased insured men. Wherever possible such losses are recovered from employers and, during last year, a sum of £366 was so recovered.

When the Government introduced legislation which effected the unification of societies, they did not regard that as a final settlement of the problems of the health insurance scheme. On the contrary, they had in view that it should be a starting point for future developments. It had this advantage, moreover, that it afforded facilities for obtaining experiences and statistics referable to the whole body of insured persons, a position which had not been possible under the old system with many societies and many different standards of administration. It is well recognised that in building for the future in any form of social insurance the foundation must be laid on the experience of the past. If that experience is not reliable, the financial security of the future is jeopardised.

We have now reached a stage where we have five years' experience of the working of the unified society. I refer to the years 1935 to 1939. The year 1934 was a transitional year and cannot safely be regarded as furnishing reliable data. The broad fact emerging is that the national health insurance fund, which stood at £3,640,000 at 31st December, 1934, has increased to £4,746,000 at 31st December, 1939.

Notwithstanding this apparently favourable result, the report of the Government actuary on his investigation of the society's benefit experience which was received in May, 1939, and laid on the Table of the House, disclosed that the expenditure on sickness and disablement, especially for women, has been very much heavier than was contemplated when the present financial basis of the Act was determined, which means in effect that there has been less money accumulating for reserves than was considered necessary to meet the future liabilities of the scheme. The point which is now being considered is whether the reserve already accumulated may not be sufficient to meet the requirements of a scheme in which all insured persons are members of one society, and under which all new entrants become members of that society. This position gives an assured annual contribution income, and the experience of the five years I have referred to indicates that that income, together with the State subvention and the interest on the accumulated funds, has been more than sufficient to meet the annual expenditure on benefits and administration. If that position could be maintained for the future it would be possible to consider the release of a certain amount of money for the provision of benefits other than the statutory benefits.

With this object in view, the actuary was asked in January, 1939, for a report on the general financial position and, in particular, as to the possibility of substituting for the present financial system of the Acts arrangements by which income would be equated to expenditure over a series of years. His report, which was only received on the 31st March, contains a full review of the finances of the national health insurance system. While the report was being awaited the whole position had been considered in great detail departmentally, and the conclusions reached are now being examined in the light of the report.

Mr. Norton

I move the reference back of this Estimate for the purpose of expressing dissatisfaction with the manner in which national health insurance is administered and the slothful indifference of the Department of Local Government in remedying the very obvious blemishes associated with national health insurance legislation. The original purpose of national health insurance was to make provision for curative treatment, on the one hand, and to provide some compensation for loss of cash income by the insured worker, on the other hand. In fact, our system of national health insurance does neither. We provide no curative treatment under the National Health Insurance Act for any sick, insured person and the cash income which a person receives—a maximum of 15/- per week for six months as sickness benefit and a maximum of 7/6 per week for any further period as disablement benefit—fails hopelessly to provide any reasonable compensation for an insured person in respect of the loss of his income through illness. At present, we have no scheme under the National Health Insurance Acts by which a sick, insured person can secure hospital treatment. We have no scheme by which a sick, insured person can receive dental, optical or surgical treatment or treatment for tuberculosis. As I have said, the cash compensation we give in respect of loss of wages is wholly inadequate. Under the scheme of national health insurance societies which existed here, certain members had additional cash benefits. On the creation of the Unified National Health Insurance Society, these societies, on amalgamation, had to take the results flowing from the valuation of the assets of all the societies grouped into one organisation. The result was that, on an actuarial basis, it was, apparently, found impossible to continue the additional cash benefits and the additional non-cash benefits which a large number of workers had enjoyed. These people have been clamouring since then to have these benefits restored to them.

I called the attention of the House on previous occasions—and I want to do it again now—to the manner in which the accounts of this society are examined. The actuary, in his periodical examination of the accounts of the society, has, invariably, suggested that national health insurance was insolvent and that the society was operating on an insolvent basis. Look at the facts. The income of the society in 1937 was £717,000. Interest on investments amounted to £162,000. There were special grants amounting to £218,000, making a total cash income to the society of £1,160,000. In that year, the society did not pay out in benefits or in administration anything like the sum they received. As the Parliamentary Secretary has indicated, the society is in a very strong position from the point of view of accumulated reserves. In 1934 their assets amounted to £3,460,000. That sum increased to £3,545,000 in 1935, and by 1937 had reached £3,617,000.

