Health Bill, 1952—Committee Stage (Resumed).

Debate resumed on amendment No. 10:—

To add to the section a new sub-section as follows:—

(3) The regulations to be made under sub-section (1) of this section shall require that as far as practicable the general practioner service to be provided under this section may be obtained by any person entitled to such service from any doctor of his choice who is a participant in a prescribed scheme and who is willing to accept such person as a patient— (Deputies William Norton and James Larkin).

Mr. Kyne

As I was saying before questions, the intention behind the amendment was that the cost of the treatment or of the medicines prescribed by the doctor would be paid, if authority were given to local councils to pay for them for that particular section of the community that would avail of them. That would meet our requirements. I was about to give an instance to the Minister. It is the case of a young lad employed in a factory, who is on workman's compensation. By attending the factory doctor, as he does under the ordinary system of workman's compensation, he gets a prescription of a certain type and each week he has to pay between 5/- and 7/6, according to the dose of injection prescribed. If he were attending the dispensary doctor the drug would be given to him by the dispensary doctor and he would have that money in hispocket. That is not particularly the case I am making but the point is similar.

I am suggesting that in a district where a working man, for some reason or other, because he has confidence in a local doctor, is agreeable to pay the doctor's fee the doctor could give him a chit for medicine, in the same way as he would receive it if he attended the dispensary doctor, even if the medicine was supplied from stock held by the dispensary doctor. If the Minister could see his way to include some provision in this Bill to authorise local authorities to deal with matters in that way, we would be happy.

The Minister has expressed his wish to co-operate and his belief that it is a good thing. I think the main Opposition Party will agree that the principle is good. Whether the technical difficulties are insurmountable or not, I do not know, but I think the amendment is worthy of discussion and, if necessary, a suitable alteration could be made in the Bill to meet it.

Dr. Ryan

While I am very anxious, like the Deputy, that this should be done and would be altogether in favour of it, I am afraid it is impossible at the moment to do anything about it and therefore it would be really dishonest to accept the amendment because it could not be done at the moment.

General Mulcahy

This question will probably arise in other directions but, having regard to the form in which it is raised by Deputy Kyne, perhaps it would be just as well to glance at what exactly is involved. Deputy Kyne has given one particular instance showing what the situation is. There are other cases, particularly where a person is living near an urban district, where more than one doctor even in the public service is available. The question arises of the value from a health and medical point of view of a person being able to choose among those around him the person with whom he has greatest affinity and the greatest personal understanding. This is probably as suitable an occasion as any to glance at the report of the inquiry into the health needs of thenation by President Truman's Presidential Commission of the 18th December, 1952.

In connection with the general question of health, ranging over a very wide field, very strong and very definite emphasis is placed upon the patient-doctor relationship. The report is available. I quote from the official text from the introduction, published in the United States News and World Report of the 26th December, 1952. At page 78, we find this paragraph:—

"In considering the rôles of the individual and various elements of Government in securing health services, one must, of course, not lose sight of a most precious relationship for health. Throughout the whole history of civilised man the relationship between patient and physician has been a special thing. In days when scientific knowledge was scanty, this relationship yielded about all the benefits the patient received. Even to-day, all the complex arrangements that exist to provide medical care have not replaced it. The patient's confidence in his physician underlies most successful care. But now the physician needs more than knowledge of human nature and love of mankind. To be effective in the modern sense he must have the help that the modern hospital supplies, the assistance of trained helpers and adequate facilities."

Very strong emphasis is laid there on the basic requirement, that there shall be confidence and an understanding between the patient and the physician.

The commission formulated ten principles and perhaps it is just as well to read them now, to show the particular context in which emphasis is still placed upon the physician-patient relationship:—

"From such considerations the commission has formulated these principles to be used as a guide in approaching our health problem. We believe that:—

1. Access to the means for the attainment and preservation of health is a basic human right.

2. Effort of the individual himself is a vitally important factor in attaining and maintaining health.

3. The physician-patient relationship is so fundamental to health that everyone should have a personal physician.

4. The physician should have access to proper facilities and equipment, affiliation on some basis with a hospital, and the help of trained personnel in order to fulfil his part in providing comprehensive health services.

5. Comprehensive health service includes the positive promotion of health, the prevention of disease, the diagnosis and treatment of disease, the rehabilitation of the disabled— all supported by constantly improving education of personnel and a continuous programme of research.

6. Comprehensive health service is the concern of society and is best ensured when all elements of society participate in providing it.

7. Responsibility for health is a joint one, with the individual citizen and local, State, Federal Governments each having major contributions to make toward its fuller realisation.

8. The American people desire and deserve comprehensive health service of the highest quality and that in our dynamic expanding economy the means can be found to provide it.

9. The same high quality of health service should be available to all people equally.

10. A health programme must take into account the progress and experience of the past, the realities of the present, and must be flexible enough to cope with future changes."

In a very realistic and practical approach to health, over a very wide-flung community, with varying problems and, no doubt, different methods of organising themselves, they place in the forefront the effort of the individual himself, first, and the importance of the physician-patient relationship.The effort of the person himself is very largely involved in confidence in the person to whom he is going for medical attention. So that, where there is the possibility of a personal choice in certain districts and particularly where the circumstances in which the man is working, his natural circumstances, provide him with medical attention from a particular physician in whom he has confidence and with whom he is in touch and with whom he has a tradition of dealing, if that person would be normally entitled to go to the dispensary doctor and to get free medical service through the dispensary organisation, I do not think it disturbs the elements of even the simplest form of administration that such a person, although not calling on the local authority for the services of the dispensary doctor, would, nevertheless, be entitled to make part of his claim, that is, the claim for the cost of medicine.

