I move that this Bill be now read a Second Time. The main purpose of the Bill, as Deputies are aware, is to improve and extend the existing health services so as to make those services more readily available to certain sections of the public. Because medical treatment is becoming more expensive as well as more efficient, these sections find it increasingly difficult to bear the costs involved.
I do not propose to-day to describe the scope of the existing services. That has already been done in some detail in the White Paper issued last July. That White Paper was issued to give a broad indication of the Government's intentions so that interested parties could say what they thought of them. I have since heard from large numbers of organisations, public bodies and private individuals and, on the whole, the reaction to the Government's proposals has been favourable. There was almost unanimity on the question of the necessity for improvement and extension. The views expressed on the scope of the extensions were not so unanimous. When I met the local authorities, for instance, I was told by representatives of the farming community that the £50 valuation limit for farmers was too low and the £600 income limit was too high, and by some of the representatives who were not farmers that the £50 valuation limit was too high and the £600 limit too low. Some groups told me I was going too far. Others were very vehement that I was not going far enough. There was fairly generalagreement that the broad lines of development were right, but a few minority groups told me that the general lines were all wrong and that, instead of developing the services along the lines on which the public assistance services and the public health services had been developed, namely, under democratic local authority control, what was needed was an entirely new approach which would virtually cut out the local authorities and hand over the services to sectional groups. Perhaps the most consistent criticism was that because the proposed developments were relatively costly, though necessary, they should be financed without direct charge on the ratepayers, which means that the cost should be met from the Exchequer.
I have considered very carefully every suggestion made to me and the Bill now before the House shows certain departures from the White Paper as a result. Naturally, the Bill will not satisfy everybody, and if I were to try to achieve that I would probably meet with the same fate as the man with the ass.
A large part of the Bill is made up of unrelated minor provisions and amendments of earlier legislation which experience has shown to be desirable, but in which no major question of policy or principle is involved. The Second Reading is not the time to deal with them. They are more appropriate for explanation and discussion on the Committee Stage. A further large part is concerned with the re-enactment, in modified form, of certain provisions of the Public Assistance Act, 1939. The only new principle involved is the handing over of the administration of certain provisions of that Act from the public assistance authority to the health authority. As the health authority and the public assistance authority are usually one and the same body, e.g., the county council (in Limerick County Borough, the corporation), the effect so far as public representation is concerned will be negligible. The change will facilitate administration, and it will, I hope, mark the last stage inthe development of medical assistance from a pauper service to the parity which in latter years it has had with the other health services. The case for the change is so obvious that I do not think I need do more than mention the proposal. An exception has to be made in the case of certain public assistance authorities in the Dublin, Cork and Waterford areas pending other changes at present under discussion with local authorities in those areas.
The remaining provisions of the Bill are concerned with the new or extended services, but before I deal with them I wish to direct the particular attention of the House to Sections 4 and 63. Section 4 lays down clearly that a person is under no obligation to avail himself of any of the services provided under the Bill if he does not want to and that he may not be compelled under the Bill to submit himself to medical examination or treatment. Section 63 provides that the Minister for Health will have no power to direct a local authority to make any particular service available to any particular person. I hope that during the discussion on the Bill these two provisions, and the intentions underlying them, will not be overlooked.
Before going further I would like to tell Deputies, so that they need not tell me, that there are several means tests in this Bill. I never at any time claimed the contrary. If there was no means test, we would have a free-for-all scheme as they have in England— it is far removed from that by the application of means tests.
I will now deal briefly with the services which, under the Bill and existing legislation, will be available to each of the three categories described in the White Paper as the lower income group, the middle income group and the higher income group.
Persons in the lower income group will be entitled to general practitioner medical care in local authority dispensaries or in their own houses, exactly as at present except that it is proposed to simplify the arrangements by which they will prove their entitlement to the service. They will be entitled to free hospital and specialist treatment as they are at present, but a much better specialist service will beprovided locally as part of the policy of bringing these services to the people in their own counties rather than requiring people to go to the cities for such services. They will be entitled to free medical and nursing care in respect of motherhood, as at present, but with the very important difference, that the patient can choose her doctor instead of the present arrangement under which she must accept the services of the dispensary doctor for her district. They will be entitled to bring their pre-school children to child welfare clinics for examination and advice (it will take time to establish such clinics outside the larger towns). They will be entitled to the benefits of an improved school health examination scheme and to improved dental and ophthalmic services, all without direct charge, with the minor exception that a small charge may be made for replacement of spectacles damaged through carelessness. A new cash grant of £4 per confinement will be payable in addition to any grant payable under the Social Welfare Act, 1952. This grant will be paid to the wife of an uninsured as well as an insured man.
