Dáil Éireann debate -
Wednesday, 24 Jun 1953

Vol. 139 No. 13

Health Bill, 1952—Committee (Resumed).

Debate resumed on amendment No. 24.

General Mulcahy

On Thursday last, I was raising the question with the Minister as to why there was this rather peculiar discrimination against maternity cases. The bed position disclosed by the answer given to Deputy Norton's question on the 23rd October, as reported in column 224 of the Official Debates, shows that there are eight maternity beds available in the County of Carlow and five available in Longford. Naturally, then, there is a very good reason why people desire, in maternity cases, to go to a private home.

Under amendment No. 45, where a person desires to go to a nursing home either for ordinary medical treatment or as a maternity case, that person is treated on exactly the same footing with regard to charges—that is to say, the idea of preference in the pre-treatment that is offered in this Bill to maternity cases is completely withdrawn. As the House will remember, the Bill proposes that when persons of the middle income group go to a local institution to get medical treatment they will be charged 6/- a day. If they go to the local institution as a maternity case, there is no such charge. If a person elects to go to a nursing institution of a private kind, this section proposes to put the maternity and the ordinary medical case on the same footing. I was asking the Minister on Thursday why the 6/- a day is imposedas an additional charge on a maternity case, where it goes to a private institution.

Minister for Health (Dr. Ryan)

There is no difference when the person chooses his own hospital. There is a difference in the case of a person who does not choose his own hospital.

General Mulcahy

The Minister is talking of a public ward in a hospital?

Dr. Ryan

It might be a public ward.

General Mulcahy

Wait now—it is.

Dr. Ryan

A woman goes to her own private doctor, who says she needs hospital treatment—not maternity treatment—say, an operation for appendicitis. If she is in the middle income group and she agrees and goes into a local authority hospital or is sent by the local authority to a voluntary hospital, the local authority may think that her means warrant them getting a fee of 6/- per day from her towards the cost of the hospitalisation.

If the same woman, expectant in maternity, goes to her private doctor, and if the doctor says that he thinks it would be better for her to go to hospital because he would not like to undertake her case, then she would get free treatment either in the county hospital or in any other maternity hospital to which she would be sent by the local authority. In other words, they cannot make a deduction of 6/-a day for her. But in either case if she chooses her own hospital she will have to suffer this deduction of two guineas a week or 6/- a day.

I do not think, in the case of a woman who chooses her own hospital, that she is treated any worse in the case of maternity than any other case.

General Mulcahy

The discriminatory preference in respect of maternity treatment is withdrawn?

Dr. Ryan

The favourable treatment is withdrawn.

General Mulcahy

Why should that be so? If there is an appreciation that maternity treatment requiresspecial consideration on the financial side, why is it withdrawn? I think the Minister has not brought out the situation quite clearly. Take, for instance, the position in Carlow, where there are eight maternity beds. If a person in the middle income group wants to go into the public ward in Carlow—into one of those eight beds —she will get the maternity treatment entirely free. If the Carlow local authority have an agreement with some hospital in Dublin—and it is a maternity case—and if they send the woman there and she is put into the public ward in that hospital, then that woman can get the full treatment free.

If a patient elects to go to a hospital with which the local authority even has an agreement for general public ward treatment, and if that patient goes into a private or a semiprivate ward in that hospital then she is charged 6/- a day in addition to what the hospital may charge generally. The only thing that she gets is the subvention. The Minister indicated that the subvention which a local authority pays a voluntary hospital or any other institution is £5 12s. per week but that where a person does not go into the normal public ward of the hospital there is a deduction of 6/- a day—that is, £2 2s. a week—and only £3 10s. is paid. Therefore, if a person who is sent from Carlow to a maternity hospital in Dublin with which the local authority have a contract and if that person goes into the public ward of that hospital then a sum of £5 12s. is paid. But if that person should go into a private ward then the £5 12s. will be reduced by £2 2s. plus whatever extra is involved.