Dr. Esmonde

This amendment deals with the choice of doctor. Surely it is envisaged in this Health Bill in a later section that a patient should have a choice of doctor in regard to maternity service. If the Minister proposes to offer a choice of doctor in maternity cases surely he would have to offer a choice of doctor in other cases. The Minister seems to think that it would not be possible to give a choice of doctor. In that I largely agree with him but, if it is suggested in a later section or amendment that a choice of doctor can be given in maternity cases, there must be some scheme at the back of the Minister's mind or that of his officials whereby a choice of doctor can be brought in. Would the Minister make us wiser with regard to that scheme?

There are certain areas in the country, particularly in country towns where there may be three or four private practitioners and there could be a choice of doctor in that case. That would apply also in the case of Dublin and other cities. If the over-all idea of the scheme is to have a free choice of doctor, surely there must be something to show how there can be that free choice of doctor. If not, has the Minister any idea how it will beimplemented? I should like him to make us clear on that point. In a country district there will be only the dispensary doctor. I agree that if you bring in another doctor you remove to a large extent the livelihood of the doctor already resident in the district. In the maternity section it is stated that there is to be a choice of doctor. If that is to apply to other classes of patients, how does the Minister intend to fit that into the Bill? Would he clarify that point?

Dr. Ryan

I spoke on this section before we adjourned and I mentioned that it would be extremely difficult to give a choice of doctor, even if we adopted the amendment. It might also have the effect, if a doctor had not a retaining salary as a dispensary doctor, that he might not stay in the district at all. We will have to do something to see that doctors will be kept in sparsely populated areas. There would, of course, be a choice of doctor in towns and villages where the population is fairly dense. The same thing will apply to a great extent in regard to maternity cases. In the case of maternity, however, the woman concerned may be able to arrange to transfer her domicile at a certain time if she wants to attend a doctor in the nearest town or village. There is at least a better chance, although I know it is limited, of being able to avail herself of a choice of doctor in that case than in cases of ordinary diseases which arise in dispensary practice.

Mr. Kyne

Perhaps I have not made myself as clear as I should. The Minister spoke of a woman being able to go to another district. That would arise in a maternity case where the woman would be attending a doctor as a private patient. But I am talking about people who would normally be unable to pay a doctor at all. They would be attending a dispensary doctor and get free attention. What I am asking is, if they chose another doctor and are prepared to pay that private doctor whatever fee they can afford, could not regulations be introduced to give the local authority permission to pay for the medicine which may be prescribed by that privatedoctor, or could it not be so arranged that the private doctor would have the right to give them a note so that they can get the medicine from the dispensary doctor? Surely that is not too much to ask. It would only apply to this particular group of people, and I know it would be appreciated throughout the country. It would only apply in particular areas. In many country areas there is only one doctor, but where an urban area is within five or six miles from them people often choose to go there for a doctor. They scrape up enough money to pay the doctor's fee and, in addition, they have to pay for the medicine because that doctor cannot prescribe State medicine for them. I feel that some provision should be made for treatment in that way by some of these private doctors.

It seems to me that this is one of the most important matters dealt with in this Bill. I would like to assure the Minister that in expressing fears on this matter I am speaking entirely for myself. They are fears that I genuinely hold and I would be glad if my mind could be freed of that concern.

Dr. Ryan

I do not think the Deputy has taken the section up properly. The only thing the county manager decides is whether a person can pay or not.It is the medical officer who decides whether he should get the treatment or not. Then, if he goes to the dispensary doctor or to his own doctor who advises him on the treatment he is to get, the man himself will then say: "I am entitled to free treatment". In most cases there is not dispute. The doctor sends him to the county hospital and the man gets his treatment. That may be challenged in some cases and then the only question the county manager decides is whether he should pay or not. He has nothing to do with the particular treatment.

I understand, of course, that it is the doctors who will prescribe the treatment which the person should get under sub-section (2). It is entirely in the power of the county manager to say who is entitled to treatment under Section 13. Therefore, whether the doctor prescribes or not, the person does not get the treatment. The power is being given solelyinto the hands of the county manager and the county manager alone to determine. I think that is a power which should not be given to a layman. It is not, I suggest, an answer for the Minister to say: "That is the law already."

If it is, and I do not question what the Minister said—I understand it is— I object to it and the sooner that is changed the better. I grant you that there must be some person who will have some say in the financial obligations that may be imposed on the local authority but that a county manager, as a layman, should have the right to determine whether a person should or should not get a treatment or a service prescribed for him under this section by a doctor is, in my opinion, giving far too much power into the hands of any layman.

Dr. Ryan

Section 18, sub-section (2) of the Public Assistance Act, 1939, defines a poor person. That Act set out to give free treatment to poor persons. Sub-section (2) of Section 18 of that Act reads as follows:—

"A poor person who is unable to provide by his own industry or other lawful means the medical, surgical or dental treatment, or medicines, or medical, surgical or dental appliances necessary for himself or any persons whom he is liable under this Act to maintain shall be eligible for medical assistance."

The only difference is that we have put in ophthalmic here as well. Therefore, we are doing exactly what has been done since 1939 and that is stating what people are entitled to free treatment. Naturally, somebody must determine that. In the past, the county manager has had the last word on the matter. It is quite true that the county manager is very seldom appealed to. In many cases the warden issues the tickets or the home assistance officer usually sends the people to hospital. Only where a dispute arises does the county manager come in. To come back to that point, the county manager has no right whatever to decide whether a person wants treatment or not.

Mr. Morrissey

I did not suggest that.

Dr. Ryan

The only right the county manager has is to decide whether or not a person should pay something.

Mr. Morrissey

Should get the treatment.