Persons in the middle income group will be entitled to dental and ophthalmic services but charges may be made in respect of such services. They will be entitled to other specialist services free of charge and to hospital services either free of charge or, where they can afford it, at a cost not exceeding two guineas a week at the discretion of the health authority. They will be entitled to free medical and nursing care in respect of motherhood (with choice of doctor) and for infants up to six weeks, with hospital and specialist backing free whenever necessary. They will be entitled to bring their pre-school children for examination and advice to child welfare clinics and to receive dental and ophthalmic treatment in respect of defects discovered at these clinics. They will be entitled to avail of the school health examination services, including free hospital, dental and ophthalmic treatment for defects discovered at the school examinations if the school is a national school.
Persons in the higher income groupcan, on payment of an annual contribution not exceeding £1 a year, get free medical and nursing care in respect of motherhood with hospital and specialist treatment where necessary and similar services in respect of children under six weeks. They can obtain the same services as the middle income group at child welfare clinics and they can avail of the school health examination services, with free hospital, dental and ophthalmic treatment for defects discovered at such examinations if the school is a national school.
All three groups will continue to be entitled to free diagnosis and treatment for infectious diseases, including hospital and sanatorium treatment.
Nobody has suggested to me that there is anything wrong with what is suggested for the lower income group. There seems to be general agreement that the £4 cash grant is a very desirable addition to the existing services and the proposed arrangement for choice of doctor for maternity has been specially welcomed by all men of good will even by those who have offered objective criticism to other provisions of the Bill.
In regard to the definition of the middle income group there has been some controversy. While there is agreement that it has become necessary, due to the increased cost of medical care, to do something for people outside the public assistance group, the limits for hospital and specialist services of £600 income and £50 valuation have been under fire, some contending that they are too low and others that they are too high. There is a good deal to be said on both sides but I feel that the introduction of the power to enable a local authority on the one hand to impose a charge, and, on the other hand, giving them discretion in cases of hardship will give the amount of latitude needed in the matter and should satisfy most of the critics. It will be a matter for local authorities to apply the section in accordance with their own assessment of local needs.
It has been suggested to me that a free general practitioner service, on the model of the dispensary service or otherwise, should be extended to thismiddle income class for contingencies other than maternity. I am not satisfied that such an extension is really necessary. It is rarely that payment for general practitioner care becomes a hardship for anybody but the very poorest and in my experience general practitioners have always been ready to adjust their fees, often to purely nominal amounts, in cases of hardship without making any compliment of the adjustment. I cannot conceive a catastrophe arising out of such expenses as one might meet from repeated or prolonged terms in hospital.
I would like the House to be under no illusion about the application of the charge for hospital treatment for persons in the middle income group as it affects those insured under the Social Welfare Act, 1952. Heretofore, large numbers of these persons got their hospital treatment free, the cost being borne on National Health Insurance funds and latterly as a temporary measure on the Exchequer. They may now have to pay up to two guineas a week, at the discretion of the health authority. In defence of the charge, I want to make the following points:—
Firstly, every insured person was not eligible for hospital treatment. He had to be in insurance for a certain period and to have a certain number of contributions paid. In fact, only about two-thirds of those insured were eligible.
Secondly, only the insured person, and not his dependents, was eligible.
Thirdly, the period for which the benefit was payable was limited to six weeks in hospital.
Fourthly, there was no guarantee of the availability of funds for this or other additional benefits. It depended on a surplus of funds at the periodic revaluations of National Health Insurance funds. The recent arrangement under which the Exchequer met the charge was, as I have mentioned, a purely temporary one pending the availability of the new health services being provided for in this Bill.
It should be mentioned that the contributions payable under the Social Welfare Act, 1952, do not include anyelement for hospital treatment. Many insured persons will, of course, fall within the lower income group and will consequently qualify for free hospital treatment.
In the light of all this and of the long discussions we had here last year on the Social Welfare Bill, it surprises me that a Deputy should have put down a question recently asking what reduction would now be made in the social welfare contributions because insured persons would not in future be getting these additional benefits as social welfare benefits.
I think the insured person in this group is making a good bargain in getting a right to a free or heavily subsidised hospital service for himself and his dependents in exchange for the possibility of a limited free service for a limited period for himself alone.
I come now to the higher income group. The only change made from the White Paper proposals in regard to that group is that maternity services will be made available only to such, outside the "hardship" class, as pay an annual contribution of £1 to the health authority.
I think it wise to anticipate here certain objections which may be made during the debate.
We have been told that we are putting the cart before the horse in bringing in a scheme without having the facilities, in beds and buildings, to give effect to it and that what is needed is to provide the physical facilities and the rest will take care of itself. It is hard to understand this criticism in view of the hospital building that is going on all over the country.
If we first take maternity accommodation in hospitals, there are at present about 1,100 hospital beds for maternity patients (excluding about 640 beds in private maternity homes) The number of births each year is about 63,000, so that if we take it that each bed can on average take 25 patients in a year, nearly 28,000 out of this 63,000 or 44 per cent. can at present be accommodated for child birth in a hospital.
