Dáil Éireann debate -
Wednesday, 17 Jun 1953

Vol. 139 No. 10

Committee on Finance. - Health Bill, 1952—Committee (Resumed).

Dr. Esmonde

When I moved toreport progress I was trying to get a comparison between the number of people who are likely to avail themselves of this scheme in the higher income group and the benefits available to them. In the Minister's speech reported in Volume 139, No. 8, column 1226 he stated:—

"The Statistics Office has given us figures showing that there were 240,000 married women under 44 years of age in the country and the number of births each year for some years back is between 60,000 and 65,000. Taking all the married women it is fairly simple to discover that a child appears every four years. Of course in statistics you must always take the whole lot and average it out in that way."

I agree with that, of course, but the point in this instance is that the amendment with which we are dealing refers only to the upper income group alone. The Minister's statement was not clear as to how many married women are in the upper income group. There are certainly not 240,000 married women in the upper income group. He bases his argument on that fact that if all, or a substantial number, of these people were to join this scheme it would work out at about £4 for each child born and that the scheme would pay for itself. To begin with these 240,000 married women are not in the upper income group, and this amendment does not apply to them at all, although it may from a statistical point of view. Has the Minister any guarantee that any substantial number of people in the upper income group are going to pay £1 per year?

If they are going to pay £1 per year, they, naturally, ask themselves what are they going to get for this £1. So far as I read the section, they are going to get a bed in a public ward. Anybody with a family income of over £600 a year is supposed to be in the upper income group. Take a person with about £700 a year, who wishes to get some benefit from this so-called contributory scheme, as it now is. What benefit are they going to get by subscribing £1 a year? They are going toget the offer of a bed in a public ward and nothing else.

I think it is clear that this scheme was unworkable from the beginning and the more the Minister tries to amend it, the worse it gets. The £1 a year proposal is now being changed to the "appropriate sum" because it dawned on the Minister that £1 a year was not a reasonable contribution. I think the Minister would be better advised to scrap the whole thing and start from a new angle. If he accepted the principle of contributory insurance, he could at least offer to the people something specific and they would know what they were going to get. Anybody contemplating availing of these benefits is supposed to pay £1 a year and for that they get a bed in a public ward. I think I am right in saying that they get a bed in a public ward for a fortnight. What is the use of that? If you have a contributory scheme you pay a certain sum of money and that sum enables the person concerned to receive certain monetary benefits. First of all, you are in a position to know what you are going to be the recipient of, and, secondly— and this is a most important point— you have a free choice. You are getting these monetary benefits and you have a free choice of where you are to go and where you will spend these monetary benefits, providing you spend them in relation to any sickness or maternity necessity that may arise.

I cannot see any sense in the £1 a year scheme and I cannot see that it is going to clarify the position in any way by substituting the "appropriate sum" for that £1. If the pioneers of the scheme pay £1 a year and accept these so-called benefits—I cannot see what the benefits are, actually—the only apparent benefit is a bed in a public word. If only a few of them accept the scheme and the scheme is going to be extended in a few years' time, the position will be that the pioneers of the scheme will be allowed to continue at £1, but if the scheme has not justified itself, the people who come in afterwards on this scheme of "the appropriate sum" will have to pay an inflated price for the losses incurred in the earlier years of the scheme.

I do not know what correspondencethe Minister has had in regard to the scheme, but I can find no enthusiasm whatever for it in the constituency I represent. Quite a lot of people of that income group have asked what they get for this particular contribution of £1. I told them that they get a bed in a public ward and that is all they do get. The benefits that accrue from this scheme as a whole are not really satisfactory. I do not think it is a workable scheme. I think it is an attempt on the part of the Minister to meet several forces of opinion. Perhaps it has been forced on him, but I do not think it is going to pay for itself. We have absolutely no guarantee that it is. I do not think that the statement which I quoted here and which the Minister made last Thursday, really does clarify the position so far as this amendment is concerned because it deals with the problem as a whole.

As Deputy McGilligan pointed out, people in the higher income group would comprise those who have more than £600 a year and £600 a year has now a purchasing power of only £240 as compared with pre-war days. I am quite satisfied that not every one of these people will join the scheme; I would say that not more than 20 per cent. of them will join it but, even if they did, I do not think this arrangement is at all practicable. I am quite satisfied that there are many people who find it a considerable hardship to pay the fees attendant on maternity cases, but if we are going to assist them—and we are just as willing to assist them as Fianna Fáil or any of the other Parties who want a free-for-all scheme—let us have something sensible and something practicable and not a scheme that experience will show confers no benefit on anybody whatsoever.

Mr. Morrissey

I want to ask the Minister a question arising out of his speech. The Minister did say something about fixing a maximum contribution of £2. Was that for some service in addition to what is set out here in sub-section (1) Section 15 or to cover some service which it was originally intended to cover by the £1 set out in the section itself? It seems tome, speaking with all the hesitancy of a layman, that under sub-section (1) we are offering so to speak to provide medical, surgical, midwifery, hospital and specialist services for whatever the period may be and, I take it, it is quite possible the period may vary. That does strike me as a layman as being very strange. I cannot understand how if all those services are required they can be provided for anything like a cost of £8. Frankly, I cannot see how all these services, or even a number of them, set out in the sub-section can be provided and the full cost of them covered by a figure like £8. It is very hard to accept that as being a fact. The Minister says he is suggesting substituting a maximum of £2 in amendment No. 20. I do not think that helps the situation at all, and, if I may say so, I do not think it makes the position any easier for those who take a particular stand for reasons different from ours on this side of the House.

Dr. Ryan

I said I was convinced that £1 was in or about the proper figure. It may be a bit more. At any rate, in order to allay the fears of some Deputies, who said it might be £25 eventually, I said we would put a limit of £2 on it. I should have said, of course, that there is great stress being laid on hospitals, public wards and so on. From the beginning I have been trying to stress as far as I can in this Bill that I expect most people will have their babies at home, and it will be a case of domiciliary treatment. Only in some cases will they have to go to hospital. As far as public wards are concerned, we can discuss that matter when we come to amendment No. 45. It is provided there that if any person elects to choose her own hospital she will get a subvention of so much per week.

Mr. Morrissey

I am obliged to the Minister for making that point because I had overlooked it. Again, it does seem to me that if medical, surgical, midwifery and specialist services have to be supplied in the home and not in the hospital, instead of being cheaper they will be much more costly.

Dr. Ryan

They may be.

Mr. Morrissey

Frankly, I cannot see how those services could possibly be provided at an average cost of £8 per year.

Dr. Ryan

We are talking about the average.

Mr. Morrissey

We must talk about the average. There will be simple cases and there will be difficult cases. There will be cases where no surgical treatment will be required. Taking the average, with all due respect to the Minister, and to the information and figures he has been given, it seems to me to be an extremely low figure. I do not see how the services can be provided at that figure. That brings me to another point. The Minister says the majority of the women—I am inclined to agree with him on the point—will continue to have their babies at home. I notice that yesterday the Minister said most emphatically that in cases such as that, if medical, or surgical or midwifery treatment was required there would be a free choice of doctors. The Minister knows that is not possible in our present circumstances. It is not fair to mislead. In rural Ireland in present circumstances it is not possible to give a free choice of doctor.

Dr. Ryan

It is.

Mr. Morrissey

If it were possible, would that not be another factor in increasing the cost? The Minister's figures, so far as they can be measured at the moment are based on the present cost in hospitals of giving this treatment or treatment akin to it to those who are at present entitled to that treatment free of charge. If the majority of women elect to stay at home it seems to me it will be utterly impossible to implement the scheme and we will only be fooling ourselves in accepting the suggestion that the services set out here can be made available and given for a sum of £8 per year. I do not believe there is a medical man in the House, including the Minister, who as a result of his own experience believes that can be done.

Mr. McGilligan

I would like a little further clarification. Section 15 deals. in totowith medical care for mothers. There is a sidenote which does not really count. Sub-section (1) says:—

"A health authority shall, in accordance with regulations, make available, without charge, medical, surgical, midwifery, hospital and specialist services for attendance to the health of women ... in respect of motherhood."

All this is confined to either medical, surgical, midwifery, hospital or specialist services in relation to child bearing. For that there is to be an insurance scheme for the higher income group, but Section 14 is still in the background with regard to institutional services for care other than that in respect of motherhood, and there is a charge in that connection of 42/- per week or 6/- per day. The position is that if a woman develops some abdominal trouble and goes into hospital for, let us say, an appendix operation, if she is in the middle income group she goes into the public ward and she, or someone on her behalf, must pay at the rate of 6/- per day or 42/- per week. If the trouble turns out to be childbirth, if she is in the higher income group, she comes in under this insurance scheme. But amendment No. 45 changes that situation. This has all to be taken in relation to the public ward in an institution. As I understand amendment No. 45, it means that if a person is going to be treated elsewhere than in the public ward of one of the ordinary public hospitals then a grant equal, so to speak, to the cost associated with the public ward will be made in respect of that person if it is a question of motherhood or institutional services of the kind set out. Let us know where we are in respect of what used to be called the free-for-all no payment by anybody type of scheme. That was the slogan up and down the country. There will now be payments. There are going to be payments in the institutions. There are going to be contributions towards an insurance scheme. In addition to that, it is understood that the local authority will have to increase the rates by 2/-. Over and above all that, we have decided to make thepeople's food dearer so that they can get better health, if anyone can imagine that happening, on dearer food which means less food. If the people on less or dearer food get ill, their treatment will depend on the class they fall into.