In 1938 the figure was £3,731,000, apart from a sum of £221,000 held by the Minister for Finance on behalf of the national health insurance central fund. A society which is supposed to be insolvent, a society which is not in a position to pay additional benefits, is able, nevertheless, according to these figures, to accumulate vast reserves — reserves which might very well be envied by any firm certified as commercially successful according to the rules of orthodox commercial success in this or any other country.

Let us examine the position of the society in relation to its finances further. Take the year 1938. After paying all claims for benefit in 1938, the society saved £290,000. If you take the income of the society in 1938 and the expenditure in the same year, you find that an unspent balance of £290,000 was available for investment by the society. When the actuary says that the society is insolvent, he is dealing with an entirely different matter from that to which I am referring. He means that it is insolvent from the actuarial point of view and that, instead of saving £290,000, the society should have saved £390,000. Having regard to our experience of national health insurance and to the dissimilarity of our method of organisation of insured persons from that in Great Britain, we should no longer be bound by actuarial methods which, while suitable to Great Britain, are entirely unsuited to the conditions obtaining in this country at present.

Any examination of the investments of the national health insurance society will disclose at once that it is a very flourishing institution from the point of view of cash investments; that each year it yields a substantial surplus for investment. My plea is that that surplus should be made available for the provision of additional benefits to the insured persons and for the provision of additional cash benefits, because the present cash benefits are clearly inadequate. As I said, the method by which this society is certified to be insolvent is probably the British method of valuing societies. In Britain there are 2,000 national health insurance societies, some of them on a territorial basis, others on a religious basis, others on the basis of some peculiarity of vocation or organisation. The British method was designed to provide for this possibility. A society in Britain, for instance, might have recruited 1,000 members and no other person might desire to join that society. Left then with 1,000 members and the dropping possibly of some of these, that society had to be concerned with providing for the theoretical last man; in other words, the funds had to be invested in such a way that, if the society had 1,000 members and 999 died, there would be still investments available to meet the claims of the survivor.

One could understand that method in relation to the circumstances of Britain. But that is not the position here. There is no likelihood whatever of that position arising here, there is no likelihood whatever of the possibility of there being a theoretical last man. So long as you assume the survival of the Irish race, there is no possibility whatever of our having to provide for the contingency of the last man. Here we have only one society. It can never lose its membership, because everybody in the country going into insurable employment must go into that particular society; everybody who is insured must be insured in that society. There is, consequently, an annual flow of members into the society, and, if there is an outflow, that is made good by recruitment of members at the other end, with the result that the society is only concerned with organising its finances in such a way that its annual income is capable of meeting its annual expenditure. There may be need, of course, for a little more prudence even than that. It would be desirable probably to have as a reserve against a possible epidemic some investments to meet the heavy claims on that society in circumstances such as that. But, if you are to put aside, for instance, one year's income and say that the reserve ought to be kept at one year's income, then the most it is necessary to put away is £1,000,000 approximately. But, at present, according to the Parliamentary Secretary, the society has £5,013,000 of accumulated assets, which really means that the society, so far as it is concerned itself, has assets amounting probably to ten times its own normal income and five times the amount of its income from all sources, namely, contribution income, interest, and State grant. What is the purpose of locking up that £5,000,000 and saving money each year?

Dr. Ward

That is the law.

Mr. Norton

I know it is the law.

Dr. Ward

Any change would involve a change in the law.

Mr. Norton

I know it is the law. What I am criticising is the reluctance of the Minister to exercise his powers to amend the law and so remedy a very obvious injustice to insured persons.

Dr. Ward

Is that in order, Sir?

An Ceann Comhairle

Deputy Norton's advocacy of legislation was indirect, and arose out of a discussion of general policy. The Deputy is moving to refer back this Vote, and is entitled to some latitude.

Mr. Norton

I am conscious of that. I am pleading with the Parliamentary Secretary to bestir himself quickly in this matter. There is no need at present to lock up £5,000,000 of the society's assets in investments. Some of that money should be made available for the provision of additional cash benefits to insured persons, and some of it should be made available for the provision of dental benefit, optical benefit, hospital benefit, and medical treatment generally. Why can we not do it? It is not that our insured people generally do not need dental and optical benefits; it is not that they do not even need medical and hospital treatment. Notwithstanding the fact that they do need these, and that there is available an abundance of money which could provide them, no steps are taken by the Department to reorganise the basis of valuation of the society in order to provide these additional benefits. The present scheme is a travesty of national health insurance, as properly understood. It is simply a mockery of health and insurance. What we do at present is to give people a small cash benefit, and to tell them: "Get well as quickly as you can", or, from the point of view of the solvency of the society: "Die as soon as you can. Do either one thing or the other—get better quickly or die quickly; if you get better quickly, you save the funds of the society, and if you die quickly, then you will not add an additional unit to that long list of units that disturbs the actuary occasionally in his reports."

