Health Bill, 1952—Committee (Resumed).

SECTION 18.

Dr. Ryan

I move amendment No. 30:—

Before Section 18 to insert a new section as follows:—

(1) A health authority shall, in accordance with regulations, make available, without charge, a health examination and treatment service for the pupils attending schools to which this section applies.

(2) This section applies to every school which is—

(a) a national school or

(b) a school to which an order under sub-section (3) of this section applies.

(3) Where a health authority are not satisfied that an adequate health examination and treatment service is available for the pupils attending a school in their functional area which provides elementary education and is not a national school, the health authority may by order direct that this section shall apply to the school.

(4) Nothing in this section shallbe construed as authorising a health authority to provide any general domiciliary service or any services such as are mentioned in Section 14 or Section 19 of this Act.

The effect of this amendment is to limit the school health examination and treatment service to children attending national schools and other elementary schools in relation to which the health authority are not satisfied that an adequate service is available for the pupils. It will be applied to all national schools and every elementary school where that elementary school has not carried out a satisfactory medical examination—that is, satisfactory to the local authority.

This amendment has the effect of confining the school medical examination to elementary schools only. A good deal of consideration was given to the medical examination of children in other schools, that is vocational schools and secondary schools, but there was a great difficulty encountered with regard to the various proposals that were put up. There is one thing that we think is definitely impossible and that is to have a medical examination of night pupils at technical schools. It would, I feel, be possible to have the pupils of the day vocational schools medically examined the same as elementary schools. When we enter into the field of secondary schools we are up against difficulties. The day pupils in secondary schools are living at home. The other boys and girls of the same age, that is 14 to 18, are going out on other business during the day. There is no medical examination as far as they are concerned. In any case, the day pupils of secondary schools between the ages of 14 and 18 are under the control of their parents and they would be looked after in the same way as any other section of the population between the ages of 14 and 18.

Therefore, it came down to a question of day pupils at national schools and boarders at secondary schools. When we came to consider the boarders at secondary schools we were up against the problem of the means of the people attending. In some of these schools, the pupils are paying a fairly substantial fee and it would look incongruousthat they should be granted free examination and free treatment. Then it was thought that we might have a clause similar to that which we have for elementary schools, that where the local authority was not satisfied that a proper examination had been carried out, they themselves would carry it out but at the expense of the manager of the secondary school.

At that stage I met the clerical managers of schools and they objected to that provision, because they said some of the secondary schools could not afford this charge. We could not see how any proper division could be made between those who could afford to pay and those who could not afford to pay. As a result of consideration and these various meetings, I thought that the simplest way out in the present Bill was to confine school medical examination to primary schools. That is the effect of the amendment offered here.

Another suggestion that was made to me was that we should give the service to secondary schools who. applied for it. I would not see any great objection to that, I must say, but I think that on the whole when we go so far as to make a proper provision in this Bill with regard to elementary schools, it might be sufficient for the moment and it would be possible to deal with other pupils as we go along.

Those Deputies who have read the recommendations of the Youth Unemployment Commission will have learned that it was recommended there that all pupils attending elementary, vocational and secondary schools should have medical examinations. But they also advocated medical examination for young people going into a trade. That would appear logical because we would be including most of the population between the ages of 14 and 18. I think it might be as well to stop, as I propose to stop in this amendment, and consider what provision can be made generally for examination of youths between the ages of 14 and 18 at another stage. Therefore, I feel that the simplest and the most logical way of dealing with it is to deal with elementary schools only, as proposed in this amendment.

Mr. Morrissey

Could I ask, by the way, if this is one of the couple of trivial amendments to which the Minister for Finance referred some time ago?

Dr. Ryan

I do not remember the Minister for Finance's comment on that.

Mr. Morrissey

That is what I mean. Under this proposed new section the local health authority is not given any further powers than they have under the law at the moment and I do not think it even purports to enable them to enlarge on the services that they provide now. It may enable them— and I do not think they need this provision to enable them—to have more frequent inspections.

I think they have that already. In relation to the bringing within the scope of this provision the elementary schools other than national schools, it must be borne in mind again that in so far as regulations are going to be made there and in so far as they are going to be enforced, and particularly with regard to the grading of the pupils from the point of view of means or capacity to pay in whole or in part for whatever treatment may be prescribed as a result of the examination, the rules and regulations made or approved by the Minister must be enforced by the county council. I just mention that, but it does seem to me that this section does not give any further powers. If it gives any more power either to the Minister or the local authority in regard to national schools than they have at the moment I would be glad if the Minister would tell us about it.

Dr. Ryan

As far as the section is concerned, the Deputy is right. It does not change the position very much but the Bill does change the position slightly. As this section is drafted now free examination in national schools and free treatment for any defects arising out of that examination are given. If the medical examiner thinks, for instance, that the child should have his tonsils removed, teeth extracted or his eyes seen to or that he should be given some treatment by way of orthopædic surgery, all that will be free. Apart from that, however, as the Bill stands, if the medical examiner, for instance, says to a child: "I think youshould go for examination to your own doctor. You seem to be suffering from anæmia," and his own doctor says: "You want hospital treatment," if he is in the middle income group, the hospital treatment is free. In that case there is better hope of treatment than there was before because I would say the great majority of national school pupils will be in the lower or middle income group. For the few in the higher income group, there is nothing being done there.