If they are completely destitute they will get free treatment in the public ward. Those in the middle income group will get institutional service at 6/-. If it is in respect of motherhood they will get maternity service on the insurance principle. That is the situation we have at the moment. We have cut subsidies in order to get something in substitution for the public ward system.

Dr. Esmonde

Does this contribution of £8 provide anything towards domiciliary treatment?

Dr. Ryan

Of course it does. That is what it is meant for.

Dr. Esmonde

The Minister made no statement.

Dr. Ryan

Have I got to make a statement again? I have already made the statement three times. What statement does the Deputy want me to make?

Dr. Esmonde

Would the Minister like to make a statement on it?

Dr. Ryan

I do not know whether the Deputy is as green as he pretends. On Second Reading I said I could not say what it was going to cost. I have to see the doctors. How could I be expected to say what the doctors will work for? I have to see the doctors. I expect that on the average we should be able to do it for £8.

Dr. Esmonde

Could the Minister clarify that? Could he give us a hypothetical bill of costs? After all, the Minister stated that it is only going to cost £8. Would he clarify that for us? It is very easy to say it is only going to cost £8. Could the Minister give us one hypothetical case and a rough idea of the expenses and work it out on that basis? The information we have had is extremely limited.

Dr. Ryan

It is as much as you will get.

Amendment No. 20, by leave, withdrawn.

Amendment No. 21 not moved.

Dr. Ryan

I move amendment No. 22:—

To add to the section the following sub-section:—

(4) Regulations shall provide that any woman entitled to receive medical services under this section may receive them from such registered medical practitioner who has entered into an agreement with the health authority for the provision of those services and who is willing to accept her as a patient as she may choose.

I was assured when we sent this Bill to the draftsman for drafting that he would make provision for a choice of doctor in the case of maternity. The Bill came back with Section 15 as drafted. We were assured that that provided for the choice of doctor. On a previous occasion it was explained that it did not appear to be as evident as it might be that the choice of doctor was provided for. This amendment is put in to make it abundantly clear that the local authority is expected to provide for a choice of doctor in the case of maternity when drawing up the scheme. There was a similar amendment in the names of Deputy Norton and Deputy Corish directed towards this end also.

Mr. McGilligan

The amendment in the names of Deputies Norton and Corish provided for the obtaining by a woman of such services in her own home.

Dr. Ryan

This amendment has the same effect.

Mr. McGilligan

Where is that?

Dr. Ryan

I do not know. If I ask the draftsman to give me a certain thing he gives it to me in certain words. Perhaps, it may not be necessary in their own homes.

Mr. Morrissey

I would like the Minister to tell us whether this provision in regard to the choice of doctor can, in fact, be made effective at all, or whether we are just purporting to put something into a Bill which, so far as the greater part of the country isconcerned, is just, to put it bluntly, eyewash. There may be a two-fold obstacle to giving this choice of doctor. First and foremost, the doctor who is prepared to operate this Bill must register. From what we read in the newspapers we know that certain doctors will not register to operate this scheme. In fact, we are told that the majority of them will not register to operate the scheme. If the majority, or even all of them, agree to register and work under the scheme, I want to repeat again that in my opinion in the greater part of this country, particularly throughout rural Ireland and in the more backward areas, it is just not possible to give that choice because the choice is not there. I think the Minister himself knows that much better than I do.

I think the Minister is not being really fair to the House or even to himself in moving this important amendment which is a very important part of this Bill by merely referring to the technical side from the drafting point of view. I think the Minister ought to tell us what are his hopes of being able to make this part of the Bill effective or to what extent it can be made effective, or in what areas it can be made effective. There is no use putting something into a piece of legislation which can only operate in part over the whole country, if it can do that, or can only operate in part or in full in certain areas of the country. Provided they register you could then get that choice of doctor in the big centres of population where you have a number of doctors. In the remote and rural areas you cannot get that choice.

Dr. Ryan

I do not fully agree with the Deputy. More than half the population live in cities and towns where the choice of doctor will be availed of. I suppose the other half would be living within easy reach of cities and towns where they can have the choice. When I was young and in a town I had a practice within a radius of 14 miles. If a radius of 14 miles is taken in by most of the cities and towns, there is not very much of the country left where there is no choice. Theremay be certain parts where it will be difficult to have choice. But even in that case I think it is possible for a woman who is very anxious to avoid the doctor to stay with her mother or sister when another doctor would look after her even if she does not go to the hospital. The great majority will have the choice of doctor. I realise that there are many who are satisfied with the dispensary doctor and will not look for anybody else.

Mr. Kyne

Would the Minister indicate if he would take amendment No. 23 with amendment No. 22? I will be moving amendment No. 23. In that amendment the words "obtain such services in her own home" are included. We attach particular importance to that. If those two amendments were taken jointly the two could be covered and would save time.

Mr. Morrissey

The point made by the Minister seems to me to add weight to what I have already said. Let us assume that what the Minister has now said is correct, that a doctor in a town can reasonably cover an area within a radius of 14 miles from that town. Is that going to fit into the £8 cost?

Dr. Ryan

He only got £1 for doing it at that time.

Mr. Morrissey

I am talking about the present time. The Minister will agree with me that it would be unreasonable to ask a doctor to travel 14 miles maybe up the side of a mountain.

Dr. Ryan

He need not do it if he does not want to.

Mr. Morrissey

With all respect to the Minister, that is not an answer to my question.

Mr. Morrissey

With all respect to the Minister that is not an answer to my question.

Dr. Ryan

He is not compelled to.

Mr. Morrissey

The Minister said a moment ago that he could not be expected to give the cost as he did not know what he would have to pay the doctors. There is no use in the Minister taking that line. Take the case where a doctor has to travel 14 miles fromhis own home to attend a patient. Surely, he is entitled to reasonable remuneration for doing that. He cannot walk there and back. He must either take his own car or hire a car. I want to put it to the Minister that the person who is living in a remote area in this country is fortunate to be within reasonable reach of one doctor, but very often she is not within reasonable reach of a midwife. May I also venture to say that the person living in such an area is probably in more need of medical as well as midwifery attention than the person who is living close to a town or a hospital? Speaking from my knowledge of the country, it seems to me that this section cannot be operated in respect to more than 50 per cent. of the people who may wish to take advantage of it.

Dr. Browne

I do not quite know what Deputy Morrissey has in mind in pressing the point that there will not be a choice of doctor. If he is anxious that there should be a choice of doctor, I am in complete accord with him. I do not think anyone can gainsay the fact that this Bill does greatly improve the position of the mother who is at present benefiting under the dispensary system. She has now no choice of doctor, even if there is more than one doctor in the area.

I think this scheme is one that is going to improve health services, and I am sure the Minister means that there will be a free choice of doctor where that is possible. That may not be possible in areas such as those referred to by Deputy Morrissey, but the important point is that it will be possible in the great majority of the population areas, the cities, the towns and the villages. As regards the mountainy areas, naturally, the Minister can do nothing there except he was to force doctors to go and live in the mountains which, obviously, would be an unthinkable proposition.

There is no doubt at all that the free choice of doctor is being extended very considerably—not to 100 per cent. perhaps—by virtue of the fact that in the cities and towns and in most of the villages there will be a fair choice of doctors. As far as I am concerned, this is an advance on the system whichI have so often deprecated, and which exists at the moment—the dispensary system under which the mother in the lower income group has no choice of doctor. If we are making an advance on that, and, personally I think this is a substantial advance, then I think the Minister is to be congratulated.

With regard to the Labour amendment, I do not see how it can be read into the Minister's amendment that it is only in a hospital an intending mother can be treated. I think the Minister's amendment clarifies the point that she will have free choice of doctor. The doctor, naturally, will not be ordered to treat all intending mothers in hospital. If that were so, it would mean the end of the general practitioner service. It would mean that a ridiculous situation had developed if it were suggested that the only service available to intending mothers was that which was provided in the hospitals. It is implied that the mother, once she is eligible for the service of a doctor, will decide herself where she is to give birth to her child. She is then covered by the scheme.

General Mulcahy

In cases where there is power to have a choice, and in which institutional treatment is required, I should like to know from the Minister in what type of institution in any particular county health area will maternity work be carried out? You have in these areas a county hospital and a district hospital. I take it that a certain number of beds is set aside in every district hospital for maternity cases. Let us assume that in a small urban district there is a district hospital which was formerly held by the local dispensary doctor. The Minister knows that the Department has, in many cases, insisted on a separate appointment being made to the district hospital and a separate appointment to the dispensary. In that case, you have at least two doctors. There are urban areas of that kind. As well as the doctor appointed to the dispensary you also have a doctor appointed to the district hospital with perhaps one or two other doctors also available.

In that situation, let us take thecase of a person who desires to have choice of doctor and requires institutional treatment. Will the dispensary doctor, who at present is kept out of the district hospital, have access to that institution if his patient requires institutional treatment? Suppose there is a general practitioner in the area and a patient of his requires institutional treatment, will he have access to the district hospital for the purpose of attending and treating his patient?