I think the Parliamentary Secretary should have told us in the course of his introduction of the Estimate what he proposes to do in connection with this whole question of providing additional cash and non-cash benefits. He should have told us above all when he was going to start doing it. I addressed a question to the Parliamentary Secretary early this month, asking him to endeavour to have these additional benefits made available in the new benefit year commencing on the 7th July. Beyond promising that he would do his best to expedite the matter, I could not extract from him any definite promise that the scheme would be made available for insured contributors in the new benefit year—either at the commencement or during the new benefit year. There is a very serious position to be met. These insured people are suffering for a long time from the withdrawal of these additional benefits, and from the failure of the society, because of control by legislation, to provide additional benefits for the contributors.

I think we have reached a stage now when the Parliamentary Secretary ought to be able to tell us, with six or seven years' working of the society, that it is intended to abandon the British method of valuing the assets of the society and to adopt a method of valuation, which, while making reasonable provision for possible heavy demands in any particular year on the assets of the society, will nevertheless release for the benefit of the insured contributors the very large sums of money which have been locked away in investments on behalf of the society.

Apart from this question, I think that there should be some effort made to co-ordinate the health services and to provide curative treatment for insured persons. The method of giving benefit, while making no systematic attempt to cure persons of the disability which makes them seek benefit, is causing quite considerable concern on the part of persons who are interested in the creation of a satisfactory health organisation in this country. I think, of course, that it is a mistake to have health insurance divorced from other types of insurance. Unemployment insurance, widows' and orphans' pensions, and old age pensions are all different aspects of pretty well the same type of social service. It seems to me that a very good case could be made for cutting out the waste and overlapping which go with these segregated services, and that, instead, we ought to adopt some kind of a coordinated social service which would lock together health insurance, unemployment insurance, widows' and orphans' pensions, old age pensions and accident insurances, and have an insurance department which would look after them. At present we have old age pensions paid by the Revenue Commissioners, with the claims investigated by the Department of Local Government. Health insurance is operated by a society and supervised by the Department of Local Government. Unemployment insurance is operated by the Department of Industry and Commerce. You have pretty well no one looking after accident insurance which is most important from the point of view of the employed worker. That is an aspect of health insurance which requires much more attention and consideration than I fear it has got so far. The most urgent problem of all is that some effort should be made to have made available some of the £5,000,000 which is locked away in investments by the National Health Insurance Society. I hope the Parliamentary Secretary, when replying, will be able to give us some idea as to when some of that money will be made available for insured contributors.

Mr. Linehan

Would the Parliamentary Secretary say whether there is any difference between his Department and the committee of management of the Unified Society on this question of extra benefits? The committee of the Unified Society passed a resolution which appeared in the public Press on the 29th March to the effect that the time was opportune for the provision of extra benefit, and calling upon the Department to give effect to the dental and other schemes already submitted and approved of. The people in charge of the Unified Society appear to be satisfied that it is now in a position to provide money for these extra benefits. Is it the opinion of the Department that the society is wrong in so thinking? After all, the committee is in control of the society. The members of it are the people who do the main bulk of the business, and they ought to know what is the best policy to pursue. When the society asks that provision should be made for these extra benefits, or for other schemes, will the Parliamentary Secretary tell us what the Department intends to do in the matter?

The question of these extra schemes— dental, optical, and others—is causing a lot of trouble in country districts where you had various types of national health societies functioning before the Unified Society was set up. The people who belonged to some of those good societies were provided with extra benefits before amalgamation was brought about. After amalgamation, they lost the extra benefits, so that they are now in the same position as those who belonged to the worst type of society that existed before the Unified Society came into being. The loss of those extra benefits has been a very serious matter for a large number of old members. Deputy Norton referred to the fact that nothing is being done for contributors so far as curative treatment is concerned. I can quote an example in support of that. I know a middle-aged labourer, a married man with a wife and four or five children, who had been putting on national health insurance stamps ever since the scheme came into operation. He became ill two years ago. He is suffering from an unusual form of heart disease. It is not ever likely to kill him, but will prevent him from doing any kind of work for the remainder of his life. He was certified as being unfit for work by doctors. At one period he was turned down by the referees, but they subsequently passed him again. He is getting 7/6 a week. He has no other means. There is no chance of getting him proper treatment for the type of disease he is suffering from. He is living with his wife and four children and has nothing but this 7/6 a week. He would be much better off if he were not getting national health insurance at all, because then he would be able to apply for home assistance to enable him to support his wife, family and himself.