Mr. Morrissey

The real purpose of the amendment is to make it clear that it is confined entirely to elementary schools.

Dr. Ryan

That is right.

Dr. Ryan

That is right.

Would the Minister allow any right of appeal by a private institution against this inspection? There may be disagreement with regard to the degree of inspection. The school could reasonably maintain that the inspection they were carrying out was a satisfactory one whereas the county manager or his delegate representative, who might be the county medical officer of health, might say it was not a satisfactory inspection. Would there be anybody to decide the issue between the two? Would the Minister himself be the deciding factor? Have they any grounds of appeal or is it an arbitrary decision that they must abide by?

Dr. Ryan

I have tried to remove all appeals to the Minister. There were appeals to the Minister in certain cases. They are going out under this Bill because certain Deputies were accusing me of advancing bureaucracy.

A national school is a definitely definable institution. It is scheduled with the Minister for Education and is a definite recognisable type of school. An elementary school is not so definable or recognisable, and a school which provides elementary education is even less recognisable and definable. The Minister must be aware that all secondary schools are to some extent based upon junior schools. Some of these junior schools may be national schools definitely recognised as such. Others are junior schools which are entirely private schools and in respect of which the State has no responsibility for examination or any payment of any kind. There are then a number of schools conducted by private persons. Some of them may be entirely elementary, for infants; some of them may range up to the ages of, say, 11 or 12, but others may be the analogy of the junior schools in some of the moreestablished institutions. They are private secondary schools. There are many parts of the country, particularly in Cork, where they have developed recently, and such a private secondary school will have its junior foundation. Now if this is so, then it is evidently a school which provides elementary education. There are, therefore, at least two points that we require some information about here—the power of compulsory entry into a school, and the power compulsorily to require facilities in a private school for carrying out the examination of such pupils there if their parents do not object. We want to know what the Minister means when he talks of elementary education and the various types of institution in which elementary education is carried out other than in a national school.

Dr. Ryan

There was the Public Health, Medical Treatment of Children (Ireland) Act of 1919. It, in a way, defines it thus:—

"An elementary school means a national school or any school recognised by the local government board as providing efficient elementary education."

Mr. Morrissey

It is one of the things that makes me rather afraid. Section 21 is so cleverly worded and so fully comprehensive that it empowers the Minister to make any sort of regulations he likes in respect of any particular service, either the manner of the service or the extent to which it may be administered and to any particular class of person. Extraordinary powers are given there and there is an amazing variety and number of regulations which the Minister could make, and there is power to enable him to make these regulations of as wide or narrow an application as to him seems fit.

General MacEoin

Is it not quite clear that the power under this section is very sweeping? I am satisfied that the present Minister would not make regulations that would outrage anybody's feelings or rights, but this is continuing legislation and this section and the amendment are of so ambiguous a nature that anything can be done. Picture for a moment one of those elementary schools with about eight or nine pupils—three of the children belonging to one family and one or two others belonging to other families.

I know that the Minister has arranged for the examination of the regulations made by him in this particular case and under other Acts of the Oireachtas and in this case the Health Council may indeed be of some very material benefit in protecting the interests of the citizen. Does everybody know, however, that the power of Ministers to make regulations is utilised to stop some loophole or some interest that the citizen may have?

The Minister says that you cannot legislate for everything. That is true, but if the citizen gets some right or if some protection is given in the Act of the Oireachtas, the Minister can then take power under a regulation to stopthat particular right and to close that loophole against him.

If, in the course of the administration of this Act, some privilege or right was established for the citizen to protect him against inroads on his rights by the Minister, the Minister could then step in and make a regulation to stop that and to close that loophole. That has been the complaint of every constitutional lawyer and every parliamentarian in the world— that the power of the Oireachtas or Parliament is handed over to the Minister or to an executive to make regulations that were never intended by the Oireachtas or Parliament when the Act was going through.

The Minister tells us that he has these two bodies on the Health Council and follows it up by saying that they have not any power to compel the Minister but that they could get in touch with their friends in Parliament. That was one of the objections that I had, prior to this—that, to get what you are entitled to, you have to go and approach some Deputy to protect you.

I think you should not have to do that. Then the Minister says that the Oireachtas may annual the regulation. We know that it is almost impossible to do that against a Government with a parliamentary majority. Their name, their reputation and their prestige are at stake. They would never dream of allowing members of the Opposition to have a regulation annulled because it would practically be a vote of no confidence in the Executive. On the other hand, to get members of the Government's own Party to approach the Government to have the regulation annulled would be tantamount almost to mutiny within the Party.

While they may look fine on paper, as protection, what rights has the citizen? I think they are very poor props when called upon to carry the burden.

Amendment put and agreed to.

New section inserted.

Section 18 deleted.

SECTION 19.

That still remains. There is no doubt about that. If you look at Section 30 you will see that they get all these services free. These sections we are dealing with now are applying them to other groups. As I said, as far as the national school children are concerned, they will get it free and children under six years attending clinics are to get it practically free also. But I want to make this reservation. I may have to make some provision under the regulations that if a child, say, is going back week after week to have broken spectacles renewed, a charge will be made. I think that is about the only case that will arise.