Mr. Kyne

I am glad that the Minister has seen fit to submit an amendment to cover the amendment that was put in, prior to his doing so, by Deputies Norton and Corish. I wish I could be as confident as Deputy Dr. Browne that what is implied in any Act of legislation will automatically become law. We want the thing to be beyond any question of doubt that if a woman chooses to receive attention in her own home she automatically qualifies for choice. If the Minister gives that assurance I will be satisfied with it, but I might say that at the time we put in our amendment the Minister had not then indicated that he was going to give a choice of doctor at all. I am very glad to see that he has now come round to our view. I am at one with what Deputy Dr. Browne says in connection with the choice. It may be restricted somewhat, as Deputy Morrissey says, although I think Deputy Morrissey has slightly exaggerated that.

There is the point that a working man is often willing to pay to come into the village or nearest town to put his wife in a home where she will even get a certain amount of refund of the price of the medical services given should that home or the doctor in charge of that home accept the conditions. The question of choice will, I hope, be extended some time when more doctors will be persuaded to come in to work under the scheme, if that point ever arrives, but the Labour Party have all the time in view the fact that even in amending this Health Bill we must have in the back of our mind that at some time some sane Government will get together and deal with the Medical Association and try to get the Medical Association toaccept a health scheme and to work a health scheme, because we feel that, no matter what we do, it is madness to be trying to fight against the people who administer the actual essential services of the scheme; you just will not make the scheme work successfully. We must look to the future and hope that at some time the scheme will be worked with the goodwill of the medical profession. We want to make the scheme as broad as we can make it at the present moment.

Dr. Esmonde

The sentiment behind this amendment is excellent in theory. Whether it is workable in practice or not we do not know. Neither does the Minister know. The Minister has made no agreement with any doctor so far. That is the difficulty. It is all very much in the air. All the different sections and amendments, that such and such is to take place, are very much in the air. I will read out the amendment:—

"To add to the section the following sub-section:—

(4) Regulations shall provide that any woman entitled to receive medical services under this section may receive them from such registered medical practitioner who has entered into an agreement with the health authority for the provision of those services and who is willing to accept her as a patient as she may choose."

The only doctors who have entered into any agreement with the health authority, so far as I know, are the dispensary doctors. As has been brought out very clearly by Deputy Dr. Browne, the position at the moment is that they are at present confined in the choice to the dispensary doctor. The only people with whom the Minister has any agreement are the dispensary doctors. Any of the dispensary doctors that I have spoken to, about this Bill as a whole, do not seem to be too happy. The amendment suggests that there will be a free choice of doctor. That is an admirable sentiment but is it practicable?

It would be all right if the Minister were able to tell us that he had made some agreement or had some constructiveconsultations with members of the profession to work out even the elementary stages. There is no scheme as far as I know and there have been no consultations whatever.

Deputy Mulcahy has made a very good point indeed. The position definitely needs clarification. If any doctor is attending a patient and that patient is transmitted to a hospital, is it the intention of the Minister that the doctor should be able to follow that patient into the hospital and continue the treatment or would that patient, ipso facto,come under the control of the medical officer in the institution? From the amendment we had last week, it is difficult to know what will happen because, apparently, the county manager will control the hospital; he will decide who will go into the hospital; he will decide how they will be treated in the hospital. If I send a patient to a hospital, if I am working the scheme and have a contract with the Minister's Department, do I lose that patient, do I lose my contract, does that contract pass to the hospital doctor?

General Mulcahy

Does the patient lose her choice?

Dr. Esmonde

Does the patient lose her choice? That is the other way of looking at it. I think it is fair to state that in Leinster, as a whole, you probably would have a choice of doctor in the majority of instances, but not a lot. Take the average country town with a population of 3,000 or 4,000. You would probably have a dispensary doctor and you might have another doctor living there who is connected with another dispensary outside, and maybe a local hospital doctor. That is all. You will not have many private practitioners available such as the amendment seems to me to envisage. In bigger towns—Wexford, Sligo, Tralee and such places—you probably would have a choice of doctor. The Minister gets over that by saying that doctors practise within a radius of 14 miles. That is perfectly true. Some good doctors practise within a radius of 20 miles. Deputy Morrissey made a point, and it is a good one, that ifyou are going to have a scheme such as this which is a State contributory scheme, or insurance, how will you pay doctors if they are going to travel that distance? It is all very well to say that there will be free choice of doctor and that that doctor can practise within a radius of 14 miles to attend a patient.

The Minister gets over that by saying that the patient can stay with a relation when she is having a baby. I do not think that covers the point. In Leinster there is a certain choice of doctor in the bigger centres. In some cases in Munster you may have it. I do not know anything about Ulster but in the West of Ireland you will certainly not have free choice of doctor. In some of the sparsely populated areas of the West and in the greater number of places in Connaught there is only one doctor—Deputy McQuillan will bear that out—who covers an area of miles.

Mr. McQuillan

I do not agree with that.

Dr. Esmonde

What about the Gaeltacht or Connemara?

Mr. McQuillan

There is more than the Gaeltacht in the West.

Dr. Esmonde

It covers a big area all the same. Legislation such as this purports to deal with the whole of Ireland and the point I am making is that there are different conditions in different places. Every part of Ireland is different. There is rural Ireland, urban Ireland and sparsely populated areas. I do not think there is free choice of doctor except in some instances.

Of course, the principle behind the amendment is very sound but it would be very difficult for us to judge whether there would be free choice of doctor until the Minister has made some arrangements, outside the doctors who are already in State employment or are employed by the health authorities, such as the dispensary doctors and rate-aided hospital doctors. These are the only doctors, so far as I know, in the scheme.

I take it the Minister intends bythis amendment, which I approve of if it is practicable, to include other doctors. Surely it would not be out of place to ask the Minister to make a statement as to what scheme he has in view, how he will employ these doctors and enable a patient to get a free choice of doctors. I do not think that anything we have had so far has clarified the issue at all.

Dr. Ryan

In reply to Deputy Kyne, I think that the clause as it is is better because, reading the amendment as put down by the Labour Party, it might be interpreted as providing that services would only be given in her own home. I think it is better to leave it an open question.

Mr. Kyne

Does the Minister assure the House that that is so?

Dr. Ryan

I will make sure about it. It is better to leave it alone. Deputy Esmonde said that it is ridiculous for me to say that she might go back to her mother's home. I have known several who went to their mother's house to have babies. It happens sometimes. Sometimes they go to a sister's house. I am not saying they always do it. I am only suggesting that it might happen. I think it should be left an open question. There will be no change so far as the hospitals are concerned. The local authority hospital has its own staff. A doctor who sends a case there does not follow up his case; neither will he under this. In the great majority of cases I expect that a doctor will treat a woman in her own home. He may have to send her to hospital. If he does, she will be in charge of the hospital staff.

In the negotiations with the doctors on this matter it is intended to pay them so much for seeing a case through and a lesser amount if they send a case to hospital. If they send a case to hospital, naturally they will not get so much. I do not think that Deputy Esmonde should repeat that the county managers will direct these hospitals as to who should go in and even control the treatment. As far as I can find out from county managers, and I asked them on more than one occasion, the procedure is that the doctor sends inthe patient. I do not know whether they have any power or not, but no county manager will have the courage to refuse to have any patient sent to a hospital if the doctor wants to send the patient. The county managers do not interfere with the patient going in, neither do they interfere with the treatment.

Deputy Esmonde must have a very poor opinion of the medical profession if he thinks any doctor would be dictated to by a county manager about the treatment of a patient. I have never heard of a doctor who will accept that from a county manager. Then why repeat that the county manager controls the treatment? He does not. He would not be allowed to by the doctors even if he tried, and the Deputy ought to know that.

Deputies have sought information as to the choice of doctor. Having got information, what do they want? Do they want a choice of doctor as far as it goes? If so, the amendment is all right. If the free choice of doctor is not there in certain cases, what is the suggestion? I must say that I cannot see how we can provide a choice of doctor in very sparsely populated areas and I do not think that we would be justified in putting in a second doctor to live beside the dispensary doctor in sparsely populated areas. I do not think Deputies opposite will advocate that either. If they accept the position that we are giving the choice of doctor wherever feasible and just face, if you like, that it cannot be done in other cases, that is all right. If there is any further suggestion to be made, let us hear it.

Mr. McGilligan

The first thing is, what is the limitation imposed, or is there any limitation imposed in the ministerial amendment by defining a registered medical practitioner as one who has entered into an agreement with the health authority for the provision of those services? Why could not that be left out?

Dr. Ryan

We must make an agreement.

Mr. McGilligan

It does not require an agreement. There is an offer which can be accepted by the doctors giving the services. A medical practitionerenters into an agreement with the health authority and that makes the doctor what the Hierarchy call a State doctor.

Dr. Ryan

No.

Mr. McGilligan

What is to be lost by leaving these words out and simply saying that the regulations shall provide that any woman entitled to receive medical services under this section may receive them from such medical practitioner, willing to accept her as a patient, that she may choose? That is a completely free choice of doctor. Anything that prevents, even by a scruple, that completely free choice, is limiting the freedom of choice. I suggest to the Minister that he should leave out the words "who has entered into an agreement with the health authority for the provision of those services and who is willing to accept her as a patient as she may choose" and let it run as I have said. That simply means that under the regulations a capitation grant or fee will be established for the provision of maternity services for a person at home, a further payment to be made if the medical practitioner sends the patient to an institution. The institution will presumably then get the payment. That is what I call free choice of doctor. That free choice is not here.