There is a lot to be said for adopting some kind of a scheme whereby a contributor, when he begins to suffer from some type of disease, will be enabled to get a special kind of curative treatment. Otherwise, he will become a burden to himself and to the State. Curative treatment of the kind suggested should, I think, be provided at the earliest possible moment. It would give a patient a sporting chance of getting restored to health. It would be a paying proposition for the patient and for the State. Surely, it would be much better to have a scheme of that kind than to have a poor person hanging on for years, with no hope of getting cured.

Deputy Norton referred to the capital of the society, its investments and the amount of its income. The Vote for this service in 1931-32 was £309,917, while this year it is £311,121, an increase of £1,204. An extraordinary feature of the Vote is that, while in 1931-32, the number of officials in the Department was 198, the number now is 304, so that we find the position to be this, that, contrasting the two periods, 106 more officials are required to administer or spend an extra £1,204. Whatever the explanation of that may be, it certainly appears to me to be extraordinary business. If there was any necessity to spend extra money in this Department it could, I think, be more usefully spent in financing some of the schemes referred to, rather than in the employment of over 100 extra officials to administer a small extra sum of money. The only thing I am sorry for is that Deputy Corry is not here. If he were he might be able to enlighten me as to why it was necessary to employ this number of extra officials. When the Parliamentary Secretary is replying, I should like him to deal with this question of extra benefits recommended by the committee of management of the Unified Society. Will he tell the House why his Department is not bringing forward schemes to make provision for these extra benefits? The committee of management appears to be satisfied that these extra benefits should be provided. The House would be glad to hear from the Parliamentary Secretary why its wishes in that respect are not being carried out.

Mr. Allen

I should like to know from the Parliamentary Secretary if the benefits of 15/- a week and 7/6 a week are statutory benefits, or can they be increased by the amalgamated society without legislation?

Mr. D. Morrissey

They can.

Mr. Allen

The general consensus of opinion throughout the country is—I am sure the Parliamentary Secretary is aware of it—that these two benefits —15/- a week for a sick man and 7/6 a week for total disability—are inadequate at the present time, and have been for years past. Because they are inadequate, a very big burden is being thrown on the ratepayers. In almost every case, when a man is totally disabled, he becomes a burden on the ratepayers. Quite a large number of people throughout the country are of the opinion that, in that respect, national health insurance is not serving the purpose which it was originally intended to serve.

A working man—say, a farm labourer earning 30/- a week—becomes ill and receives 15/- a week to maintain himself and family. He may get free medical attention, but must be maintained in his own house and his family must be maintained at the same time. The time is opportune to consider this whole matter of national health insurance and insurance benefit. Something more is needed for the breadwinner who becomes sick. I do not know whether the national health insurance scheme was originally meant to give a disabled man complete benefit to maintain himself, to get over his illness, and to maintain his family, but everybody who has anything to do with local authorities knows that a man who becomes totally disabled and goes on home assistance at the age of 40 or 50, suffering from chronic rheumatism— which is especially the case amongst agricultural workers—may go on until he is 70 years old. The sum provided is totally inadequate to maintain himself and his family. The whole question of that insurance and the other insurances mentioned by Deputy Norton should be reconsidered now, if that has not been done already.

It is felt generally throughout the country that some big change is needed. Whether it can be brought about in a very short time or not I do not know; nor do I know whether it can be done in this time of war, but I am convinced, from my own experience, that a radical change is needed on this whole question of insurance. I would say very definitely that it is not serving the purpose for which it was intended originally. Nobody will doubt that the payments are inadequate to maintain a man, his wife and family, when a man is ill—and no one is getting full benefit unless ill. There are other cases of workers on higher rates of wages who are even more seriously affected than agricultural workers, and I hope the Parliamentary Secretary will deal with them in the near future. We understood some years ago that this whole question was being considered, and we should like to know now what progress has been made.

Mr. Hickey

It was instructive to hear Deputy Allen make suggestions from the Government Benches. He has made an appeal with which I am entirely in agreement. When we consider the position of a man who falls ill, we know that if he becomes unemployed he will get 15/- from the unemployment exchange, 5/- for his wife and a shilling for each dependent child, but under the Unemployment Insurance Act all he would get would be 15/- a week for himself and nothing for wife or children. If he is unfortunate enough to remain sick for over six months, instead of an increase in his weekly payments they are reduced by half. I could give several cases of this kind, especially cases of poor men suffering from rheumatism. It is most depressing to see young men of 45 or 50 become physical wrecks from rheumatism and receiving 7/6 per week when they have been ill for over six months, their only redress being to fall back on public assistance for a supplementary benefit to make up the meagre amounts they receive.