Dr. Ryan

The treatment will be given and he will not attempt to stop it. But he will decide whether or not a person should pay something.

I know that it is easy to say that we should not put so much power into the hands of one man. I know that it is easy to condemn the county manager and to talk about the democracy of the county councils, and so forth. Does any Deputy want me, however, to insert a provision in this Bill that where there is a dispute the circumstances of the person will be discussed by the county council?

Mr. Morrissey

No. Certainly not.

Dr. Ryan

It must be done in a confidential way. Therefore, a person must decide, or three persons if you like. It is not a question for the county surgeon to decide. He has his own work to do and, anyhow, he has not the staff to investigate. It is not a matter for the county medical officer either in my opinion. I think that the right person is the county manager who has his staff of home assistance officers, and so forth, to give him the report that he needs. I suppose, in fact, he will rely entirely on the home assistance officer's report.

Mr. Morrissey

I am not casting any reflection on anybody but the type of person to whom this service should be made available is specifically set out here and nobody but the county manager can determine whether that person is or is not one who, by his own industry or other lawful means, is unable to provide the medical, surgical, ophthalmic or dental treatment necessary for himself or his dependents.

Apart from the other aspect—which is the more important one—the county manager himself is being put into rather a difficult position. He is the guardian of the funds of the local authority. He is the person who is charged with the collection and thedispensing of these funds. He is the person who is expected to keep the rates as low as possible. I am not saying that a county manager would allow even that consideration to influence him against allowing treatment to be given to a person who had been certified as a person in need of it, but that feeling will always be at the back of his mind to some extent or another: there is no doubt about that.

I must confess that it causes me a certain amount of uneasiness that, in a matter that is purely surgical or medical, a layman is to have almost the entire say. If the county manager, acting in the best of good faith, decides that a particular person or patient does not come within this category—and makes that decision in absolute good faith—he may, in effect, be depriving that person of the treatment because that person may not be in a position to pay the charges that would be laid down for him.

Dr. ffrench-O'Carroll

There are two points of view with regard to the question of the administrative side of medical work. I want to put the opposite point of view to that which Deputy Morrissey has put forward. I can understand that, naturally, a doctor is worried and has genuine fears on the question of whether or not he will be directed by people who do not know what they are talking about. Another point, however, which must be considered is that if you are going to weigh down the ordinary doctor in a hospital or a dispensary with a lot of administrative duties he will not be very pleased either. Remember that a doctor is a man who is trained in medicine, surgery and allied subjects. His interests and work and vocation in life lie in those channels. For a doctor to be faced with administrative problems for which he has no aptitude or training it can, in certain circumstances, be a very unwelcome responsibility.

In my experience, talking to district medical officers, what they resent most of all at present in the dispensary medical service is that they have so much administrative work to do. Again, on the Dublin Board of Assistance, I have put forward the ideathat we should be able to get some clerical assistance for the dispensary doctors. The average dispensary doctor has so many forms to fill in and so much clerical work to do that he must necessarily spend a certain amount of time at that work—time which he would otherwise be able to give to medical work. I am not suggesting that he omits his medical work but I am suggesting that it will be a burden if you give a medical officer of health all these duties to perform.

Mr. Morrissey

I have not suggested that at all.

Dr. ffrench-O'Carroll

Therefore, as far as the administrative side is concerned, we have to recognise that you have got to separate clinical work and administrative work. In hospitals which have nothing to do with State services they are training people and looking for administrators—men who will take the administrative work from the shoulders of the doctor and leave him free to do his clinical work. I do not see anything wrong in letting a county manager make the decision on the administrative side provided the doctor is left free to do his medical work.

Mr. Morrissey

The Deputy is knocking down skittles that he put up himself. I did not mention that matter.

Dr. Esmonde

That was not the point Deputy Morrissey was making at all. The point he is anxious about is that if a patient requiring treatment is recommended for treatment and if the county manager considers that, by reason of his financial circumstances, he is not entitled to free treatment, the patient will get that treatment. It is not suggested for a moment that the doctor should be responsible for the administrative end at all. The point is that if a doctor sends a patient for treatment—this will arise in rural districts more than towns—and if the county manager decides that that person does not come within the section, he is not entitled to free treatment.

Deputy Morrissey wants to ensurethat the man or woman will get the treatment. That is the only matter in respect of which he wants a guarantee from the Minister. If a doctor sends a patient for treatment, that patient may be a border-line case—he may or may not be able to pay—and the county manager may say that the patient cannot have the free treatment. How is the Minister going to get around that? It is not suggested that doctors should be administrators because they have enough to do already. The best way for the Minister to deal with it would be to call the medical officer of health, who has his assistants, into consultation and, if the case is urgent, to ensure that it will be dealt with. You will not then have a position in which an urgent case is sent with a recommendation for treatment to the county manager and sent back, because, according to the regulations, he is not entitled to treatment, and for all we know may die.

Dr. Browne

The answer to Deputy Esmonde and Deputy Morrissey's point is that we should reject some later sections of the Bill and see that a free, no means test, universal and general health service is brought into operation. Deputy Esmonde must understand that a manager would not dare to reject a person for treatment, unless he was acting within the law which we are drafting here. Surely he must be bound by these laws and regulations made under them and would not take it upon himself to reject a doctor's proposition in relation to treatment, except on legally binding grounds that we are attempting to draw up here. In pursuance of that general attitude, I suggest that we bind him to the least possible extent and allow him, generally speaking, to tell a doctor: "Whenever you have a sick patient, a patient who wants an operation, send him to the local surgeon or physician and we will pay for the service". I am in complete agreement with Deputy Dr. Esmonde there and also with Deputy Morrissey, if I understand him aright.