If, on the other hand, patients are going for medical treatment then they would be charged the 6/- a day in Carlow. They would be charged the 6/- a day if they went into the public ward in Dublin but that 6/- a day is taken as a special deduction from the maternity case. I think the Minister has given us no explanation at all as to why that should be so.

Mr. Morrissey

Perhaps the Minister would clarify this point? I understoodthe Minister to say a moment ago that if the local authority decided that the patient was to go to a maternity home whether in Carlow or elsewhere then the 6/- would come into play.

Dr. Ryan

No.

Mr. Morrissey

That is what I understood the Minister to say. I am putting the point to him now because it seemed rather strange to me if the matter were determined by the local authority for the reason, say, that they had not a bed available in their own maternity wing.

Dr. Ryan

Take, again, the case of the lady who goes to her own doctor and the doctor says: "I think you should go to hospital." If she says: "I will go wherever the local authority wishes to send me," then she has free hospital treatment. There is a distinction here now between private and public ward. If may happen that that type of case may be sent by the hospital to a private room because, in their view, the case requires isolation. Therefore, she may get a private room and yet be free—that is, if they sent her there. If the patient says: "I want to go to a certain hospital and not to any other," then she must suffer the penalty. This woman has no grievance from the medical point of view.

I think that everybody will admit that the best possible treatment is given in the maternity ward and that it cannot be beaten. I admit that a woman may prefer a private room in a private home but she is not going to get any better treatment there.

Dr. Esmonde

I am afraid I am not very clear on this. I have read the debate over the week-end. If a doctor is going to send a patient in the middle income group for ordinary non-maternity treatment, and if he decides he wants to send that patient to a particular hospital, I take it from the Minister's remarks the other day that, in certain instances, even in the case of a person in the middle income group who is being sent to any sort of hospital, even actually to the local hospital, it rests at the discretion of the county manager or the local healthauthority as to whether or not that person is to be asked to pay anything. That is what I understood the Minister to say.

I was under the impression, until we started to debate this particular amendment, that the middle income group were entirely free with regard to medical and institutional expenses for specialist treatment. Apparently, they are not. In certain instances they may be charged £2 2s.

This amendment purports to offer a choice of hospital. Now, I am dealing not with maternity at all, but with the ordinary specialist treatment. Even if they were free, and it was agreed by the health authority that they were entitled to free treatment, if they go to any other hospital they are not free. The last day we were debating this here I understood from the Minister that if the patient decides that he or she wants to go to a particular hospital then they are not free. If, however, it is recommended by their doctor that it is desirable that they should have treatment in some particular institution in Dublin, Cork, Limerick or any other place outside the rate-aided hospitals, they would be entitled to Health Act treatment but, at the same time, they lose. They get only a subvention and they lose £2 2s. a week.

On reading the debates further, I took it that what was in the Minister's mind was that if they were specifically recommended by the doctor, and it was agreed in the recommendation of the doctor that it was necessary for them to be transferred to a hospital for specialist treatment—I am still dealing with the middle income group—they would be entitled to the full amount and not the subvention. I am not clear about this.

If I, or any other doctor, am attending a patient and I wish to have that patient transferred to a hospital, have I to send the patient into the local county hospital and, if it is a medical case, it to be decided by the physician in that hospital and, if it is a surgical case, it to be decided by the surgeon in that hospital, as to whether or not the patient is to be transferred for treatment? I am inclined to thinkthat that is not a satisfactory arrangement.

Let us look at it this way. If a doctor is sending a case into a local hospital—human nature being what it is—in effect, what he says is: "I prefer to have this patient sent further to some other hospital for treatment." It is sort of implied, although it need not be. But, human nature being what it is, the local surgeon or physician may say that he feels he is not good enough for the treatment and it has to be transferred elsewhere. That is rather placing both the local practitioner and the resident medical staff of the hospital in an awkward position. I should like to meet it this way if the Minister would agree. I think the county medical officer of health would be the most suitable person to decide that. He is not in medical practice and would not be concerned with the actual treatment of the case. I ask the Minister to consider that. I am discussing purely specialist treatment in the middle income group.