The time is long overdue for recasting the whole social arrangements in connection with workmen's compensation, national health insurance, unemployment assistance, unemployment insurance, home assistance, the child welfare league, blind pensions, widows' and orphans' pensions and old age pensions. All these purely social insurance schemes should be under one national head. It would be most interesting to go into the cost of maintaining these various schemes as separate social services. I hope that the Minister will seriously consider what has been said about recasting the organisation and increasing the benefits of national health insurance. Nobody can claim that it has met the point that it was intended to meet.

I could give very striking instances of distressing cases to show the necessity for increasing the benefits. I understand that the Committee of Management of the National Health Insurance Society over 12 months ago asked the Minister for Finance to bring in the necessary legislation to increase these benefits. From replies here lately there is no indication that that will be done very soon. Therefore, I wish to support Deputy Allen in this matter, and would be glad to see a statement from the Government Benches that the Minister is taking steps to make the necessary changes.

Mr. Byrne

I should like to support the request made by various speakers. It will not require new legislation, in my opinion, for the Government to restore certain benefits which were taken from the people when the societies were amalgamated. Some of the societies gave dental and optical benefits, and these were withdrawn and have not been restored. Especially in cases where the societies taken over gave those benefits, the Government should see that the members are not deprived of the benefits which encouraged them to join certain societies. If it is admitted that those societies are entitled to have dental and optical benefits restored, surely that should be passed on to every insured person.

Further, I join with the other speakers in requesting that something more be done to deal with cases of tuberculosis. I hold that it is very definitely the duty of the National Health Society of the country, when one of its members becomes broken down with tuberculosis, to provide proper accommodation, indoor treatment, sanatorium and other benefits necessary for restoration to full health. It should not be left to people outside to find that accommodation, but it is the duty of the Government to find it. I will go further and say that it is the duty of the Unified Society, when one of its members breaks down in health— or when a child of a member breaks down in health—to find proper hospital, medical and surgical treatment for that person.

Dublin was shocked a very short time ago on hearing a prominent medical man tell of the case of a woman of this city who carried a baby to five separate hospitals, and was refused at each, and who found the baby dead in her arms on bringing it home. That shows complete failure on the part of the national health insurance and of the hospitals of the city. The Government and the public authority allowed that statement to go unchallenged, though I think it was the Parliamentary Secretary's duty to make inquiries within one hour after it was published.

An Ceann Comhairle

Those matters are irrelevant to national health insurance. The Parliamentary Secretary's responsibility does not cover them.

Mr. Byrne

He is charged, I believe, with the responsibility for the public health of the whole country.

An Ceann Comhairle

There is only one section of it under discussion.

Mr. Byrne

I went away from the point. I wished to draw the attention of the House to the fact that, before this society became unified and controlled by the Government, there were societies giving benefits which members are not enjoying now—dental and optical benefits. With other members of the House, I appeal to the Government to see that those benefits are restored, and that, where possible, further benefits be given where they would be to the advantage of the people, and which would keep them on the employed list instead of on the unemployed list and receiving the present miserable benefits.

Mr. D. Morrissey

Seeing that this is one of the largest Estimates that come before this House, dealing with a very large number of men and women in this country, it is rather strange—particularly in view of the questions which have been put to the Parliamentary Secretary in the House recently—that he did not consider it necessary or desirable to give any information to the House as to whether the question of additional benefits was under consideration by his Department or not, whether the Department had come to any decision on the questions submitted to them by the committee of the Unified Society, whether the consideration had been concluded in his Department, and whether the matter is really being held up by the Department of Finance. It is a very big service. It is, perhaps, one of the most important services that we have in the country dealing with public health. It is dealing very inadequately, to say the least of it, with the health of the very poorest section of the community. As has been stated by other members of the House, it is, of course, farcical to think of restoring to health a married man with a family on 15/- a week at the present cost of living. As this Estimate comes before the House year after year, it only goes to show some of us that our fears were only too well-founded when this unification was brought about.