I listened very attentively to Deputy Morrissey's proposition and I understand his difficulty with regard to interferenceby lay administrators in the medical control of a case. I would deprecate that in the strongest possible terms. I admit it is a possible danger, a danger about which we have to be particularly careful, but I think it is up to the medical profession, if a clear case is made to show that there is an encroachment, to guard against such encroachment. So far, I do not think the case has been made.

With regard to administration, Deputy ffrench-O'Carroll's point is an excellent one. A doctor is trained in his particular profession—he has a medical outlook, a surgical outlook or a highly specialised training—and he knows very little and wants to know very little of the purely administrative side of health services. I should like to know who does Deputy Mulcahy propose should make the final decision, if not the managers, on the advice, of course, of the medical adviser, the dispensary doctor, the medical officer of health or the county surgeon? First of all, the manager cannot controvert, on anything except grounds which are really binding, the decision of the doctor and the patient will then get whatever service he is entitled to.

That is what we are discussing now —the services which we are going to allow our people to become entitled to under the Bill. I should like the scope to be as wide as Deputy Esmonde suggests it should be. Where a doctor says that a patient needs a particular treatment—surgical treatment, medical treatment or treatment with certain medicines—and feels that he ought to have it, the manager is bound to take a decision and the patient then goes to hospital. It is quite obvious that in relation to this question of the county manager, more than the doctor is concerned and bound by administrative control. The engineer, the architect and various professional employees of a local authority are bound by the country manager's decision in various ways and the average professional man would much prefer to stick to his profession, about which he is reasonably well acquainted and in which he is reasonably well trained, than try to cope with balance sheets, tax returns, costs and prices of drugs and medicines,tenders and the thousand and one other things which the unfortunate manager has to deal with in trying to co-ordinate the different services of the average local authority.

General Mulcahy

I feel that we ought to prepare an agenda for dealing with this section because we can come on to the matters of which Deputy Dr. Browne has spoken later. We are dealing with the power to decide that a particular person and his family are entitled to this service and the sole power of deciding these things is put in the hands of one person, with no appeal whatever, that person being an official who, in the words of Deputy Dr. Browne, has a thousand and one things to attend to. The White Paper issued by the Minister originally indicates what the problem here is. It says in paragraph (2) under the heading "Public Assistance Act, 1939":—

"So far as numbers are concerned, by far the most important of these enactments is the Public Assistance Act of 1939 which replaces in consolidated form the earlier legislation which dealt with medical services for the poor."

Later on, it says:—

"It is estimated that this service is availed of by about one-third of the population."

In respect of a class which the White Paper tells us numbers one-third of the population, we are putting it into the power of the manager in any county to say that such a person is inside or outside that class. When you take a population of about 3,000,000 and draw an imaginary line cutting 1,000,000 of the population off from the other 2,000,000, and then put into the power of one man, a particular type of official in each county, the sole power of saying on what side of that line a particular person or his family is, it emphasises our general approach to the Bill, that we are not saying and cannot say what ought to be done to settle that problem, but asking the Minister to give us some kind of idea of his mind on what the process is of people having it decided on what sideof the line they are. This apparently is the white ticket section. Would the Minister let us know what is the process of obtaining a white ticket? If we could get a picture of what the process is of getting a white ticket then we could go further on with the other matters.

Another point arises. We are concerned with the cost of the proposals that are down here under each one of these sections. The Minister has indicated that the total cost to the local authorities when this scheme is put into operation will be £900,000. I would like to draw his attention to an article on this Bill in the March quarter of Studies,on page 3 of which an attempt is made to examine the cost. It says:—

"The only yard-stick of comparison which we have is the British cost. There it costs about £2 5s. per head to give everyone much the same ‘general practitioner services' (including pharmaceutical, dental and ophthalmic) as are outlined in the new Bill."

That being so the free services of this nature for 1,000,000 people, one-third of the population, would cost about £2,250,000. That is for general practitioner service alone, leaving out entirely the provision of free institutional services or specialised services, which I take it, are also included in this. The article in Studiesgoes on to say: “The British cost per head of free institutional and specialist services is over £6. Hence our cost would be about £6,000,000.” Therefore, taking the British figure just as a baseline, including general services and institutional services you would have to add £2,250,000 to £6,000,000 that is, £8,250,000.

The Minister will understand that putting the situation in that way brings us up against the question: does he accept the figure in his own White Paper that one-third of the population will be entitled to use the services? Can he tell us what the cost will be? If he still sticks to his £9,000,000 for the local authority and £9,000,000 for the State, can he reconcilein any way by any reference or comparison to the services given the extraordinary discrepancy between his estimate of the cost here and the actual cost of what is provided along the same lines in Great Britain? Can he also tell us the procedure to be adopted by the county manager in deciding who is going to be a white ticket case?

Dr. Ryan

It is very hard to understand the mentality of some people. Deputy Mulcahy stands up and paints a picture of a county manager having to decide between one-third of the population and the other two-thirds as if it were going to be a full-time job for the county manager and he would not have time to do anything else. He has been doing that for the last ten years and if you ask any county manager he will say that he decided about four cases in the year and that is about all that will come to him.

Is it not obvious to any sane man— perhaps it is too much to expect sanity from the people opposite—that in regard to 99.9 per cent. of the people involved there will be no question about them? As a matter of fact, a lot of people who do not claim free service would be entitled to it but they decide that they will not take it and do not apply for it. There are very few above the income limit who would be entitled to it and there are very few appeals to the county manager. I would like to know from the Deputies opposite what would they suggest. The way Deputy Mulcahy is talking you would imagine you would want seven high court judges in every county. Do they suggest we should set up a special commission in every county?