Dr. ffrench-O'Carroll

Do I understand as to paragraph (b) here that the reply applies to that same qualification that applies to a similar paragraph in the previous section, that is, the Minister under his regulation would propose to discriminate between the four classes of persons that are indicated in Section 14, sub-section (2) as regards charges?

Dr. Ryan

No, as I mentioned on the section, when it came up, and again on sub-section (b) it is intended that in the case of any defects discovered on examination in the child clinic, the treatment will be free, ophthalmic and dental.

Question put and agreed to.

SECTION 20.

Amendment 37 not moved.

Question proposed: "That Section 20 stand part of the Bill".

General Mulcahy

I would like to hear the Minister on the section.

Dr. Ryan

The White Paper pointed out that complete medical and hospital services would be made available free of charge for children up to the age of six weeks whose mothers are entitled to avail of the maternity service and for children attending welfare clinicsor similar institutions up to six years of age, and a school medical service for pupils attending national schools. It says then that it is intended at a later date to extend these and make them available to persons in the middle income group for a charge not exceeding half the cost. It is not possible however to provide these services until suitable arrangements be made and until local authorities have adequate personnel and facilities available. This is the section dealing with the middle income group. We have dealt with children under six weeks, and then children from six weeks to six years and then children attending national schools and now we are coming to the people in the middle income group who are not covered by these juvenile classes and it is laying the obligation on the local authority to provide the services for dental, optical and aural appliances and treatment for which a charge may be made. That charge will be made by regulation, but as laid down in the White Paper it would not normally exceed half the cost.

General Mulcahy

Could the Minister give us any idea where dental services are at present operating, the extent to which they are adequate or otherwise, and could he give us any idea what organisation is ultimately contemplated or likely to be established under this section?

Dr. Ryan

Dr. Esmonde

Has the Minister had any discussion with the dentists in regard to their embodiment in the service?

Dr. Ryan

I had. I mentioned here already that I had, but we did not have a full discussion on it.

It is part-time employment anyway?

Dr. Ryan

Yes.

Question put and agreed to.

SECTION 21.

Amendment 38 not moved.

Question proposed: "That Section 21 stand part of the Bill."

General Mulcahy

Would the Minister tell us his approach to this section? There would appear to be an awful lot to be said by way of explanation about it.

Dr. Ryan

This section replaces Section 28 of the 1947 Act and Sections 20, sub-section (3) and 90 of the Public Assistance Act of 1939. Section 28 of the 1947 Act is in much the same words as this. It reads:—

"The Minister may make regulations applicable to every health authority of a particular class or a particular health authority as to the manner in which and the extent to which they are to exercise their powers under this Part of this Act."

The two sections I refer to in the Public Assistance Act of 1939 are very long and I do not propose to read them, but they also give power to make regulations. I should like to say, however, that, in the White Paper, there is section 35, which says:—

"Modifications of the scheme to meet local requirements may be necessary."

I think that would be a case where it would be necessary to have different regulations for different health authorities. It also says:—

proposed under this scheme can be

"The full additional benefitsmade available gradually only. The enactment of legislation, recruitment of staff, provision of clinic buildings and other facilities are steps which must be taken before the full services can be made available."

It is fairly obvious that, in relation to some of these services at least, some local authorities may be ready before others and they may indeed be urged by intending or expectant beneficiaries to bring in the scheme, and they, in turn, may urge the Minister to make the necessary Order to set the scheme up, so that from many points of view it will be necessary to have regulations which will apply to some authorities and not to others, at least at the same time. There is quite a lot to be said for the section as drafted.

Mr. Morrissey

This is the section to which I referred earlier when discussing the new Section 18. It is the section which provides the Minister with the power to make all or any regulations dealing with the preceding seven or eight sections which cover perhaps one of the most important, and certainly one of the most controversial, parts of the whole Bill. The cost of providing the services is to be borne, in the main, by three different parties—the patient, the central authority and the local authority—but all power under this section is being taken exclusively by the Minister. The section says:"The Minister may make regulations applicable to every health authority..." It does not even include the words in some of the other sections: "...or the Minister may approve of regulations." May I respectfully suggest that, if regulations are to be made for a health authority, for every health authority of a particular class or a particular health authority as to the manner in which and the extent to which the services shall be made available, and, in particular, the services for a particular class of persons, these exclusive powers should not be given to the Minister? Where variations in the regulations will have to be made by the Minister, they will have to be made in the main because of differences in local conditions. Where differences in local conditions are concerned I submit that,while I do not want to cram any more power or authority into the hands of the county or city manager, whoever he may be, regulations suggested by the local health authority with full knowledge of local conditions for the approval of the Minister would, I think, be a more satisfactory way, and probably get better results than having it exclusively in the hands of the Minister.

I know that I can be answered by saying that the Minister, before he makes regulations, will consult with the local authority in regard to the regulations he proposes to make, or that it will be in response to suggestions made by the local health authority that the regulations will be made and that they will be restricted either to the manner, the extent to which, or to the particular class of persons as suggested by the responsible local health authority. Frankly, I would prefer that all the power was not reserved to the central authority in a manner like this.