One of the main objections that the medical association and the Hierarchy have to this scheme is that the limitation to certain people means a limitation of choice. They will not have full freedom of choice. The limitation contained in the words I have quoted means that people are being directed to what is called the State doctor and cannot go anywhere else. It may be that you will get more State doctors under this than under the more severely limited provision that was previously in the legislation, but there is still the limitation. I do not see what is to be lost by cutting out these words.

The second point which the Labour Party were attentive to, and which others would be attentive to, is where a person must enter an institution to get treatment. With regard to Section 14, sub-section (9) provides "specialist services shall not includeophthalmic services and services provided otherwise than in a hospital, convalescent home or home for persons suffering from physical or mental disability shall not be institutional services". As far as Section 14 is concerned, the doctor is not at liberty to treat a patient at home. The patient will have to go to a dispensary or to an institution. That particular provision is met in England where they have provided what is called a mileage grant to enable the registered State doctor to give his services outside the institution by going to the patient's home. Another provision is that, in order to prevent institutions being crowded with people who might like to avail of them and who used to get service at home, they make a charge for maintenance. The tendency here appears to be the other way, to cut out maintenance and make charges for medical attention. I suggest that the English system is better, that by making patients in certain groups pay maintenance charges you keep people out of institutions. They have a choice, but when they go to an institution they pay for maintenance. If they do not go, they get what is called free services. By going to an institution they have some payment added.

The other point included in the Labour amendment is that the patient may get State service in her home, subject only to the advice of her doctor. That is not in Section 15.

It is true that it is not prohibited in Section 15 as it is prohibited under Section 14 because there, the services have to be institutional. But it is open to this: the health authorities are to make these services available but they have to do it in accordance with regulations. What is to prevent a regulation being made following the lines of sub-section (9) of Section 14 and saying these services shall not be made available except in institutions? It is all very easy for the Minister to say here that he intends to have professional services at home, although he veered away from that a moment ago by making an objection that will not stand, that if he is to use the termsthat are in the Labour amendment that might mean the services can only be obtained at home. By no possible means of forced interpretation could that construction be put on it. It quite clearly states these people may obtain these services in their own homes. I suggest this section should be very definitely clarified and, of course, very much improved, and would accord more with Catholic principles if the full freedom of choice were given. I do not see anything at all against having it announced in the terms of the Act itself that the regulations shall not provide, and shall not impose any prohibition against the services being obtained at the patient's home.

Dr. Esmonde

With regard to the remarks of the Minister just now about health authorities and control of the hospitals, the amendment to Section 9 says:—

"The Minister may, by Order made in respect of a specified health institution, direct:—

(a) that institutional services of a specified class shall be given in the institution,

(b) that institutional services of a specified class shall not be given in the institution,

(c) that institutional services shall be given in the institution to a specified class of persons, or

(d) that institutional services shall not be given in the institution to persons of a specified class,

and the health authority maintaining the institution shall comply with the direction."

The health authority would appear to be the county manager. Those four sections there would appear to give the county manager unlimited power to decide who is treated at the hospitals. I think he could counter any order of the doctor—I do not say he would do so—but I think he is empowered to do so. That was the point I was making when the Minister was replying just now.

Dr. ffrench-O'Carroll

It struck me reading the Bill that the domiciliaryservice was not mentioned as much as I would like. If the Minister says there is every intention to develop domiciliary service I would like to hear from the Minister if it is his intention to follow the development of the domiciliary service on the lines that have been done with the medical scheme in England, because it has been a tremendous success. I think it is the outstanding feature of the present service in England. I am sure it is the Minister's view that the delivery of as many babies as possible should be conducted at home. Apart from the fact that it is desirable, it is going to help the hospitals enormously. I would like to know from the Minister if he is thinking of providing the new domiciliary units which they have in England which go out fully equipped to deal with maternity cases. They have gas and air machines, and they are able to get medical services and even specialist services, and this is associated with the provision of nurses, domestic assistance and home help is provided along with the grant.

Mrs. Crowley

I think this is the most valuable part of the whole Bill. It is a matter that I have been pressing for a long time. I know how many women there are who prefer one doctor to another and quite often, though they can ill afford it, they will pay for a doctor who is not a dispensary doctor when having their babies. I would ask the Minister whether this arrangement should be run on county lines or whether, for instance, somebody living on the border between one county and another could avail of the services of a doctor in the other county; or must they only keep to the doctor in the county in which they are living? I think if they could avail of another doctor it would give greater freedom of choice. I think in most counties there is good freedom of choice and any town of any size would have certainly two or three doctors. Now that cars are so plentiful it is quite easy for a doctor to travel 14 or 15 miles. After all, that is only 28 miles of a journey—just one gallon of petrol. It would not be very expensive and cars are fast nowadays. I do not see it would add very much to the cost. Iwould like the Minister to answer that question because it is rather important.

Dr. Ryan

With regard to the domiciliary services, it is naturally intended to develop it as far as possible for two very good reasons. First, it will be cheaper and, secondly, there would not be enough hospital accommodation if all these women were to use it. It must be encouraged, and there is no doubt about that. What type of service we can provide is another matter. Deputy Dr. ffrench-O'Carroll, I am sure, knows that at the moment all we can offer is that if the woman chooses her doctor he will look after her as he looks after his patients at the moment. I do not think we could have that type of service mentioned by Deputy Dr. ffrench-O'Carroll because we have not got the State service of sending along all this equipment. These doctors will be private practitioners so far as the scheme is concerned and will have to provide their own equipment and make their own arrangements, and look after patients in their own way.

Deputy McGilligan said there was no necessity to make an agreement. There is. First we have to make sure that where a woman enters into an arrangement with a doctor for the time of confinement that he does actually look after her and that he cannot draw money without seeing her at all. In other words, he must visit the woman before and after the birth. It is also necessary to know what doctors are entering on this panel as we call it because it may happen—and probably will happen in many cases— that a woman may make inquiries through the local authority what doctors are available so that she can make her own choice. Therefore, for two reasons we must have doctors on this panel and they must make the agreement. I cannot see how that limits the choice of the patients. If the doctor is willing to take on the patient then she has a choice under the scheme amongst the doctors who are willing to take her on. I cannot see how it makes any limitation in the choice.

Mr. Morrissey

What about Deputy Mrs. Crowley's point? Is the patient confined to the county health district?

Dr. Ryan

Obviously there will be no limitation, if the woman can choose any doctor she likes.

Mr. McGilligan

No.

Dr. Ryan

Yes, I say. She can choose any doctor she likes.

Captain Cowan

If the doctor has entered into an agreement with the health authority.

Mr. McGilligan

The agreement only requires that a particular doctor shall attend in a particular maternity case. A lady might make inquiries as to who would attend her and suppose the local authority says that they are not in a position to tell her that a particular doctor will attend her——

Dr. Ryan

How can they know that unless the doctors say they will?

Mr. McGilligan

If a doctor beforehand is not going to say so, he is out. Supposing there are a group of doctors and a woman is approaching childbirth and she wants to know who will attend her, and the local authority says that she must receive medical services from a doctor who has entered into an agreement with them. Is that not an obvious situation?

Captain Cowan

Suppose he started and then stopped?

Mr. McGilligan

What is the good of supposing these fictitious bits of nonsense? Suppose a man joins the scheme, can he not pull out of it also?

Captain Cowan

He must complete the agreement.

Mr. McGilligan

The agreement is the agreement he makes with the health authority and he has to send in his bill with proof that he attended at a certain time. If this limitation is imposed on people, that they must have made an agreement with the health authority, the reason is that the Minister wants to get so many people into what is called a State service. The Minister in reply to Deputy Dr. Esmonde said that theDeputy must have a very poor opinion of the medical man who would submit to dictation from the county manager. I understand that at a recent meeting of the Health Council a statement was made that the county manager might have a very delicate and difficult task in deciding what particular institution a patient would be sent to or in saying that one particular hospital should render a specialised type of treatment rather than another and the county manager said he was making that decision every day.

Dr. Ryan

He did not. He said he never made the decision without consulting the county medical officer.

Mr. McGilligan

He said he made the decision every day.

Dr. Ryan

On the advice of the county medical officer.

Mr. McGilligan

He made the decision.

Dr. Ryan

He said that he was told to make it by another person.

Mr. McGilligan

All that we ask is that he must be made to consult the local authority. That is regarded as being more desirable than the present terminology.

Dr. ffrench-O'Carroll

I want to refer again to the question of domiciliary service. I think it is of tremendous importance. I seemed to have conveyed, although I did not mean to, that I was making inquiries about a domiciliary service staffed by State doctors. That is not what I had in mind at all. Basically the essential domiciliary service is a nursing service. I do not see why a domiciliary service should not be available to a patient, while the patient could still choose her own doctor. If the case is an abnormal one, she can choose her specialist, in addition to her own private practitioner. I want to submit that unless a first-class domiciliary service is provided there will be a much greater demand for accommodation for normal cases in a maternity hospital. I think if we are going to operate this scheme successfully from the beginning, it is essential that, asfar as possible, only abnormal cases should be dealt with in the maternity hospitals, and unless the intention is to have a first-class domiciliary service, you will have a frightful number of cases going into the maternity hospitals when it should not be necessary for them to go there.