Surely it is common sense that when a thing has gone on smoothly and efficiently for ten, 12 or 20 years it is satisfactory? Why should we change it if it is going on smoothly and why should we not repeat the very same words that are in the Act of 1939 and why should we spend hours in discussing it when we put in the same words?

Deputy Mulcahy also speaks about the cost. I was asked by a certainDeputy the other day what benefit would such and such a class get. I said they could not get any benefit because they are getting free treatment already. Deputy Mulcahy quoted figures from Studiesin regard to the lower income group. They are getting free treatment already. I expect that treatment will be improved, so that, to that extent, there will be a slightly extra cost. But our present services are costing us £10,000,000 between what the local authorities and the central authority spend. I do not know what portion will go to the lower income group. It may be the figureStudieshas mentioned, £6,000,000, but it is there already and all that will be added is the cost of improving the services that are there. I do not know exactly what that will be but the estimate I gave of the total cost of this particular Bill was made out on as firm a basis as we could get and it works out somewhere around £1,000,000 on the local authorities and £1,000,000 on the Exchequer.

Brendán Mac Fheórais

I am suggesting that the county manager is not in a position to do it. The Deputy with respect is thinking very largely of city conditions. I am thinking of country conditions. I am thinking of a patient living 35, 40 or 50 miles away from the manager's office. I am thinking of somebody living on the side of a mountain in Kerry, Galway or Tipperary. With the exception of the local assistance officer or the local doctor, who else is in a position from local personalknowledge to say whether the person has the means or can afford to make payment or if he is to be put outside the category we are dealing with here? How is the county manager going to ascertain that? Is the patient to be brought in 30 or 40 miles to the county offices there to be interrogated by the county manager or by somebody on the county manager's behalf or is the county manager to select some road overseer, some official or employee of the local authority to go into that person's house and carry out a means test there? I am trying to look at the practical difficulties. I am not saying for a moment this is going to happen in thousands of cases but I am saying that we cannot afford to have it happen perhaps in a dozen cases or 100 cases.

I want to put this point in reply to what the Minister said about the existing law and the existing practice in regard to people who are entitled at the moment to services and treatment. The Minister knows as well as I do that, as a result of all the talk and the publicity there has been in this country for the last eight or ten years about all the new medical services and treatments that are being provided and that were never provided for before, the great bulk of our people believe that automatically they are going to become entitled to many benefits if and when this Bill becomes law and is brought into operation. Unquestionably you will have people applying for treatment and for services under this Bill when it becomes law who did not formerly apply even though the Minister says there is nothing in this that is not in the Principal Act itself.

I want to put this point again to Deputies. I must say I am rather surprised that medical Deputies here, with personal knowledge and experience of dealing with patients and their conditions, can take up the line that a layman is the proper person to decide an issue like this. I do not think so. I never thought so, and the fact that it was so for the last ten years does not make it any dearer to me personally. Realise the difficulties. I am not saying that this would make it muchsweeter to me, but suppose you had some system under which the manager after consultation with the medical officer, whether he is the county medical officer, the dispensary doctor or whoever he may be who is dealing with the case and who knew all the circumstances of the patient could decide, would that not be a more acceptable arrangement?

May I put another point? A good deal may depend on the disease or the type of disease from which the patient is suffering. A good deal may depend on the doctor's view as to how long that patient is going to be incapacitated. The county manager might decide, and rightly decide, that a patient who is going to be incapacitated for four weeks is a person who would be able to pay his contribution for a period of four weeks, but it might be utterly impossible for that patient to pay his contribution if he was going to be incapacitated for 12 weeks or 20 weeks. Surely that is something that will have to be accepted and admitted. I think the Minister will agree with me that that might make a difference, and surely it is only a medical man, not a layman, who can determine whether a man's incapacity is going to be completely cured within three weeks, six weeks or ten weeks. That cannot be determined by a layman.

I would like to convince the Minister, if I can, that this is a very serious and important matter, one of the most important with which we have to deal here. I want Deputies, if they will, to consider the last point I put about the duration of the illness. That in itself could determine, either partially or wholly, whether a person is a person who should or could contribute or whether he should come fully within the scope of Section 13. The whole trouble is that the Minister's intentions are all right. What we ourselves believe is all right. If that was all we had to worry about our worries would be trifling but we cannot assume that we will have the same Dáil, the same Government, the same Ministers or the same county managers, or the same system of county managers, in relation to their powers or their appointment or in relation to those to whom thecounty manager will ultimately be responsible. We are not legislating here what is supposed to be an important Bill merely to run for the lifetime of this Dáil, or the lifetime of the next Dáil, or the lifetime of this Government or of our present county managers. We are enacting something, that, once it passes outside this House, passes completely out of our control and the interpretation, administration and enforcement of it will lie in hands other than ours. We will be powerless to do anything except to amend the law by another Bill. I think there is a case here for a much fuller examination by the Minister, a case for the protection of certain citizens. I am not concerned whether the number is 50, 500 or 5,000. When it is a question of health and when it may be a question of life, or death, I think that absolute power in the hands of a layman is something we should not give.

Dr. ffrench-O'Carroll

I think Deputy Morrissey, and I listened very carefully to the case he made, has to a certain extent proved the case against himself because he has pointed out that between the Social Welfare Act and this Health Bill a vast amount of investigation will have to take place. He has referred to the investigation officers and the staff required to carry out all these means tests provisions. He then tries to make the case that the doctors should be asked to do some part of this work. I do not know how much of it actually he is trying to put on to the doctors. Obviously, he is suggesting the doctors should do some of it.

Mr. Morrissey

Of course, I am concerned about the patient.

Dr. ffrench-O'Carroll

General Mulcahy

The Minister will not tell us that.