Some of us then expressed our fears that the only effect of the move which was then made would be to deprive great numbers of persons who were insured for national health purposes of very valuable benefits which they were then enjoying. Those valuable additional benefits were not confined to the big societies. For a number of years I was connected with a comparatively small society that had a membership of between 2,000 and 3,000. It was not a select membership. Its members did not consist of people who were in sheltered occupations but of people in a rural area. As a result of careful management and close watching of the funds of the society, the members of that society were getting 18/- per week cash benefit. Maternity and other benefits were correspondingly increased. The society paid five-sixths of the cost of new dentures, full dental treatment, full optical treatment and full hospital treatment. Not only that, but if a member was unfortunate enough to lose a limb as a result of disease they provided a free artificial limb where required. To-day, those unfortunate people are reduced to the position that they are getting the lowest cash benefit allowed by law. That being so, one would have expected from the Parliamentary Secretary a statement as to what the intentions of the Department were in that connection.

In connection with what I might describe as a huge service like this, affecting some hundreds of thousands of workers throughout this country, I think one is entitled to have a more complete review of its operation over the previous 12 months. I think we are entitled to be told what is being done, say, in connection with medical certification, whether that position is improving or disimproving, whether the Department is satisfied that things have been tightened up—and I think very few people who have any practical experience of the working of national health insurance in previous years are satisfied that there was not need for tightening up—or whether there is greater loosening as far as certification is concerned. I submit that we should have been told what is the position regarding malingering, whether it has improved or disimproved. We are asked here to vote a very considerable sum of money. We are not told what has been done or what is being done or what is going to be done. In a service like this where, I think it is no exaggeration to say, the lives of so many people are at stake, where there is so much of the human element, I think we are entitled to something more than bald statistics. I hope, when he comes to reply to this debate, the Parliamentary Secretary will give us a little more information than he gave when he was introducing the Estimate. In particular, he ought to let us know what is the position at the moment regarding the question of additional benefits, what are the prospects of having additional benefits provided and when he is going to be in a position to take the necessary steps to have that decision made.

Mr. Murphy

I only intervene in this debate in order to amplify the point made by Deputy Byrne in connection with the most deserving section of our sufferers in this country, the people afflicted with tuberculosis, and to recall to the House that in fact insured persons who were afflicted with tuberculosis did at one time enjoy special benefits administered through what were termed insurance committees. At that time the insured person had special rights of sanatorium and what was then termed demiciliary treatment through the insurance committees which functioned in various areas. That benefit was withdrawn a considerable time before the societies were amalgamated. I think that was a very serious loss to a very deserving section of our afflicted people. There can be little doubt about the fact that in the matter of the treatment and even any reasonable approach to the treatment of tuberculosis in this country we are lagging very sadly indeed. I believe that in the contemplated scheme for extra benefits for insured persons, special provision in this connection ought to be made. I do not know whether any provision of that kind is included in the proposals of the society that have been submitted to the Government. If not, I think they ought to be made and I think there ought to be recognition in this House that the service for national health insurance, instead of being the miserable thing that it is, should be a big measure of social protection to the sick people of this country. It is very far from being that at the present time. I say that, as one who has not altered his opinion in any way about the mistake that was made when a monopoly was given to one society in this country for what is termed national health insurance. I think that was a mistake, and I think that three or four societies in this country, competing with each other as to the manner in which provision could be made for their members, would afford much better results for the insured people of this country than could be got otherwise.

I press this point, of special benefits for insured persons afflicted with tuberculosis, on the notice of the Parliamentary Secretary. As a medical man himself, he must have very specialised knowledge of the needs of such people, and he must be aware of the fact that in many cases it is the fate of these people, when they become afflicted with tuberculosis, either to live at home for the short period of their lives, with the consequent danger of infecting other members of the family, or to go to the local poor law institution, or some other institution of the kind, not much better in some cases, for the purpose of ending their days.

A great reform and a great change and improvement in the health of such people could be brought about, I think, through the agency of the national health insurance if it were developed on broad lines, and I see no reason why provision could not be made, in special circumstances and, of course, in normal times, to send people, who would need special treatment, out of this country to places where they could get that treatment, as a right inherent in their membership of the National Health Insurance Society and in return for the contributions paid by their employers, themselves and the State. I hope the Parliamentary Secretary will be able to give us some information on this matter, and that he will be in a position to give some definite information to the House as to when insured persons in this country may expect some advance in the direction that has been asked for by the Deputies who have addressed themselves to this question here this evening.

Dr. Ward

Most of the speeches— in fact, all of them—on this Vote, have been directed rather to the defects in the law in relation to national health insurance than to any criticism of the administration of the law. The Chair has been very indulgent, and I presume that if I were to follow the Deputies who were, in my humble opinion, at any rate, rather disorderly, the Chair, perhaps, would extend a similar indulgence to me.