This is the section under which Sections 13 to 20, inclusive, will in future be operated and, if the local authority is so empowered to make these regulations subject to the approval of the Minister, then I think at least we could assume that these regulations which would be proposed for the Minister's approval would only be put forward by the local health authority after consultation with the county medical officer for health and the other medical men in the particular health area. In that way I think we would be more likely to get rules and regulations suitable to local requirements than if we leave it exclusively in the Minister's hands. I do not see that the Minister can have any very strong grounds against inserting or agreeing to insert in this connection the words "or regulations approved by the Minister", the intention being to give to the local health authority the power to draft regulations to meet local requirements, to send them to the Minister for his approval, or otherwise. In that case we would be more likely to get for each health authority a set of regulations and rules more suited to its particular requirements than we would get byrules and regulations made entirely by the central authority.

Dr. Ryan

I agree with a good deal of what the Deputy has said. If the regulation were to come from the local health authority it might be a very good thing. There are two matters that we must keep in mind. Firstly, we want a certain amount of uniformity. I am sure Deputies will admit that if there are contiguous counties giving different benefits, the one that is not doing so well as the adjoining counties will have to be compelled by regulation to come up to that level of efficiency in benefits.

One might as well let them all start off on the same level because we want a certain amount of uniformity. On the other hand, we recognise that conditions vary in the cities and towns and the rural areas and that is why we say here that we can make a different regulation for a specific health authority. If a particular health authority drafts its own regulations and sends them to me for approval and I then say that I am prepared to make the regulations, we actually achieve what the Deputy has in mind. I would be very glad indeed to have that co-operation from the local authorities. I am sure we will have it. I would like to have the local authorities take the initiative. We will certainly accept their co-operation and I think it is unlikely that we will have to force any unwelcome regulations on them.

I was looking at sub-section (2) again. I will consider it to see if it is really necessary. It may not be necessary. I notice it was not in the 1947 Act. Why it is put in here I do not exactly know but I will have the matter examined to see if it can be removed on the next stage. I think sub-section (2) is the one that gives rise to most anxiety so far as members of the Opposition are concerned.

Mr. Morrissey

Of course we have already met that in a previous section. I am glad, however, that the Minister will have another look at it. I am afraid that what he has said now does not resolve my fears. He said it was desirable to have uniformity. I agree that is desirable in so far as it is possible.We know, having regard to the different health authorities, that it is very difficult—indeed almost impossible to have uniformity. I do not want to be misunderstood now and I want it to be remembered that I am not talking about anybody here present, but we are not legislating here for to-day, to-morrow or next year. I am afraid that people in the central health authority without a local intimate knowledge may be so concerned in getting uniformity that they may, in fact, make regulations impossible to implement or likely to cause hardship in their implementation. The Minister says they will have the co-operation of the local authority. I have no doubt at all about that. If I had any fears on that point it would be that the local health authority might be inclined to co-operate too freely, if the Minister and the House understand what I mean; the local health authority might accept something about which it had doubts merely because it was framed and made a regulation by the central authority to whom the local authority is responsible.

I think there is a distinct difference between having regulations governing the operation of the sections to which I have referred—regulations thought out, drafted and initiated by the central authority — and the central authority examining proposed regulations which have been thought out and considered in the light of local circumstances and initiated by the local authority. I think there is a very big difference there. Frankly, I do not see that the Minister would take from himself any of the powers that he should reasonably expect to have or would in any way forgo any of his official authority by agreeing to amend this section to read "that the Minister may make regulations or approve of regulations".

As a matter of fact, that is in some other section in the Bill. In my opinion it would not in any way weaken what the Minister wants to do. I would suggest it would make it much easier even to get as near as one can to the uniformity about which the Minister speaks. There is no use in thinkingthat we can have uniformity as between County Dublin and County Leitrim or as between County Limerick and County Donegal. I think it will be almost impossible to get it. I think we can get nearer to it by giving the local health authority the right to draft and submit to the Minister for his approval with or without amendment or addition, a set of rules which, in the opinion of the local health authority, with the advice of the county medical officer and the other medical officers attached to that particular authority, are satisfactory. I seriously suggest to the Minister that what I am now putting forward would improve rather than disimprove this particular section.

Dr. Ryan

Yes. I am prepared to consider that but not as suggested by the Deputy. I am not going to make a point about that, however. I am afraid another sub-section is required and I will have the matter examined.

General Mulcahy

The uniformity here is for the purpose of giving the Minister administrative control over the situation. Uniformity is very often the foster-mother of delay, frustration and disorganisation rather than anything else. You will have cases, say, where the Department will hold out for the appointment of a full-time assistant in a particular place because there has been satisfactory work done by a full-time man in some other place. The result is that there is delay if somebody is appointed and he does not get satisfactory assistants. They have not a satisfactory income and their services are wasted. You will come up against cases in relation to a small district hospital where the work is being carried on by the local dispensary doctor who is the doctor for the hospital as well, because in some other part of the country there is a person in charge who is a medical officer in charge of a district hospital. That is his sole public appointment. A vacancy occurs and a separate dispensary doctor is required for the area and for the district hospital. Two people are appointed to part-time positions. Neither of them will be able to give adequate assistance to the area. The result is that both the dispensary doctor and the district hospital doctorappointed are only waiting to get out as quickly as they can. There is a delay in getting people to take the jobs and, when they are filled, the people stay for a short time only and then clear away. Then there is not a satisfactory medical officer because the principle of uniformity has been brought in. That which operates well in one particular part of the country does not operate so well in another. I think the Minister in looking for too much uniformity will want to be careful that he is not looking for just delay and frustration and disorganisation.