Mr. MacCarthy

Is that not happening every day in the week in decisions as to who or who will not have to pay for hospital treatment?

General MacEoin

What are you doing? I submit that Deputy Kyne has more or less put his finger on the case, that it is the relieving officer who will give the red card or the white card, and if the relieving officer is to give the white card have you not still the pauper system? When the relieving officer comes to any person is it not a reflection on that person there and then? I am not objecting to it so much on that ground as on this one, that this is a complete new Fianna Fáil development to make one-third of the population of this country mendicants of the Fianna Fáil Government. As a matter of fact, at the moment, a number of people cannot get what they are entitled to for housing, drainage, land reclamation or whatever it may be without going to a Deputy. I will admit it may be any Deputy — Fianna Fáil, Fine Gael, Labour, Clann na Poblachta, Clann na Talmhan or Independent. The point is that they have to go to a Deputy to get what they are entitled to.

Is that in order on the section, that I joined the Blueshirts?

Mr. O'Higgins

They saved this Parliament.

General Mulcahy

They left a Parliament behind them to us to maintain to-day.

Dr. Ryan

Because they had to. They were wiped out.

General MacEoin

The Minister says that this is a repeat section. The section provides that:—

"A health authority shall, in accordance with regulations, makeavailable, without charge, for the person specified in sub-section (2) of this section and their dependents a general practitioner medical and surgical service..."

It does not matter what the Minister says, there has to be a card of some sort. The case has been made that the red ticket was a badge of poverty and that one of the great things about this Bill was that we were getting rid of the badge of poverty. If that is so, I want to know how it is done? I do not want to have another badge substituted, a worse badge which is the badge of the mendicant having to go to a political partisan to get what one is entitled to in law.

Dr. Ryan

The Deputy should repeat that again because he has been saying it for the last five minutes.

An Leas-Cheann Comhairle

It does not seem to arise on the section.

Dr. Ryan

Of course, it does not.

Yes, an increased cost.

In subsection (4), page 6, line 9, to delete "forty-two shillings for each week" and substitute "six shillings for each day".

In subsection (4) the local authority is given power to make a charge on certain people who can afford to pay the charge in a hospital, up to £2 2s. per week. That was considered to be inconvenient, as a person might be in the hospital for only two or three days. It has been thought better to make it 6/- per day, in order to calculate it for the number of days a person is in hospital.

Yes.

One of the things that actuated me personally more than anything else in drawing up the new health services was the need for hospital treatment for a certain class above the lower-income group, namely, the middle-income group. In the middle-income group you have, in my opinion, people who can well afford to pay an ordinary family doctor's fees, but the disastrous thing in their case is some sickness in the family which requireslong hospital treatment, especially if that should occur fairly soon again with another member of the family. I know of some very distressful cases of people in the middle-income group who had to get hospital treatment and pay all the costs.

In determining the category, I suppose we were largely influenced by the legislation already there. First of all, as outlined here, there are the people who are insured under the Social Welfare Act and who are already entitled to sickness and medical benefits. It is always easier to carry on with what you have than to try to make any changes, because if you change and make it worse there will be a great deal of trouble about it. In that particular class you have all those working for an employer, every manual worker is in the insured class and non-manual workers up to £600 a year. It seems logical, therefore, that we should take those earning up to £600 amongst the self-employed as well as those who are employed. That is category (b).

Then (c) deals with the farming class. I put up the proposition to the Government, and it was agreed to, that we should try if at all possible to avoid inquiring into the means of persons when making this series of classes. There is no doubt about the persons in the insured class, but as far as farmers are concerned, instead of investigating their means, it was decided to put down a certain valuation. At the time we were preparing the scheme we thought £50 valuation was fair as compared with the other incomes that were mentioned.

I think that in doing that we succeeded in a way in getting a very big portion of the population where there would be no necessity to investigate means. If a person is an insured person, that ends the matter. If he is a farmer of under £50 valuation that ends the matter and there is no further investigation. The only place where there is a necessity for investigation is in the case of the self employed person who is not a farmer, not insured and who claims his income is less than £600 per year. There was no way out of that as far as I could see. We had to put some limit there and it is the same limit that is already there forthe insured person. You always have the hard case and category (d) covers that. The farmer who is not under £50 valuation and the person whose income is not below £600 may at the same time claim that it would be inflicting extreme hardship on him if he had to pay the hospital bill, especially if he had to pay the bill over a long period.

I think it was Deputy McEoin who mentioned that it made a difference how long the person was in hospital, that if he was in hospital for a short period he might be able to pay but if he were in hospital over a long period it would be extremely difficult for him to meet the bill. Category (d) is put in to meet the case of the person who is not qualified, has a bigger income than will qualify him but who at the same time, as a result of a long term of illness or two long terms of illness, should therefore, get help from the local authority.

I think that is a rough outline of why the limits were put that have been put. Many people have written to me and the type of letter I get from the city says it is unfair to class the £600 per year person in the city as highly as the farmer with over £50 valution in the country. From the country I get a letter saying it is unfair to class the farmer of over £50 valuation as highly as the person with the £600 per year in the city. It is not easy to get agreement all round. We have, therefore, to do whatever we think is fair in the circumstances. The cost under this section is about half the total cost. If the cost were about £2,000,000, roughly half of it would come under this section.

General Mulcahy

What and where are the services being provided?

Dr. Ryan

Specialist services will include x-ray examination in the hospital and will include, if you like, specialist services which are orthopaedic. Specialist services for cancer, which will be a specialist service in the near future, are also included.