Mr. Morrissey

I asked the Minister for information on a point arising out of a question asked by Deputy Mrs. Crowley. The Minister said in reply to Deputy Mrs. Crowley that a patient would not be confined to a selection of doctors within the area of her own county health authority. The Minister said there would be a free choice from outside. At the same time we are saying here that a doctor must enter into a contract or agreement with the health authority. If a patient goes over the border to get a doctor whom she may prefer, obviously he will not necessarily have entered into an agreement with the health authority functioning within the area within which the patient resides.

Dr. Ryan

He can attend the case immediately because as far as these regulations will go—I do not know whether the regulations can change the fundamental principle or not—any doctor who says to the local authority: "I am going on the panel," can attend the case. That is sufficient. He must sign the form, but all he need say is: "I am accepting the conditions, and I want to be put on your panel."

Mr. Morrissey

I just want to get this clear. Can a doctor living, say in Loughlinstown, enter into a contract with the health authority in County Wicklow?

Dr. Ryan

Yes.

Mr. McGilligan

It does not say any health authority. It says the health authority.

Mr. Morrissey

Is he not bound to enter into a contract?

Dr. Ryan

There is nothing in it about the county.

Mr. McGilligan

It says the health authority.

Mr. Morrissey

The health authority means the health authority within the administrative county. I am making the point: what is the position of a patient who selects a doctor from outside the county administrative area? He will have a contract with the health authority in his own county but does that enable him to provide a service in an adjoining county over the border with which he has no contract?

Dr. Ryan

I do not see how any difficulty would arise because a doctor who wants to take on these patients would naturally fix up with his own health authority. If by any chance a woman came from another county and said she wanted to stay with her mother and that she wanted to be attended by the local doctor, he need only write and send back the form to be registered in the other county.

Captain Cowan

As far as Deputy Morrissey is concerned it is no use giving him an assurance. The Minister has made it as clear as a pikestaff, that a particular woman can have these services whether the doctor lives in her county or not. If you have a doctor living on the border of a county he is not going to confine his private practice to his own county. At least I do not suppose that even Deputy Morrissey would compel a doctor to do that.

Mr. Morrissey

We are not talking about private practice. The Deputy does not know what he is talking about.

Captain Cowan

You cannot confine a doctor in his private practice.

Mr. Morrissey

The Deputy does not know what he is talking about.

Captain Cowan

Deputy Morrissey does not even want the Minister to give an assurance that he has given in answer to Deputy Mrs. Crowley. I say that Deputy Morrissey could not stop a doctor from going into a county adjoining that in which the doctor lives and carries on his private practice.

That doctor can enter into a contractor agreement to provide services not only for one county but for several counties. If he practises in these counties there is no trouble whatever about that unless Deputy Morrissey wants to make out that cannot be done. Of course, it can be done and the Minister says clearly the system of choice is not confined to the county. That is a very clear statement. Deputy Morrissey does not want to accept it; he wants to create the usual obstruction.

Deputy McGilligan was very anxious about these agreements—the doctors should not enter into agreements. Of course, they should enter into agreements. They should enter into a definite contract with the health authority. Then this House would know how many doctors would be available to provide the services proposed under this Bill. When such an agreement is entered into by a doctor I am perfectly certain that under the terms of that agreement he will be required to give a certain amount of notice before he terminates the agreement and he will be morally and legally bound to carry on in accordance with the agreement until such time as he tenders notice of his intention not to continue. That in itself will be a guarantee to mothers that they will have available to them the services for which the doctors will be paid under the provisions of this Bill. That ought to be clear to Deputy McGilligan. It is clear.

Mr. McGilligan

If you say so, it must be.

Captain Cowan

It must be perfectly clear to Deputy McGilligan.

Mr. McGilligan

If you say it three times, it will be very clear.

Captain Cowan

That makes it clearer still. I agree with the view expressed by Deputy Dr. ffrench-O'Carroll in relation to these domiciliary services. There ought to be travelling hospitals in the city areas—indeed, I would like to see the service extended to the rural areas too—properly equipped for dealing with difficult cases where the doctor and the nursefind themselves confronted with unanticipated difficulties. There should be no trouble in providing such a service in the cities. I am sure they could be extended to the rural areas without much difficulty. Such a service exists in London and has proved very satisfactory. It has resulted in the saving of many lives. I hope that when this Bill comes into operation it will be possible to provide this type of ambulance service with first-class equipment and specialists that can be called out on receipt of an emergency telephone call to the appropriate hospital.

Mr. Morrissey

Notwithstanding that very nice piece of nonsense from Deputy Cowan on the point I am raising, I want to draw the attention of the Minister and the House, and even the attention of Deputy Cowan— though he might read the amendment——

Captain Cowan

I have read it and I understand it.

Mr. Morrissey

Then the Deputy ought to speak what he understands.

"Regulations shall provide that any woman entitled to receive medical services under this section may receive them from such registered medical practitioner who has entered into an agreement with the health authority for the provision of those services and who is willing to accept her as a patient as she may choose."

"Who has entered into an agreement with the health authority": that definitely and specifically pins that to an agreement with the authority within the county administrative area.

Dr. Ryan

Yes.

Mr. Morrissey

Of course, Deputy Cowan has an advantage over me inasmuch as he is able to put a legal interpretation on it. I only understand ordinary plain English.

Captain Cowan

The Deputy understands the difficulties.

Mr. Morrissey

I want to get from the Minister, not from the gentlemanwho wants to pose, not only as Minister for Health but as Minister for everything else in this House, an interpretation of this: "who has entered into an agreement with the health authority" means a doctor who had entered into an agreement with the health authority within the county administrative area. Unless, for example, a doctor living in Wicklow has also entered into an agreement with the public health authority of Dublin County, he cannot attend a patient or be paid for attending a patient resident in County Dublin. Surely that is clear. I want to hear the Minister on that.

Dr. Ryan

I must admit I cannot see the Deputy's point at all. The section says a health authority. If you like, any health authority shall provide these services. Then sub-section (4) says: "shall provide that any woman entitled to receive medical services under this section may receive them from such registered medical practitioner". There is nothing about any county there.

Mr. Morrissey

But it must be a practitioner who has entered into an agreement with the health authority.

Dr. Ryan

If he has entered into an agreement, then it is all right. For instance, a doctor living in Dublin may have a patient in Sligo. He can write to the Sligo manager and ask him to send on an agreement stating that he wants to join. There is no difficulty about that.

Mr. Morrissey

But he must enter into an agreement with the health authority in the county in which the patient lives.

Dr. Ryan

He must, but there is no trouble about that.

Mr. Morrissey

That is the very opposite to what Deputy Cowan said a moment ago.

Captain Cowan

It is not.

Mr. McGilligan

What is the objection to saying: "has entered into an agreement with a health authority or any health authority"?

Dr. Ryan

It is not necessary.

Mr. McGilligan

It would clear up the doubt.

Dr. Ryan

It is all right as it is.

Mr. McGilligan

The health authority is the opening phrase in Section 15. I turn to the 1947 Act to see what a health authority is. It is the council of a county or a corporation of a county borough. Let me interpose here the first phrase—a council of a county. Transpose that into this section and it reads: "A council of a county shall make available medical, surgical etc., treatment in accordance with regulations." The regulations may so provide that any woman entitled to receive medical services under this section will receive such from the council of the county. Surely it is the same council of a county. In other words, it is a county council. A county council shall make available certain services and the regulations under which these services are made available are to provide that the patient may receive them from such registered medical practitioner as entered into an agreement with the council of the county. It is quite clear that it is tied down to one council. At any rate, whether it is clear or not, would not the whole difficulty be obliterated—if there is a difficulty—by saying "enter into an agreement with a health authority or with any health authority"?

Captain Cowan

With the health authority.

Mr. McGilligan

The health authority ties it to a particular authority in a particular county.

Dr. Ryan

If I put in "any health authority" does not that mean that if a doctor has an agreement with Sligo he can be taken over by a person in Mayo and be paid? That would not work at all.

Mr. McGilligan

That is what Mrs. Crowley was at. Let us have the matter considered moderately.

Dr. Ryan

That case is not ever likely to happen.

Mr. McGilligan

Take what might happen——

Dr. Ryan

Take the thing seriously.

Mr. McGilligan

——to a patient in Kerry on the borders as between Kerry and Limerick or Cork who might want as the doctor of her choice the doctor in Cork. Why should she not have him?

Dr. Ryan

Certainly.

Mr. McGilligan

It is not allowed here.

Dr. Ryan

It is.

Mr. McGilligan

A moment ago a point was made about the person getting the Sligo doctor.

Dr. Ryan

But you changed. It is all right.

Mr. McGilligan

The matter is not all right and being bad tempered about this is no use. The matter is capable of easy interpretation.

Dr. Ryan

I do not like mischief making in the name of good law.

Mr. McGilligan

I do not know what the mischief is. The mischief is to allow a Cork maternity patient living on the borders of Cork as between Cork and Kerry to get a Kerry doctor. Why should that not happen? If putting in one word means that the patient could look for a Sligo doctor, we could consider the circumstances in which that was likely to happen. The matter is nonsensical and has only to be mentioned in that way to show how ludicrous it is.

Captain Cowan

The Leaderrefers to Deputy McGilligan's “unworthy effort” last week.