Dr. Esmonde

I am inclined to think that the central control of local authorities and the power to induce them to accept certain principles as to how they should govern are being put into effect in this health administration. I am convinced that it will lead to dire confusion everywhere. I feel myself in agreement with what Deputies Morrissey and Mulcahy have said, that a different set of circumstances will apply to practically every county. To start with, the financial conditions in each one of the Twenty-Six Counties are different. Certain counties will be in a position to introduce certain regulations and carry out certain types of health administration efficiently, while other counties will be unable to do that. The matter would certainly rest with the local authority which, I presume, is the county manager. I hope that he will consult with the medical officer of health as well. The local people will be in a better position to decide what is suitable to local conditions. I do not suggest that the Minister will do anything out of the way if he gets these powers, but the whole trouble in this Bill is that we are legislating for the future. We want to ensure as far as we can, if we are going to have these health services, that at least they will be run with as little friction as possible. A parallel case exists in regard to housing where the local authority is subservient to the Local Government Department. Local authorities can do nothing without reference to it. This leads to delay and confusion and maladministration. I think this section is of the same kind. If you are goingto have health services they must be put into effect by the people on the spot who know local conditions. I am glad to see that the Minister is inclined to meet Deputy Morrissey's suggestion. That will be welcomed by the people on these benches.

Question put and agreed to.

SECTION 22.

Question proposed: "That Section 22 stand part of the Bill."

Mr. Hickey

Are we deleting paragraph (b)?

If she is there for any medical reason that is all right.

Question put and agreed to.

SECTION 23.

(b) in any nursing home or maternity home approved of by the Minister for the purposes of this section,

and where a person so arranges, the health authority shall make, in respect of the services made available, a payment as provided for in this section.

(2) Where institutional services are made available in pursuance of sub-section (1) of this section otherwise than in a private or semi-privateward in any institution (not being a health institution) with which the health authority have made an arrangement under Section 9 of this Act, the payment to be made by the health authority to the institution in respect of the institutional services shall be equivalent to the payment which would be made to the institution pursuant to the said arrangement, less a sum of 6/- for each day during which the services are availed of.

(3) Where institutional services are made available in pursuance of sub-section (1) of this section, otherwise than in a private or semi-private ward in any institution (not being a health institution) with which the health authority have not made an arrangement under Section 9 of this Act, the payment to be made by the health authority to the institution in respect of the institutional services shall be equivalent to the payment normally made by the health authority for similar services made available in an institution (otherwise than in a private or semi-private ward) with which the health authority have made an arrangement under Section 9 of this Act, less a sum of 6/- for each day during which the services are availed of.

(4) Where institutional services are made available in pursuance of sub-section (1) of this section in a private or semi-private ward in any institution (not being a health institution) with which the health authority have made an arrangement under Section 9 of this Act, the following provisions shall have effect:—

(a) the payment to be made by the health authority to the institution in respect of the institutional services shall be equivalent to the payment which would be made to the institution in accordance with the said arrangement for services otherwise than in private or semi-private wards, less a sum of 6/- for each day during which the services are availed of,

(b) nothing in this Act or any regulations made thereunder shallbe construed as restricting the amount of any charge which the institution may make on the person availing of the services.

(5) Where institutional services are made available in pursuance of sub-section (1) of this section in a private or semi-private ward in any institution (not being a health institution) with which the health authority have not made an arrangement under Section 9 of this Act, the following provisions shall have effect:

(a) the payment to be made by the health authority to the institution in respect of the institutional services shall be equivalent to the payment normally made by the health authority for similar services made available (otherwise than in a private or semi-private ward) in an institution with which the health authority have made an arrangement under Section 9 of this Act, less a sum of 6/- for each day during which the services are availed of,

(b) nothing in this Act or any regulations made thereunder shall be construed as restricting the amount of any charge which the institution may make on the person availing of the services.

(6) Where institutional services are made available in pursuance of sub-section (1) of this section in a nursing home or a maternity home, the following provisions shall have effect:

(a) the payment to be made by the health authority to the home in respect of the institutional services shall be equivalent to the payment normally made by the health authority for similar services made available (otherwise than in a private or semi-private ward) in a hospital with which the health authority have made an arrangement under section 9 of this Act, less a sum of 6/- for each day during which the services are availed of, and unless the health authority otherwise determine, shall be limited to payment in respect of a period of six weeks in the case of a nursing home ortwo weeks in the case of a maternity home,

(b) nothing in this Act or any regulations made thereunder shall be construed as restricting the amount of any charge which the institution may make on the person availing of the services.

(7) Where institutional services are made available under Section 14, Section 15 or Section 16 of this Act in a private or semi-private ward in a health institution on request made by or on behalf of the patient, there shall be charged therefore, in addition to any charge under sub-section (4) of Section 14 of this Act, a sum equivalent to the difference between—

(a) the charge approved of or directed by the Minister under Section 24 of this Act for such services in a private or semi-private ward (as the case may be) in that institution, and

(b) the charge approved of or directed by the Minister under Section 24 of this Act for such services in that institution otherwise than in a private or semi-private ward.