Dr. Ryan

I must say I feel it hard to answer the question whether the county medical officer of health would be the proper person to advise or not. I am afraid he would not be the best person to give advice in all cases. Secondly, I am afraid a lot of them would say that they could hardly undertake to advise the county manager on this question. What, in fact, would happen is this: If the Deputy has a patient whom he wants to send for hospital treatment he may perhaps ask: "Are you in the middle income group because, if you are, you can get some help?" If the patient says: "I am in the middle income group," and the doctor thinks that particular case should be sent to a specialist hospital in Dublin, he will write into the office or, if he likes, he can give the patient a letter and tell her to go in herself. I do not think it will be necessary in all cases that the patient should then go to the county hospital to be examined by the surgeon or the physician. I think things will settle down eventually. Probably the surgeon or physician would say: "There is no doubt about that case; let it go to hospital; I do not want to see thepatient at all"; or he may say: "I am not sure about that case; I think we should see it."

There is one thing which I should like the Deputy to realise. As far as my experience goes in dealing with county hospitals, the only complaint from the administrative point of view that I ever got is that certain medical men were not undertaking enough. In other words, some of them are too prone to send difficult cases elsewhere. I have never heard a complaint yet that any of them was too daring by taking on too much. After all, these men have a full-time life job and there is no necessity for them to undertake these cases. I do not think there is any danger that they will do that. If there is any doubt and they think it is not a case for them, I think they will be more inclined to send it to another hospital. I do not think the Deputy need have any fear that they would be inclined to say: "I will not send this case to another hospital; I will deal with it myself".

The Deputy will realise that it would be too much to ask the local authority, acting through the county manager, to accept the recommendation of every doctor in the county. I think the county manager would want some check. I think he would have to get some medical opinion from his own staff, whether the surgeon or the physician or the county medical officer of health. He will have to get some advice I think from some medical authority to verify what the doctors recommend. As I said the last day, when things settle down and are working smoothly, the county manager may say: "You can always take this doctor's word. I need not bother asking the question; the patient can go straight to Dublin".

Dr. Esmonde

The Minister stated that these doctors in the hospitals are whole-time officials. Surely that is not correct. Are not the physicians in the county hospitals now in active practice and in competition with other practitioners in the area?

Dr. Ryan

Yes, in most cases.

Dr. Esmonde

That is the difficulty I see in these cases. It would not be right that the local authority should not have some safeguard. I am not suggesting that the local practitioner should have the right to transfer a patient anywhere he likes without consultation of some sort with the local authority. What I am fighting for is the principle of the contract that exists between the doctor and the patient with as little State interference as possible. The only real way to preserve that is to bring in the county medical officer of health. He is a quasi-State official under the local authority or under the Minister's Department and represents the interests of the State. You will then preserve the right of the individual to consult a local practitioner and the right of the local practitioner to do the best he can for his patient in consultation with the medical officer of health. I cannot think of anybody else who would be really fair and who would understand the circumstances.

I think that the Minister should do it in that way, have a consultation between the county medical officer of health and the local practitioner if the local practitioner wishes to send a patient to some particular hospital. That would meet the case. Otherwise, the situation will arise where you will have two medical officers, both practising in the same area, and one will more or less have to divulge the fact that he is attending some person in the district, while if the county medical officer of health is brought in, he will be safeguarding the local authority and will have no interest one way or the other. He is not a practising doctor. In that way you will be preserving the right of the medical practitioner to say where a patient is to go. That is what I am fighting for-the rights of the doctor.