Mr. McGilligan

I object to this being limited at all. I do not see why there should have to be any agreement entered into with the health authority or any authority. Why should not the patient be entitled to receive service from such registered medical practitioner who is willing to accept her as a patient, whomsoever she may choose?What is the difficulty about that? I am told that the health authorities ought to know what doctors are available. You might as well suggest a scheme for grocers and that the people who wanted groceries would want to know what shops are open to them. If I want to buy groceries I can go anywhere. That is the type of freedom we want or if I want to buy law, for instance, I could go to Deputy Cowan if I wish to do so. Why have a man enter into an arrangement? I cannot understand that point at all. The other method does give complete freedom of choice.

On the question of domiciliary care, in England the general practitioner service can be given in the patient's home. Here the services under Section 14 are limited to institutional and specialist services. The institutional services are more or less described by the episode that is put to them and the specialist services are not to include ophthalmic services and services provided otherwise than in a hospital, convalescent home or home for persons suffering from physical or mental disability.

It is quite clear where we have departed from the freedom which people have in England so far as the general practitioner is concerned. They have a mileage grant which allows a doctor to go to the patient's home and charge for it. The English system aims at producing good results. In this country where institutional services are not adequate to cope with a very heavy demand, by allowing the practitioner service to be given at home and by making charges for maintenance in the institution an incentive is given to the patient to be treated at home.

With regard to the child service. I put it to the Minister that this suggestion of domiciliary visits does not enter into the legislation. There is no phrase that points towards services being rendered in a home. The Minister said he was aiming at treatment in the institutions and treatment in the public ward of the institutions. That is the slogan the whole time.

Amendement No. 22 put and agreed to.

Amendment No. 23 not moved.

Question proposed: "That Section 15, as amended, stand part of the Bill."

General Mulcahy

On Section 15. We have Section 15 as it stands in the Bill except that one amendment has been put in which implies a choice of doctor, but I do not think we are quite clear yet what really is involved in that. At any rate, it applies only to domiciliary work. In so far as a woman goes into a local institution, whether a county institution or a district institution, the question of choice does not arise. She is dealt with by the official doctor who is appointed to that institution. The section does propose certain services, and I take it that the section from the Minister's point of view is intended to work.

If it is intended to work, then it will cost a certain amount of money to deal with certain classes of persons, and it will require a certain amount of institutional arrangement to carry out that work. It purports to provide for women of all classes in the country who want to come in under it. It covers the persons who are referred to in Section 14, sub-section (2) (a), that is, persons insured under the Social Welfare Act, (b) adult persons whose yearly means are less than £600 and all adult persons mainly deriving their living from farming and whose rateable valuation is not more than £50. I take it that sub-section (2) (d) of Section 14, which says: "Persons not specified in the foregoing paragraphs who, in the opinion of the health authority, would be unable, without undue hardship, to provide institutional and specialist services for themselves or their dependents", covers the public assistance classes. In terms of population, sub-section (d), the public assistance classes, covers 1,000,000 people. In regard to sub-section (2) (c) which covers persons who derive their income from farming and whose rateable valuation is £50 and under, I would like the Minister to give us some idea as to how many persons are involved under that.

An Leas-Cheann Comhairle

The Deputy is talking about Section 14.

General Mulcahy

Section 15 deals with the providing of medical, surgical, midwifery, hospital and specialist services for certain women. Sub-section (2) of Section 15 defines the type of women in respect of whom services are provided under sub-section (1), which reads:—

"The women referred to in sub-section (1) of this section are:

(a) women who are in, or who are dependents of persons in, any of the classes mentioned in sub-section (2) of Section 14 of this Act."

I take it that we are dealing with maternity services for women who belong to any of the classes described in sub-section (2) of Section 14. The Minister has given us certain figures in regard to the number of women of marriageable age and the number of births on which the calculation of cost is based. If the Minister is in a position to give us figures of the number of women of marriageable age who come under these four sections, that is, persons insured under the Social Welfare Act, adult persons of less than £600 income, adult persons who come under the farming heading and persons who come under the home assistance heading, we would be glad to have them.

The only basis to go on for estimating the range of the population in respect of which these services can be required is by taking, in such a scrappy way as we can get them, the figures for the population as a whole. Under sub-section (2), paragraph (d), we have the figure of 1,000,000 as the population. Under Section 2, paragraph (c), that is farming, the only information I can lay my hands on handily relates to the number of people who occupy farms with valuations not exceeding £50. That information is contained in a table on page 2 of the Commission of Inquiry Report on Derating. That was published quite a number of years ago, early in the 1930's. The structure of our farming population, in relation to the size of the farms they occupy, with their valuations, does not change very much, so that we have at any rate an approximate figure as to the size of our farming population, or of thewomenfolk who will come under this service. On page 2 of that report on derating it is stated that, out of 378,568 occupiers of farm holdings, 346,689 or 91.5 per cent. occupy holdings with valuations of £50 or under. That means that under Section 15 facilities for domicilary and, where necessary, institutional treatment, will be required under Section 14, paragraph (c) for 91.5 per cent. of the farming population.

Under sub-section (2), paragraph (b), we deal with persons, whose income is £600 or under. I do not know if the Minister can give us figures as to the part of the population that will be covered by that. When we come to sub-section (2), paragraph (a), that is, persons insured under the Social Welfare Act, we find that there are 630,000 persons who are insured under that Act. These are the population figures at the back of the various classes that are referred to in Section 14.

Can the Minister give us any estimate of the cost of applying these services, and, in relation to the cost, can he give us any information as to the percentage of the cases that will be dealt with in institutions? The Minister has already provided figures with regard to the beds available at the present time for maternity cases in the various counties. He gave these figures in reply to a question by Deputy Norton at column 224, Volume 134, No. 2, of the 23rd October last. From that reply we find that in the County Carlow there are only eight maternity beds available in the local authority hospitals; County Cavan only 15; Longford only five; Monaghan only eight; Offaly only eight; Roscommon only ten, and in Waterford County only three. These figures relate to general maternity beds. Can the Minister give us any idea as to whether an estimate is being made as to the number of beds that will be required?

Captain Cowan

Obviously, children are being born every day in these counties.

Mr. Morrissey

Obviously, Deputy Mulcahy is taking the section seriously, but Deputy Cowan is not.

Captain Cowan

Children are being born in all those counties every day.

Mr. Morrissey

There was one too many born.

Captain Cowan

That is certainly high politics.

General Mulcahy

I want to get some kind of an impression in respect to a section about which there has been a considerable amount of discussion. I infer that the Minister considers it should work and hopes to endeavour to make it work. Those who will be looking for services under this section will require very positive and definite attention and treatment. They may get it in a domiciliary way or in an institutional way. I think everything that is being done at the present moment with regard to propagandising health services and institutional services is creating a very definite increased demand for institutional services, particularly for maternity cases. We want to get from the Minister information as to what estimate has been made of the number of people likely to require these services, particularly in the four classes that are mentioned specifically. Can he tell us what the increased cost is likely to be?

We have seen from the Minister's reply to the question asked by Deputy Norton last October that there is a very great dearth of accommodation for maternity cases in most of the local authority hospitals. Therefore, I am asking him whether any estimate has been made as to the increased number of beds that will be required in these areas, whether anything is being done at the moment, whether any progress is being made in the way of additions to these hospitals and what the capital cost of work of that kind is likely to be? I am asking for an estimate of the cost of carrying on these services on the one hand, and for an estimate of the additional capital cost of providing buildings in which to carry on these services on the other, so that we may have some idea of the financial aspects of these proposals.

Mr. Kyne

May I join on behalf of the Labour Party in the appeal of Deputy Dr. ffrench O'Carroll for anextension of domiciliary services for mothers, even to the limited extent of the provision of a nursing service for mothers?

Might I take advantage of this section to ask the Minister if he intends, or to what extent he intends, to improve the conditions and the emoluments of midwives? I think everyone will agree with me that the present position in this country is scandalous, that the most essential service that can be given to a mother by a midwife is carried out for a pittance, carried out usually under terrible conditions and even the provision of a motor-car has to be paid for out of the very small allowance that is given at present. The Minister has made promises to a number of local authorities who view this matter with alarm and who also view with alarm the fact that there are hardly any applicants for vacancies for midwives at present due to the small salary. A number of local authorities, including County Waterford, have already sought sanction to increase the allowances but the Minister has put them off on the plea that this Bill was coming out. I would like the Minister to indicate to what extent he proposes to improve the conditions or, if he foresees a delay in this measure coming into force, would he indicate now if he would give an interim measure of justice to these people?

Dr. Ryan

There are some figures that Deputy Mulcahy has not up to date. The latest figures I could get from some recent issue of the Abstract of Statistics,I think it was—I am not exactly sure but I can look up where I got them—would put the number of farmers on a £50 valuation at 220,256, 88 per cent. of the total number of farmers, and the number of insured people is 679,700, practically 680,000 people. As far as maternity beds are concerned, I gave very full particulars in the Second Reading speech. I do not think we should go into this again at this stage.

General Mulcahy

The Minister appreciates that the position is very inadequate?

Dr. Ryan

No. I showed there that we were in as good a position as England and some of the Scandinavian countries. The Scandinavian countries are very often held up as the best hospitalised countries in the world and, as far as we are concerned, we have at the moment almost as good accommodation and, in the course of a year or so, we will have better, according to our population.

I do not think we could discuss the conditions of employment of midwives at this stage. I prefer to wait for another opportunity.