The idea behind this amendment is that if a person in the middle income group, seeking hospital treatment, is anxious to have a choice of hospital, the local authority would give the choice of hospital but would only be responsible for the payment of a subvention for such hospital treatment. The next point is, how is that subvention to be calculated? The local authority will take the weekly agreed amount paid to voluntary hospitals at that particular time, and from that amount they will deduct two guineas. The difference between the two would be the subvention which they would pay.

Persons who opt for choice of hospital and accept this arrangement with the local authority of a subvention of so much a week would be entirely responsible for all the charges, in addition to that subvention, wherever they might go, whether to a voluntary hospital, to a private ward or a privatehome. All that the local authority is bound to take responsibility for is the subvention. Let me give an example of the subvention. At the present time, local authorities are paying £5 12s. per week to voluntary hospitals for any patients they send to them. If we deduct £2 2s. from that, we are left with £3 10s., so that if this section were in operation at the moment and a person were to approach a local authority, sent, of course, by his family doctor and preferring a hospital, and the local authority were to say: "Yes, you have been sent by your doctor there and we accept it that you want treatment in hospital; you are in the middle income group; we have verified that, and so we are prepared to grant you a subvention of £3 10s. a week."

That is the meaning of this particular amendment and that is how it is intended that this particular amendment would operate. On the Second Reading of this Bill, Deputy Dr. O'Higgins expressed a desire for a choice of hospital; so did others. The Catholic Hierarchy were most anxious for a choice of hospital and I think this is the amendment that meets the situation.

Dr. ffrench-O'Carroll

I would like to point out to the Minister that as far as people insurable under the Social Welfare Act are concerned, their lot under this section is not going to be as good as it is at present. It is not a very big point but take, for example, the case of people who are in insurable employment at the moment and who go to a semi-private ward of a hospital or to a private hospital. They are in a position to obtain the full amount of what the contribution is from social welfare towards the payment of their expenses there Under this amendment and under the new Bill they will not get the full amount. They will get £2 2s. a week or 6/- a day less than the full amount. Therefore, the person who elects to go to a private ward in a hospital or to a private hospital, instead of having £5 12s. per week towards the cost of the expenses, will only have £3 10s. That is quite a drawback for a large section of the public. They will lose very considerably by it.

Dr. Esmonde

That is what the Minister stated. I took a note of it. He said that in relation to the middle income group. The voluntary hospitals are charging £5 12s. per week to the local authority. If the local authority is sending a patient to a hospital that has a contract with the local authority that full sum will be paid for specialist treatment for the middle income group. This amendment permits him to send that patient to another hospital that has not got this particular agreement with the local authority. If he does that, as I heard the Minister and as I read this amendment, the patient will be at the loss of £2 2s. per week. He will receive only £3 10s. instead of £5 12s. He will also lose the right to free treatment. I cannot read it in any other way.

I do not think this is a satisfactory amendment at all. You are purporting to offer the people a free choice of hospital and free choice of doctor and you are penalising them for doing so. I do not think that is a satisfactory state of affairs. As I have stated before, and as I state again, what we in these benches regard as right is that people should have a free choice of doctor and that a doctor should have the right to send a patient to any hospital. That is the only way you will have a satisfactory health service or give the people the best services available within the State.

Mr. Morrissey

This amendment, although it is very long, is fairly clear as far as it goes. It provides that the patient may be sent to a hospital or a nursing or maternity home approved by the Minister. The particular hospital or home must be approved by the Minister. The rest of it sets out what is to be paid by the local authority towards the cost of the services which the patient will get. It will be a sum £2 2s. less than the amount charged by the hospital or nursing home at the particular time to the local authority. These are the only two points that are really covered in this amendment.

Of course, all that is qualified by sub-section (1), which I want Deputies to read, because it brings me backagain to the famous Section 21. It says the person is entitled, "having regard to the regulations under Section 21 of this Act." We are going to pass this amendment, but we do not know what the regulations will be or what type of person will become entitled under them. Whatever is proposed to be given in this proposed new section, it will be governed entirely by the regulations which will be made later by the Minister himself. Those regulations will not determine the amount to be paid, because that is set out in the amendment, but they will determine the persons entitled to take advantage of this free choice of hospital or home.

Deputy Esmonde, if I may say so, appeared to be making the point which Deputy Dr. ffrench-O'Carroll endeavoured to make when he made the distinction between what will be allowed under this new amendment and what the person is entitled to under the National Health Insurance Act. The two things which are specifically set out here are that the hospital to which the person may be sent must be approved by the Minister, that it must be on the approved list——

Dr. ffrench-O'Carroll

That is only right.

Mr. Morrissey

I am not challenging that at all. The home or hospital must be approved by the Minister. I merely say that, plus the proportion to be paid, are the only two conditions set out here specifically and that are not conditioned by the regulations to be made under Section 21. What we have been asked is to pass the amendment without knowing to whom the benefit is going to be available or what type of person can avail of it. That will be determined under those regulations.