Mr. Hickey

But the Parliamentary Secretary, just the same, is a member of the Government.

Dr. Ward

I am not sheltering in that way at all, but I do not see how we can have a detailed debate here on this Vote on matters that would involve new legislation. However, seeing that no other aspect of the Vote has been adverted to by the speakers, in a very general way, I shall deal with the one question that everybody appears to be concerned about, and that is the question of the possibility of securing additional benefits for the insured persons. But let me say this at the outset: that, personally, I should be very happy if, to-morrow, the money could be found to finance full medical benefits for all our insured population and their dependents.

Mr. Davin

Why cannot you find it?

Dr. Ward

Now, never mind. I did not interrupt anybody who was speaking, and perhaps the Deputy would be good enough not to interrupt me. Perhaps, if it rested solely with me, I would find the money.

Mr. Davin

That is good enough.

Dr. Ward

But, at any rate, if additional benefits are to be provided— medical benefits, dental benefits, optical benefits, hospital benefits, or any other benefits—the money must be found wherewith to finance these additional benefits. How can it be found? It could be found by increasing the contributions, by increasing the State grant; or possibly the money could be found—a limited amount anyhow—by radically altering the whole foundations of our scheme and the method of assessment. Deputy Norton says that we are slothful—let me see if I have got his actual words here—and "indifferent towards remedying that position." Now, that is scarcely fair. We are not not as bad as that. As far back as January, 1939, we referred this matter, of altering the basis of valuation, to the actuary for a special report. Now, it is not a matter into which to rush blindly. We have to ensure that, if we make a radical departure in regard to the structure of national health insurance, the finances of our scheme are reasonably sound, and we have to have actuarial guidance and advice in that matter. It is easy enough to submit schemes; there is no difficulty whatever in drafting attractive schemes of additional benefits for insured persons, but I think every Deputy will agree that it is of vital and fundamental importance that the financial basis of such schemes should be sound so that we should not find ourselves in the position in the future of having to withdraw some benefit that was hastily provided.

I have been questioned on this matter from time to time during the past 12 months, as to when we were going to announce a decision in regard to policy. I have not been in a position to give a definite announcement, and I am not in a position to give a definite announcement to-day. The actuarial advice we have sought on this particular aspect of health insurance was only received in my Department on the 31st March last. It is a big, comprehensive and complicated document. It will have to be studied, and studied carefully, before any decision can be come to, but the Department were not idle since 1939, since we asked the actuary to give us a special report on this matter. In so far as the staff of the Department could investigate the position and have tentative proposals ready for operation, the Department have given the position very full examination, but their tentative conclusions must now be related to the advice that is tendered by the actuary, and what the ultimate decision will be I cannot tell until that further examination, in the light of the actuary's report received on the 31st March last, is available.

Deputy Linehan raised a question about the increased cost of staff in recent years. There is no denying that the cost of administration under this Vote has been increased, but Deputy Linehan did not advert to the fact that the Widows' and Orphans' Pensions Act was not operating during the time which he took for the purpose of comparison. The enactment of the widows' and orphans' pensions legislation was responsible largely for the increase. Deputy Morrissey and other Deputies have referred to the effect of unification. It is true to say that, by unification, certain societies that were flourishing financially prior to unification, have had to withdraw from their members, by reason of unification, additional benefits that their members previously enjoyed, but it is equally true to say that had the resources of all the insurance societies not been pooled, many societies would not have been in a position to give the statutory benefits to their members. There it is. The people who, by unification, have, at any rate, secured the statutory benefits have gained to that extent. The people who previously were in receipt of additional benefits now lose to that extent.

Mr. Morrissey

That is what we call robbing Peter to pay Paul.

Dr. Ward

Peter and Paul were very closely related in this and it was felt— I think many people will agree—that in the particular circumstances obtaining, after all, Peter ought to contribute a little so that Paul would not starve.

Mr. Morrissey

We would not agree that unification was the best method and I think that has been proved.