Mr. McGilligan

This section, 15, is one of the pivotal sections of the proposed legislation and, of course, it is to be welcomed in so far as it gets rid for ever of the harmful Part III of the 1947 legislation which, I take it, this is to be regarded as substituting. However, properly to get the background of this clear again, we have it now determined that this section operates in respect of all three groups. We have it determined that the population of this country may, roughly, be divided into three groups, more or less, of 1,000,000 each. The first is a group of 1,000,000 who are destitute, who are unable by their industry or other lawful means to provide their own essential medical requirements. Now we are told that, under the blessing of a free Government in this country, they amount to one-third of the entire population. The second are the people in the middle-income group. I take the high level of that to be people who are described as having a family income of not more than £600 per year, that is, where you have a man working and, say, a couple of children working, where the entire income coming into the house exceeds £600 a year, then that family is classified as being in that high income group, the highest level that the legislation discussed. The people who are under the £600 or, at least, not above it, are in the middle-income group. The test we take here is the £600, the equivalent of the old £240 in 1939, say, less than £5 per week. These, roughly, are the three groups.

General Mulcahy

How many are in that last one?

Mr. McGilligan

Vaguely, we are told there is about 1,000,000 in each group. That, I think, is only a guess. The 1,000,000 we have put precisely before us are the 1,000,000 in the lowest group.

Speeches that were made in connection with health legislation before drew very vehement statements. One was by a Deputy in this House who said that he would not vote under any circumstances for any amendment to a Health Act which would authorise any Minister to bring into life that which should be dead 50 or 100 years ago, namely, this means test, the pauper law of the red ticket, and all the rest of it. We have got all these things. We have got means tests all over this legislation, and properly so, but we have got, certainly, the pauper law, although we do not call it that any longer; we speak of something about the test under the Public Assistance Act or we speak of destitution, and the red ticket is no longer to be a red ticket; it is to be a white ticket.

General Mulcahy

It has gone back to the red.

Mr. McGilligan

These are the changes which take place in a few days. In any event, the system of the red ticket is still to be with us.

Section 15 gives what are regarded as the most up-to-date proposals in respect of medical care for mothers. We know that an amendment was proposed and discussed here or, at least, a suggestion, or amendment, was proposed and discussed here for a long time. Apparently, there was some more patchwork done upon it but the amendment is to the effect that, instead of this £1, this subterfuge £1, there is to be charged an "appropriate sum".

Mr. Morrissey

It has been withdrawn.

Mr. McGilligan

It has been withdrawn, I understand, to be reinstated, but with a ceiling to it that there may be a £2, charge made instead of a £1. The £1, we are told, being the equivalent of half the cost of the service being provided, on that calculation, £2 would pay the full cost. However, we will see that when it comes.

In any event, the mood has changedand the mood is now that maternity services are to be, for a certain group of the community, based on an insurance scheme. Of course, there again, there is no reason why it should not be completely and entirely an insurance scheme for people who are in the upper-income bracket. I think it should most decidedly be completely and entirely an insurance scheme and, I believe, when the cost of the insurance under a proper scheme would be related to the benefit to be derived under a proper insurance scheme, it would be better than what the Minister is here proposing, which destroys the sort of old free-for-all idea, so far as that is accepted by anybody nowadays, by putting in something that will not be effective and will not be desired by many people, and I do not think will be availed of by many people.

It is to be said with regard to what this substitutes, that that was, of course, defined as being entirely unacceptable to the Hierarchy. On 7th October, 1947, the Hierarchy mentioned their grave disapproval of certain parts of the then recently enacted Health Act of 1947, but particularly Part III, dealing with mother and child services. The point was made that to claim such powers for the public authority, without qualifications, is entirely and directly contrary to Catholic teaching on the rights of the family, the rights of the Church in education, the rights of the medical profession and of voluntary institutions. That was the section—Section 21—under which the health authority was given power, in accordance with regulations made under Section 28, to make arrangements for safeguarding the health of women in expectant motherhood and their education in that respect. That, of course, it was pointed out, could cover such things as whether a woman was to have a baby at all, what treatment she might take either for the event of childbirth or to prevent it, and the question of operations and certain types of operations clearly arose under that and if certain types of operations were to be permitted to be under the control of a health authority.

However, that has gone and insteadof it we get this, Section 15. I am taking Section 15, not as it now stands but with the background, the essential idea which is now being worked in under it, that is, something in the nature of a contributory scheme, an insurance type of scheme. We have it from the Minister as being in touch with Church authorities in the matter that, apparently, the stand they take in this matter is that a contributory scheme is in accordance with principle, a non-contributory scheme for the entire population is not. On that, the Minister says that what the amount of the contribution might have to be in any case was not a matter, of course, for the Church to interfere in, that it was a matter on which they might have views, but that it was a matter for the civil authority to determine, and the determination was the £1 which was derided as a subterfuge, although the Minister may still argue against the application of that term that we will get a more realistic standard from experience over a number of years and that it will be 50 per cent. of the cost of the treatment. That is a step in the right direction.

I mentioned before that as far as I understand Church principles on this matter of a graded subvention according to the means of people what seemed to be desirable was that if that graded subvention is given, then citizens should be allowed to obtain treatment in the hospital of their choice and from a doctor of their choice. Again, we have got a limited advance to that in amendment No. 22, which I think has been passed. Still I think there are certain restrictions in it which are not necessary and that only just a certain amount of vanity prevents the Minister from giving what would be complete freedom to the patient to choose a doctor.

The question of the hospital is a different matter. I do not understand that the choice of hospital has yet been granted. There is still in this legislation authority bestowed on the health authority, which is a lay body, to determine the institutions in which certain treatment is to be given. I donot know whether Section 15 is excepted from that general power of the health authority to regulate the particular institutions in which maternity services are to be provided. So that, far from having a free choice by the patient both of the doctor and the hospital, the contrasting service, which was the one to which the Hierarchy objected, was where citizens were to be compelled, if they took treatment at all, to undergo that treatment in the institutions that a public authority or a public official might decide. Again, I understand the Hierachy's objection was that the public official was a person who was entirely subordinate to the Minister and, therefore, the general objection was that in this part there was at least a section of the general bureaucratised system of the State type. That was definitely objected to.

To clear away these objections one would require: (1) that there would be an insurance scheme, which has been partly accepted; (2) that there would be freedom on the patient's part to choose the doctor, which has been, with some limitation, accepted; (3) that there would be freedom on the part of the patient to choose the institution if it were an institution in which services were given that the patient required. I do not think that these have been granted. The point has been raised that the patient may desire to be treated at home and that the doctor might approve of the treatment being given at home. There is no specific statement that the patient may avail of this treatment at home.

Lastly, there is the background of the public official being a person entirely subordinate to the Minister and the Government. I know that that is in accord with a view held by a member of the Government, the present Minister for Posts and Telegraphs, who boldly came out in favour of paternalistic Government when he said that "paternalistic care of a community by a Civil Service acting on instructions from a Government elected by the people could alone preserve the fundamental freedoms and sanctity of human existence". That is an utterly wrong point of view. It could be, I think, expressed to be apaganised point of view and in accord with the statement already made by people who support such legislation, those who are in charge of the Irish Times.Of course, they told us that in legislation of a health type such as this is, certain Christian principles must inevitably be defeated.

An Leas-Cheann Comhairle

The Minister for Health is not responsible.

Captain Cowan

The Irish Timescriticised the Deputy.

General Mulcahy

You should read it to-day.

Mr. McGilligan

I am speaking of what has been said outside by people who approve of this type of legislation. I do not think anybody in this House should accept that it is necessary to break Christian principles in order to get what is called progress in health legislation. It is completely unnecessary and it is, of course, fundamentally wrong to have any such standard accepted. But the blessing of the people who speak that way has been given to this legislation and, more particularly, to the wilder scheme of a "free-for-all" and the nonsense of "no payment for anybody". That point of view would be put forward by people who have that concept.

Finally, in this particular section, there comes the question of the type of services to be given, more particularly when one considers that part of Section 15 is particularly reserved or supposed to be appropriated to the higher income group. The writer of an article in Studiesof March, 1953, drew attention to that. He asks the question:—

"Will the type of hospital or nursing-home service for mothers be uniform all through where the service is free?"

I ask whether the service is to be paid for at the 6/- a day rate or to be under this type of insurance scheme.

"Is a woman to pay a £1 contribution per year to enjoy the same services as she has already paid for in taxes for less-well-off women to enjoy free? Private rooms, a special nurse, a different type of cooking,general amenities—presumably these will not be supplied free to mothers in the middle income group and to those paying the £1."

This was written when the subterfuge of the £1 had been put into the proposal.

"When our legislators discuss this Bill, will they know in their hearts that they are merely putting up a pretence and a facade of giving all mothers free maternity service? In order to avoid a means test and in order to be able to boast of at least a juridical and formal equality of service, are we going to provide a service of a type which we know many women will be deterred from using for various good reasons?"

Captain Cowan

What is the Deputy quoting from?

Mr. McGilligan

I have already stated that.

"And do we know therefore, that we are compelling these people—and they will be many—to pay twice or possibly three times: once for a service for their poorer fellow citizens; once for the availability of the same service for themselves, which in practice they cannot use; and once for the service they will use. On such doubtful paths of conduct must honourable men walk when they seek the Welfare State."

The Minister has not yet spoken on that point. As I was absent on Thursday, I cannot say whether any change took place. I have not discovered any in the time I have had to investigate the report of that day's proceedings.