Dr. Ryan

I wish to say a few words to remove any misunderstanding or misapprehension. Deputy Esmonde was under the impression that a person in the middle income group is entitled to free hospital treatment. That is not altogether true. A person who goes into the county hospital in the ordinary way does not ask for choiceof doctor or hospital, but he may be charged up to £2 per week. It depends on his means.

Dr. Esmonde

In the middle income group?

Dr. Ryan

Yes, that is quite definite. A person who is told he will be charged the £2 may say that he will choose his own hospital, in that case; or he may say he is quite satisfied with the county hospital in any case and is making no change. I want to make it clear that a person in the middle income group may be charged £2 at present.

Deputy Esmonde spoke of the doctor sending his patient to hospital. I had that in mind myself. Although we innocently make legislation here giving the person the choice of hospital, we really give it to the person's doctor. The person will very seldom express a choice. The doctor may advise the patient and the patient will probably accept the advice. Therefore, Deputy Esmonde was speaking correctly, to that extent.

The choice of hospital, the Deputy says, carries a heavy penalty, because if a person chooses for himself he will have to pay something as well and will also have to pay his doctor. I have not great sympathy for that person. I have sympathy for a person who has that sort of mental anguish that leaves him not prepared to face a certain hospital which he may be prejudiced against. It would be very bad to drive that person there and a great pity not to give him a choice. But the person who has no prejudice gets no great sympathy from me. Our local health institutions give as good treatment as any hospital in Dublin or elsewhere. If a person has a whim or fancy for another hospital, I do not see why the local authority or the Department should be put to the expense of paying something extra to satisfy that whim. I am talking now only of a whim or fancy. It is quite a different matter if the doctor says there is a very good reason why his patient should go to a certain hospital. It may be specialising in a certain ailment, such as genito-urinary disease. Whether the patient is able to pay ornot, if the doctor has a good reason, the patient will be sent to that hospital. The doctor will send a note with the patient into the county hospital, as he must get the medical surgeon to agree. Then the patient will go to the hospital indicated. There is no doubt about that. No lay person is going to interfere with it and all the lay person will be asked to do is to make the necessary arrangements.

I would like Deputies to realise that if there is a good medical case for a choice, it can be made, without any extra expense to the person concerned. Secondly, even if the person does not choose his own hospital, he may have to pay up to £2 a week. When we are told that the patient has to pay heavily for choice of doctor, I may say there are modifying circumstances, and it is not as bad as that.

On the point made by Deputy ffrench-O'Carroll, it is true that under this section an insured person will not get as good terms as he is getting at the moment. Against that, however, every member of his family, if he is in the middle income group, will get free treatment or treatment at a small charge; whereas at the moment only he himself is entitled to free treatment.

Dr. Esmonde

The Minister said that in certain circumstances a patient may be charged £2 2s. in the local hospital, even if he is in the middle income group.

Dr. Ryan

Yes, according to his means.

Dr. Esmonde

Dr. Esmonde

He might.

Dr. Ryan

Never.

Dr. Esmonde

We are bringing in legislation for the future, not for to-day or to-morrow, and I am trying to give a precedent for the future that if the doctor is treating a patient surely he ought to be free to decide where that patient goes to get the best treatment without having it referred to the county manager.

Dr. Ryan

I want to point out that the law as it stands, as I pointed out a few moment ago, says that the local authority shall do so and so and so and so.

That brings me back to what I object to. Section 21 is completely sweeping. It says:—

"The Minister may make regulations applicable to every healthauthority, every health authority of a particular class or a particular health authority..."

It may operate over the whole of the country or only for one authority. That is to be determined by the Minister. Furthermore, the Minister may make regulations which govern entirely this new section we are discussing, as to the manner in which and the extent to which the services are to be made available. I do not want to refer again to sub-section (2), as the Minister has promised to look at that again.

When you relate this amendment No. 45 to the type and scope of the regulations to be made, and to the manner and extent to which the services shall be made available, which will be for the Minister to determine, and whether this is to be applicable to every health authority in the State or only to one, one can see the trouble there is about it.

General Mulcahy

There are some aspects of this that need to be discussed further. The question has arisen as to the general implication of sub-section (4) of Section 14, which reads:—

"Where institutional services are made available under sub-section (1), in cases not governed by sub-section (3), there shall be charged such charges, not exceeding..."—

It is 6/- a day now, for each day—

"...during which institutional services are availed of, as may be determined by the health authority..."

I take it that here we are dealing with the general class of the "second 1,000,000," which implies that it is a rather general matter, in the case of that class, that they will be charged 6/- a day for institutional treatment, unless they can show that their financial situation leaves them unable to bear that charge. The implication is there that normally 6/- a day is charged. When you come to Section 15, the maternity services are provided free, that is, without any implication that there is to be a charge of 6/- a day. When we come to the facilities provided for going to an institution ofyour own choice under the Minister's amendment No. 45 now before us, we see that the payment that is made on behalf of the person by the local authority is what they would normally make per person in respect of a person who normally came under Section 13, less the 6/- a day. That may be understandable in relation to the ordinary person going for surgical or medical treatment to an institution of that kind. But the same deduction of 6/- a day is made in the case of a person going for maternity treatment to an institution of her choice.