Dr. Esmonde

Could the Minister state if these services are in the public ward? Is there any allowance in this part of the Act for treatment in anursing home? Could he further state if this treatment will be in the local hospital in the area of the county in which the actual illness takes place or does this portion of the Act allow for the transfer, if necessary, of people to larger centres to the voluntary hospitals? Will they be included in this treatment as well? Will there be in some cases any allowance for people with an income of over £600 per year? Would the Minister clarify that a little bit? If payment is to be made, what will be the general principles governing that payment per week? How much is it intended to charge? Perhaps, the Minister would give us information on that point.

Mr. Morrissey

I do not think that anybody in the House will take issue with the Minister on what he has said regarding the necessity of providing for that particular type of person it is intended to provide for in this section. I do not think anybody will dispute what he has said with regard to cases of extreme hardship which have occurred and which have placed a very heavy burden on families which they were not able to get rid of, perhaps, over a long number of years.

I am sorry to say, however, that we have not got from the Minister very much information as to how this section is to be operated or when the services under it will be provided. I think it is admitted that our present resources, either in beds, buildings or personnel, are not sufficient to enable us to give the services that are set out here in addition to the services set out in Section 13 and for the people who are covered by Section 13.

This brings me back again to what the Minister said and to the point I raised originally about the regulations being made by the Minister and the Minister for Finance. The Minister said—I think rightly—that there would be exceptional cases and that he was making an attempt under category (d) of sub-section (2) to ensure that in very exceptional cases, which are not covered by any of the other categories mentioned in Section 14, provision should be made there. The strange thing to me about it is that it is justin relation to paragraph (d), which is to provide for exceptional cases, that the regulations are to be made by the Minister and the Minister for Finance.

How the Minister and the Minister for Finance can draft regulations which will have general application for the whole country to meet very exceptional cases that are not already covered under any of the other three sub-heads is something I do not understand. Frankly, I cannot see how it will be possible for the Minister and the Minister for Finance to draft the various regulations applicable to the whole country and to every health authority in this country regarding the provision of institutional and other treatment for very exceptional cases— cases other than those regarding the people with £600 per year and so on. I presume there is some reason, good or otherwise, for bringing the Minister in specifically in relation to category (d). Personally, I should be very glad to hear what the reasons are.

Mr. O'Higgins

This section does interest me and I would like to find out something with regard to it from the Minister. Up to recently there was in operation here, apparently not in accordance with the law, a form of family insurance under which persons in the middle income group could insure against the accident of a serious operation requiring hospital treatment over a period of time. Under that insurance scheme a choice of specialists and of institutional treatment was made available. That insurance was recently prohibited by the responsible authorities here. Accordingly, it is not possible in this country at the moment to insure a member of the family against a serious illness. What is offered instead is the provision contained in this section. I should like to know from the Minister how, in fact, that will operate. Will there be a choice of specialists? Will it be possible for persons who come in under the section to be treated by specialists of their choice. Will there be, in addition, a choice of institution — or is it the policy behind the section that, for instance, in my constituency of Leix-Offaly the persons who benefit must goto the county hospitals and must avail of such specialist services as may be there available? I should like to know from the Minister whether, in fact, this section will meet the case that, up to recently, was being met by a form of family insurance.

If all that is intended here is that institutional and specialist services will be granted free in the county hospital to those who come within the categories mentioned, I do not think it is adequate. In most county hospitals— certainly in the county hospitals of my constituency — many of the persons within the group set out in sub-section (2) of this section did, in fact, receive specialist and institutional treatment free because of cases subsequently made by them in relation to the accounts sought to be recovered. I think it is important to know whether there would be any method under which a choice of specialist or institution could be made available to the people intended to be benefited.

General MacEoin

Sub-section (2) (c) of this Section 14 states:"..., the rateable valuation of the farm or farms (including the buildings thereon) being £50 or less." I should like to know if sub-paragraph (d) of that sub-section would operate in a case where, say, the Land Commission divided an estate and on one of the holdings on that estate was an outoffice. Sometimes such buildings have an extraordinarily high valuation and yet it is a farm within the meaning of the Act and an agricultural holding. I am wondering if sub-paragraph (d) covers a case where, for instance, there might be a valuation of £20 on buildings and £30 on land. Would sub-paragraph (d) allow, on the examination of that person's means, that the valuation is under £50? All over the country there are ramshackle old buildings which have very high valuations and yet they are not altered. In the case of ordinary farm buildings, the valuation is never more than £5 or £10, but in a number of these cases — and especially where the Land Commission have divided holdings — you may have a farm with buildings far out of proportion to the land. I suggest deletion ofthe expression "including the buildings thereon" in sub-paragraph (1) of the subsection.

Mr. P.D. Lehane

I think there is a certain difficulty in regard to this point. Take, for instance, a person with a £50 valuation and a person with a £50 5s. valuation. The person with the £50 5s. valuation might be worse off than the person with the £50 valuation.

There is an education and an encouragement for increased agricultural production and yet if anybody extends his farm buildings the valuation goes up. I think that sub-section (2) (c) will have the effect of restricting agricultural production in the future. I wonder if it would be possible for the Minister to have some sort of sliding scale or a grading scale. It is peculiar that a person with £50 valuation can get the benefits, and that a person with a £50 5s. valuation cannot.

Captain Cowan

Naturally, I am delighted to hear what Deputy MacEoin and Deputy Lehane have just said. It is wonderful. In other words, what they are suggesting is that the limits of the Bill, as far as they are concerned, are too restrictive. That is what I anticipated a long time ago —that once we got this Bill into operation attempts would be made from all sides to extend its benefits and that, in a very short time, it would be a free for all.

Deputy Lehane pointed out that a person with a £50 1s. valuation might be a more deserving case than a man with a £50 valuation and the same thing applies to the £600. A man with £601 may be a more deserving case than the man with £600. I think, therefore, as a result of these two speeches that we have just heard, that everything is most hopeful.