Certainly the Minister did boast first of all that he was travelling all the time towards institutional services. He wanted these services provided. There was no talk when he was speaking about care at the home. It was institutional care and all the time he said that the institutions into which people would have to go under this health legislation would be public institutions and the services they would get would be services of a public ward type. If that is still the situation we should be told of it. It is clearly possiblethat the Minister's views may have changed, and are going to be changed by other amendments, but he must have some fairly good idea of where he is going, or is being purshed. Are we to have services, in so far as they are institutional, confined to the public health institutions and is the service to be only one of public ward type?

In England—we refer again to their legislation—they have written into the legislation from the start a type of thing which there is a late effort being made to put forward in amendment No. 45 here. Under it the people were entitled to get on contributions and charges put upon them services of any type they liked to choose, but only certain of them were provided more or less free in return for contributions which they made. But they could go anywhere for those services—to a private home, public hospital or semiprivate hospital—and give a contribution to get that treatment that the person desired. The service would not be entirely paid for but only some appropriate part which would be measured by the charge imposed on the person. If these improvements could be made, then, of course, we have a piece of health legislation which goes away from the so-called welfare State business and gets more nearly to the proper ideal.

I do suggest that the proper ideal would be if we could reconstruct society so as to have people obtaining so much for the services they render to the public in the different walks of life that they would be able to provide for the services they need out of their emoluments. That I think is the proper idea, especially for a small community like ours—that people be better paid and allowed to spend their own money as they like. It is not possible to reconstruct society all at once and therefore, some type of service has to be made as an emergency one. That could be met in a sort of scheme of sliding arrangements for people as they grow better off, or are helped to be better off, until they can maintain those services themselves.

Again there are certain people who —by being handicapped in certain ways —will not be able, through the servicesthey render to the community, to earn enough to provide what is considered necessary for them in the way of education, sometimes of food, and lastly, in the way of health. It is even suggested that people who might have enough money are not always provident people and cannot be relied upon to make the provision which their means allows them to make and you must have regard to those. Those are people who can be met, not by this over-all business of levelling down to get a kind of egalitarian scheme, but on the lowest possible level. That, I suggest is not the proper approach.

Finally, in regard to the cost, we now have a system of charges, and certain people will have what is called free services. They will pay for them in the end of course. They are already paying for them. Deputies voted to give them dearer food so that moneys could be put in cold-storage to give services of this type. Certain other people are being asked to pay certain sums of money with a ceiling of 6/- a day, and whether they will get some treatment for lesser rates will depend on local authorities. In one county a person may be charged 6/- a day and another person may get off in another county for 2/6.

I suppose it will mean that in poorer counties it will be 6/- a day, because such counties will not be able to afford it at a lesser rate, but in good counties where the land is good and where people's properties are valued better and more money comes in from the rates, then the rates will be able to afford better services at a lesser charge. You will have the reverse happening to what would be the ideal. The people who are living in the more impoverished counties will pay the full rate and people living in good surroundings will pay less, and that will be at the disposal—not of the Government, nor the Minister—but of the local authority, the county manager, who in these counties is a layman, and will not have any real outlook in medical matters. He may take advice about treatment to be given from the medical officer, but the decision in the end is with the county manager.

In addition to that, there is to be a charge by way of the appropriatesum for taking out an insurance policy for people in certain groups, and we have been promised that this is going to cost an average 2/- extra on rates. So you have cut subsidies on food; you have 2/- on rates, 6/- a day charged for certain people, and that is all to get treatment in the public wards.

Dr. Ryan

How many times did the Deputy make the same type of speech? Is it not shameful obstruction? He has repeated it about six times.

Mr. Morrissey

A very good speech. I am sure the Minister knows a lot more now than he did when he started.

Dr. Ryan

I do not know much more.

Mr. McGilligan

Whether you are learning or not, your education is proceeding.

Dr. Ryan

I do not want any education in scoundrelism.

Captain Cowan

Deputy McGilligan said he was not against the Bill on the Second Reading.

Dr. Browne

My feeling listening to Deputy McGilligan was that it was a perfect example of my description of our progress of dragging these people —the McGilligans—kicking and squealing into the 20th century. We heard the squealing to-night, but fortunately it is not going materially to affect the passage of the Bill. I was only interested in one aspect—a poisonous reference made by Deputy McGilligan in relation to the inter-Party scheme considered and accepted by him as proved by the Minister here recently, in which he left the impression—on my mind at any rate—that under that scheme it was intended that legal abortion operations, contraception and other objectionable practices were intended to be introduced and carried out. The Deputy knows them to be untrue. Every hint or suggestion of that kind is completely untrue. He is being, in his suggestion or in leaving that impression on anybody's mind— he certainly left it on my mind—unfair to his colleagues who, I think, to a man, would repudiate the suggestionthat they would be prepared to stand over any such thing. From Deputy Costello, the former Taoiseach, down to Deputy MacBride, I think they would all have repudiated it. Certainly any such suggestion would be, and still is, completely contrary to any of the moral teachings which I, myself, accepted in regard to these matters. Again he is being unfair to the vast majority of members of the Irish medical profession who operate our health services in suggesting that a mother and child scheme would have compelled them to carry out any such objectionable practices, practices which must be objectionable to their religious principles.

Finally, Deputy McGilligan impugns the integrity, the honesty and the high moral standing and beliefs of the vast majority of the mothers of Ireland in suggesting that under any Government scheme, or under any conditions, they would acquiesce in the introduction or carrying on of such practices.

I am not going again to enter into the details of Deputy McGilligan's part in considering, accepting and providing money for that scheme, for all its implications and all the different points it contained. I merely want again to reiterate clearly and unequivocally that there was no such suggestion. The purpose which I had in mind, which the Department of Health and all the officials concerned had in mind, was that we might help to educate mothers at the time of motherhood in relation to such simple matters of hygiene as were recommended by the commission of which Dr. McQuaid, the Archbishop of Dublin, was a member—to educate young mothers before and during maternity in relation to exercises which they should take and other purely medical matters that arise at that time. I want to conclude on that point and to make it quite clear because this suggestion was part of the whispering campaign carried on mainly by my opponents over the years. That suggestion is a foul suggestion, a malicious suggestion and a thoroughly dishonest suggestion, completely worthy of Deputy McGilligan's record during the major part of his political life as I have either known of it or read it.

Mr. Morrissey

Deputy Dr. Browne has put up a skittle for the purpose of knocking it down. I understood Deputy McGilligan to quote from a letter of the Hierarchy of October, 1947, referring to the 1947 Health Act. Deputy McGilligan did not say anything in that connection with regard to any proposals, or what Deputy Dr. Browne calls a scheme, of the inter-Party Government. His reference was entirely to the observations made by the Hierarchy in respect to the sections of the 1947 Act that are now by this Bill being deleted and repealed. Deputy Dr. Browne with all respect to him, completely misunderstood Deputy McGilligan. There was no necessity whatever for him to get up so completely filled up by what was stated and, in my opinion, stated correctly. Deputy McGilligan referred entirely to the objectionable sections of the 1947 Act, those very objectionable sections, now at long last—and it is not a day too soon—being repealed by the measure which we are now discussing.

I would have expected that Deputy Dr. Browne and some of his colleagues would have addressed themselves to this section which is, I think, the fundamental section of this piece of legislation, particularly so far as they are concerned because it was on the issue enshrined in the section that Deputy Dr. Browne and his colleagues completely burst a better piece of health legislation, or what promised to be a better piece of health legislation, than what we have now before us. The whole issue, not merely vis-á-vishis colleagues in the then Government, not merely so far as those who are competent to give direction or instruction on morals were concerned, but so far as the general public were concerned, the whole issue was on the means test. That was the cardinal issue and it was on that issue that Deputy Dr. Browne, Deputy Cowan and others gloried in the fact that they were going to bring down the then Government and put the present Government in its place. Now they are sitting down on this fundamental section quite prepared to swallow it without even a protest or a reference to it. That is the acid test for these Deputies. How can whatwas according to them, fundamentally wrong and entirely unacceptable to them in 1951 be acceptable to them to-day? The principle, if principle there was, must be the same to-day as it was then. The Deputies are in as powerful a position or even in a more powerful position to insist on their point of view to-day than they were in 1951.

Mr. McQuillan

Was Section 15 not accepted in 1951?

Mr. Morrissey

It was not accepted by Deputy Dr. Browne and Deputy Cowan and I do not think it was accepted by Deputy McQuillan himself.

Mr. McQuillan

I was present at a Party meeting of Clann na Poblachta where it was decided to accept that.

Mr. Morrissey

I do not know what happened at the Clann na Poblachta meeting.

Mr. McQuillan

Before any decision was taken by the Cabinet Deputy Dr. Browne was knifed by his colleague the then Minister for External Affairs.

Mr. McGilligan

You do not know what they accepted. You were not there.

Mr. McQuillan

You accepted it

Mr. McGilligan

You said the inter-Party Government accepted it. How could you know what the inter-Party Government accepted?

Mr. Morrissey

Deputy Dr. Browne and Deputy McQuillan repeated to-day that they were completely opposed to any kind of means test no matter by whom imposed.

Dr. Browne

I accepted the £1 contribution.

Mr. Morrissey

I move to report progress.

Progress reported; Committee to sit again.