The difference in the free treatment that is implied in Section 15 for a maternity case as distinct from an ordinary surgical or medical case under Section 14 is wiped out in the case of a woman who elects to go to a nursing home of her choice. I would direct the Minister's attention to that as a special aspect of this matter.

A question has been raised about the necessity for patients to look for a hospital of their choice. It is suggested that in very many cases it is rather a hospital of the doctor's choice than a hospital chosen by the patient. I would agree that that is an important aspect of the matter and that it is a further extension of the doctor-patient relationship. We have already stressed the importance, from a medical point of view and from the point of view of confidence and health, of the relationship and the confidence between a doctor and a patient. When it comes to choosing a specialist or an institution I think that the doctor's choice of a specialist to deal with whatever additional work that requires to be done or of an institution to which to send the patient is a most important extension of the doctor-patient relationship. That aspect of that relationship is very definitely maintained when the patient knows that he is being handed over to an institution or a specialist with whom the doctor himself has established that particular type of intimate relationship that inspires confidence.

Deputy Dr. ffrench-O'Carroll mentioned the question of the national health insurance person and the loss oftwo guineas a week as far as a person like that is concerned under the present scheme. He makes the remark that it is not a very big point. I think it is. These questions of two guineas here and two guineas there make the marginal difference between a person being able to get the treatment of his choice and not being able to get it. When it comes to illness, and particularly a long drawn-out illness, two guineas a week makes a very material difference.

I want to revert again to the maternity case. I want the Minister to explain why, in the case of a nursing home and a maternity home, there is a stipulation that the period in respect of which payment will be made will be limited to six weeks in the case of a nursing home and two weeks in the case of a maternity home. It does not seem that a restriction of that particular kind applies to a hospital or institution. Under Sub-sections (2) to (5), there does not seem to be a suggestion of a limit in period like that. Why is it introduced in sub-section (6)?

Dr. Ryan

With regard to the expression, "hospitals or homes approved by the Minister," I should like to put this for consideration to Deputies. The Minister always had that power with regard to the national health scheme. We did not want people going into what are not exactly private homes but places where people are kept, such as places beside the sea, and some of which are more of a boarding-house than a private home. The line has to be drawn somewhere. For that reason, it is necessary to have the expression, "hospitals or homes approved by the Minister". The regulations lay down the conditions necessary to qualify. The same will be here, I expect. There will not be a question of disqualifying any ordinary hospital or home. That brings us to the point about the six weeks for the ordinary case and two weeks for the maternity case. In some of these private homes, people are kept over a long period. I myself have known fairly wealthy old people go into a private home and stay there for months and have a good rest, a good time and be well looked after. We do not want the fairly wealthy person—Iuse the words "fairly wealthy"—to avail of our scheme, to get £3 10s. a week out of it, and help them to stay in a private home for many months. That is the reason for the limit which is put there. However, Deputies will notice that it is subject to an extension where a case is made that an extension is necessary for medical reasons.

General Mulcahy

I pointed out the difference between Section 15 where free institutional attention is given in a maternity case and Section 14 under which a person, say, of the middle income class is charged 6/- a day in respect of institutional treatment. Take, for instance, two women—one looking for treatment under Section 15 and the other looking for treatment under Section 14. Let us assume that they take that treatment in the ordinary institutional way under the health authority. One of them is charged 6/- a day—that is the non-maternity case—and the maternity case is not charged anything. But if these two people elect to go to a nursing home then the maternity case loses the advantage that is assured to her under Section 15 and she is charged the 6/- a day as if she were an ordinary non-maternity case.

Dr. Ryan

If she chooses her own home or hospital that is true.

General Mulcahy

Can the Minister give any explanation for that?

Dr. Ryan

Just that I do not think, as I said before, that local authorities should be asked to pay for the fancy of a person like that. A local authority is providing the best possible serviceboth in its own institutions and in the voluntary hospitals to which it sends its patients. If local authorities send their patients to places where they can get the best possible treatment, then I think they are doing their duty. If a patient, through some whim, says: "I want to go to another hospital— one of my own choice", I think the local authority can say: "Well, in that case, we cannot give you the subvention."

General Mulcahy

Withdraw the subvention, yes, but why withdraw the 6/- a day which is guaranteed to her under Section 15? The Minister has had put before him very clearly the inadequacy of the number of beds in quite a very large number of our counties. It has been made clear to him that the fact that a large number of maternity cases like to go to nursing establishments of their own choice is of very great convenience at the present moment to local authorities and is a very great help to the class of people under Section 13 who require institutional maternity treatment. Why should the Minister arrange that, say, financial facilities that are very definitely prepared for the maternity case under Section 15, as compared with the ordinary medical cases under Section 14, should be wiped out just because a woman requiring maternity treatment goes to a private nursing home? I move to report progress.

Progress reported; the Committee to sit again.

The Dáil adjourned at 6 p.m. until 3 p.m. on Tuesday 23rd June, 1953.

Dáil Éireann debate - Thursday, 18 Jun 1953

Health Bill, 1952—Committee (Resumed).

Mr. A. Byrne

Mr. A. Byrne

Mr. A. Byrne

Mr. A. Byrne

Dáil Éireann debate -
Thursday, 18 Jun 1953