When this Bill becomes law, no matter what the restrictions are, from every local authority and from every public representative, whether he be a member of the Dáil or of a local authority, there will be a clamour for extension of the benefits to other classes — and then we shall get the Health Bill that we should have.

This is a most welcome development as far as this debate is concerned. I am delighted that Deputy MacEoin and Deputy Lehane have made that point. I think that the majority of Deputies in this House would like to extend the classes and extend the benefits and, in fact, to make it a completely free-for-all scheme. But, of course, we had objections in this House to a free-for-all scheme. However, the moment we get down to the practical realities of the sections and the sub-sections we have the very reasonable comment from Deputy MacEoin and Deputy Lehane that the restriction in regard to £50 valuation may impose a hardship on some particular farmers and that a farmer with £51 valuation would not be entitled to benefit under this scheme while a farmer with a £50 valuation would.

It has, yes. Deputy MacEoin put a question with regard to a person who gets the central buildings on a divided estate and who might have a very high valuation. That is certainly a case which would be taken into account by the local authority and sub-paragraph (d) would apply, unless the person had very big means apart from that. If he was an ordinary farmer trying to live on 30 or 40 acres with a very high valuation, it would naturally be taken into account.

With regard to Deputy Lehane's point, I was very keen at one time on grading it, of setting out so much valuation for a single man and adding to it for a wife and for the first couple of children, but in the end I was persuaded — and, I think, rightly — to cut out all these competitions and make the scheme as simple as possible. We did that and really what we did was to put in sub-paragraph (d) to cover the hard cases. I think it is better on the whole.

Mr. Morrissey

Would the Minister deal with the point I made about sub-paragraph (d) and the regulations under it being made by the Minister?

Dr. Ryan

I find it hard to say what these regulations are going to be. I think we should be able to lay down some sort of uniform guide for the country. Take the case mentioned by Deputy MacEoin, the man over £50 valuation where there was hardship or what Deputy Lehane had in mind, the man with a very big family just over the £50 mark. There are quite a fair number of categories of that kind that could be considered sympathetically. The Deputy being a member of a board himself will understand that when Iput this scheme up, the Minister for Finance asked me what (d) was going to cost. I said I did not know and I think he was reasonable in saying: "If you do not know, you must at least give me some check". I said I was quite prepared to do that and said that I would get his approval for whatever regulations were made. On that basis he agreed and I think he was quite entitled to it because I could give no indication of what that sub-paragraph might cost.

Question put and agreed to.

SECTION 15.

Dr. Ryan

I move amendment No. 20:—

I attach considerable importance to this amendment. I have the greatest sympathy indeed for the Minister in the problems which have been put up to him and which have been, by various influences, magnified in his genuine attempt to introduce very valuable health proposals. I am myself much indebted to the 1947 Act of the Minister. During my period of office, the benefits of the 1947 Act, particularly in relation to T.B., and the advantages which I was given under that Act, were largely responsible for the fact that we were able to tackle the serious problem of T.B. in 1948. I do not think that the Minister gets half enough credit for the fact that he did at least make that power available to us by the provisions of the 1947 Act. Whether he continues with his amendment or whether he removes it, I do not think anything can detract fromhis contribution to valuable health legislation during his term of office.

It is unfortunate that the question of the £1 contribution, which was an amendment of the 1947 Health Act, particularly in relation to the mother and child section, was ridiculed, as he said, when it was put before the House. I would suggest, however, that that is not a sufficient reason for making this very radical and very serious departure from the excellent lines of this aspect of the present Bill, the radical departure being, as pointed out by Deputy Morrissey, the fact that we now are being asked to approve of an insurance scheme on the lines largely suggested by the Irish Medical Association — at any rate an insurance scheme. I objected to this amendment in the health council on grounds, strange as it may seem, very similar to those put forward by Deputy Morrissey this afternoon. The way I look at it, is that while we had the £1 contribution we had a fixed definite amount for the lady which would bring her into benefit under the scheme. Now, the appropriate amount, of course, throws the whole thing wide open and gives us no assurance whatever that even in this small part of this Bill we shall be providing benefits for mothers and infants which we know we could provide by the provisions of the 1947 Act, that is, that the service should be freely available to all without a means test on the principle which we have seen was so terribly valuable in another aspect of our health services — the T.B. service.

The Minister, I feel, must try to give us a better justification than that which he has already given us for this serious radical departure from his £1 contribution proposal, before it could be agreed to as Governmental policy. We well know that the Government policy in relation to mothers and infants service is enshrined in the excellent 1947 Act. Certain difficulties occurred and it did appear understandable that the Minister should pare down those proposals to the extent that they were pared down after the recent White Paper was issued. I understood the Minister's difficulties and was glad to some extent that he had found it possibleto retain the better aspects of the free services envisaged by him and by the Government of which he is a member under the 1947 Act. My difficulty is this. I know that the underlying principle proposed by the Minister and the Government in 1947 in respect of this type of service was that it should be free and that there should be no means test. As I say that principle was vitiated to a certain extent, if not destroyed, by the most recent proposal of the Minister — that is up to this last amendment — the £1 proposal. I must ask whether there are more cogent and more compelling reasons than that given by the Minister —that is, that the £1 contribution is ridiculed by Deputies — before I can accept the very radical departure from the proposals put forward by the Minister here in the form of a White Paper and later in the form of the Health Bill. I move to report progress.

Progress reported; the Committee to sit again.

Dáil Éireann debate - Thursday, 11 Jun 1953

Health Bill, 1952—Committee Stage (Resumed).

Mr. O'Higgins

Dáil Éireann debate -
Thursday, 11 Jun 1953