Dr. Ward

On the question of certification Deputy Morrissey is concerned, but I can only say that certification is less unsatisfactory than it was previously. I do not think that what is called lax certification is entirely the fault of the medical certifiers. Medical certifiers are mainly generously disposed, kind-hearted men, and they give claimants to national health insurance benefit the benefit of any doubt that may exist, but it seems to me that the drain on national health insurance benefit would be substantially less if the employment position were better. If a man is unemployed and has a minor ailment, and if he goes along to his doctor and asks for a medical certificate, that man is not necessarily malingering at all. His ailment would be a substantially less burden to him if, in fact, employment were available to him at a good rate of wages. I am giving my own personal opinion. It may not be sound, but I have a fair share of practical knowledge of this problem inasmuch as I was medical certifier in my time in fairly populous areas. The medical certifier, faced with such a dilemma, may not be sure that the patient has not the pains and the aches that he describes, but he is sure that the man is in need and he probably says to himself, in some instances: "This man must be carried by some of our social services, and seeing that I have a doubt, I shall give him the benefit of that doubt." I find it hard to criticise harshly a man who certifies in that way. I do not think that Deputy Morrissey would harshly criticise him.

Mr. Morrissey

I think the Parliamentary Secretary knows that that is not the type of case to which I was referring at all.

Dr. Ward

There are exceptional cases. There are cases where there has been lax certification.

Mr. Morrissey

Would the Parliamentary Secretary allow me to put this point? Is he not aware, at least as well as I am, that there is such a thing as the signing of a book of certificates, leaving them to be called for week after week?

Dr. Ward

There is such a thing.

Mr. Morrissey

That is what I had in mind.

Dr. Ward

When we come across such gross carelessness and irresponsibility, we are inclined to deal rather drastically with it. I have here a return showing the number of fines that have been imposed within the last 12 months. In one case the fine has been £10, in three cases £5, in five cases £3, in one case £2 and in 36 cases the certifier was warned. That may seem a big number of cases but, as compared with the number of certificates issued, it is a comparatively small number. Men who are found to be grossly careless in certification will certainly be drastically dealt with, but I do think that, if economic circumstances were better, our insurance position would rapidly improve.

I do not think any other point was raised. We have now the actuary's report on the financial structure. We are examining that and relating it to the ideas we had before being furnished with his expert advice. As soon as it is possible to give it full examination, we shall determine what the future policy will be.

Mr. Allen

Can the insurance society increase benefits without legislation?

Dr. Ward

It would be true to say they can, with this qualification. If under the existing financial scheme they had a surplus of funds, that surplus could be devoted to providing additional cash for benefits but, in fact, under the existing financial scheme they are in deficit, substantially.

Mr. Norton

An actuarial deficit. Actually, they have a surplus.

Dr. Ward

That is not the point to which I am replying. The point raised by Deputy Allen is whether in fact the society can in present circumstances pay additional benefits. In present circumstances they cannot, because under the actuarial basis at present operating, the society is in deficit, but if the basis of assessment were altered, money would then be available for the financing of additional benefits. That is the question that is being examined and it is on that question that a specific report has been received from the actuary.

Mr. Norton

Can the Parliamentary Secretary give any indication as to when a decision will be arrived at?

Dr. Ward

I cannot. Deputy Norton will appreciate that it is not possible to give any approximate date on which a decision on a question of such magnitude can be reached. Deputy Norton was not in the House when I was speaking earlier. This question has been under consideration for a considerable time. It was in January, 1939, that we asked the actuary to give us a report on this particular matter. The actuary was not able to report to us until the 31st March last. We certainly would have got a report from the actuary much sooner were it not for the war position and the fact that he was engaged in other duties. We have not an actuary of our own. He was engaged on other matters arising out of the war position. We, however, got his report on the 31st March last and we have to examine it carefully before we come to any decision. How long it will take I do not know, but I can assure the Deputy that we are quite anxious to reach a decision on this matter and that there will be no delay that can possibly be avoided.

Mr. Norton

Would the Parliamentary Secretary say whether the examination will be completed in time to enable a decision to be taken this year?

Dr. Ward

The Deputy means before 31st March, 1942?

Mr. Norton

I mean by 31st December next?

Dr. Ward

I would say so.

Mr. Norton

And any such scheme can be made applicable to the benefit year commencing January next?

Dr. Ward

Well, that is somewhat more than what I have said.

Mr. Norton

The Parliamentary Secretary is not saying very much.

Dr. Ward

I believe we would be able to reach a decision before 31st December, but whether we would be able to reach a decision in time to have the new benefits, if any, available on 1st January next is a somewhat different problem. If possible, we will do it.

Mr. Norton

It will be done if possible?

Dr. Ward

We will try to do it, if there are any additional benefits at all.

Mr. Norton

And you will not make a raid in the meantime for Budgetary purposes.

Dr. Ward

We will not do that.

Motion to refer back, by leave, withdrawn.

Vote put and agreed to.