Dr. Ryan

I agree that there is quite a lot in what the Deputy says. There may be towns where the county physician is practising in competition with a private practitioner who wants to have a patient sent to a certain hospital. My difficulty is that I do not know how far we can get the county medical officer of health to cooperatein this. The county medical officer of health up to this was in an entirely different service. He was on the health side, whereas the people in the hospitals were on the home assistance side. They were two different branches. They will all be amalgamated when this Bill goes through. But then it may be difficult to get the county medical officer of health to depart, as it were, from his appointment, from what he has been doing, and undertake duties of this kind. I think that any local authority or county manager would be inclined to do what the Deputy suggests if they could get the co-operation of the county medical officer of health. I think it would be better, however, not to be too specific in the legislation as to whom they should consult. I am quite satisfied that things will work out all right.

Dr. Esmonde

The point about this is that we feel we are fighting for the future. I am not suggesting that the existing county managers would usurp the functions of the doctors. It is the principle we are fighting for.

Dr. Ryan

The county medical officer of health could say: "I am not bound to do it."

Dr. Esmonde

The only alternative is the county surgeon or physician and I have given the Minister my objection to that. I think the Minister accepted it or sees the point of view. If the county manager is to decide, he cannot possibly know whether a patient wants a particular kind of treatment. The Minister is a doctor and appreciates that.

Dr. Ryan

He will act on medical advice of some sort.

Dr. Esmonde

We are legislating for the future. We are fighting for a principle, the rights of the patient and the doctor as against State interference. We appreciate the fact that if the Government is introducing a Health Bill which is subsequently at some time, possibly, to become law and is giving some powers they are entitled to a certain amount of control, but we do not want to hand over responsibility.Unless something is put into this amendment on the lines I suggest, neither the patient nor the doctor are safeguarded against State interference. Surely the Minister should meet it that way. I do not know any other way he could meet it.

Mr. Allen

Deputy Esmonde suggested that the medical officer of health would be the appropriate and proper person to recommend. I disagree entirely with that. The medical officers of health are dealing with health matters; they cannot be said to be in active medical practice other than health matters—which is a different thing. The surgeon or medical officer attached to the county hospital would have far closer contact with medical and surgical cases than the county medical officer of health. I could see other problems arising as Doctor Esmonde was speaking. I could see the doctors who want to send all their cases to Dublin or Cork and who want to ignore the local authority institution. The problems mentioned by the Deputy have already arisen and are in everyday operation. The Deputy is well aware of that. There is a trend by some medical officers to ignore the local authority institutions and shift all their cases to the city. You have the problem coming up again that the local authorities would be asked to pay for those patients in many cases. It is a problem that is there at the moment and has existed for many years. You have one doctor who wants to ignore the existence of the local institutions and wants to shift everyone to the big centres, or to a particular hospital that he may be interested in himself.

General Mulcahy

Could we have any idea how these problems have been dealt with?

Mr. Allen

The medical officers at the principal institutions, such as the county hospitals, have determined those matters in all cases and no one else. They recommend to the county manager or to his office that A or B should be transferred to a particular specialist hospital. That is what happens and there is no question thatthe manager even questions that procedure, or that it even comes to his notice. In every case where the surgeon or the principal medical officer in the principal institution attached to the local authority are operating they have decided up to this in all cases, and no question of doubt ever arose. Even when the boards of health were operating you had the same problems and the secretary was given authority to deal with these matters by the board where there was a recommendation from the doctor.

Mr. Morrissey

Of course the Deputy is talking about things that have nothing to do with this Bill, or section, or amendment.

Mr. Allen

Oh, no, they have a whole lot to do with it.

Mr. Morrissey

There is nothing in this section or amendment about even the county surgeon, the county physician or the county medical officer of health.

Mr. Allen

It was raised by the Deputy.

Mr. Morrissey

It was raised by Deputy Dr. Esmonde because, as the section and the amendment stand, there is no mention of the county surgeon, county physician or county medical officer of health. So far as this Bill is concerned the only authority, and the only person to whom we are giving authority, is the county manager. That is what we are doing. I am not disputing that what Deputy Allen has said has happened, in other words, that the county surgeon or the county medical officer of health or the county physician have in the past been taken into consultation by the health authority. But we are not imposing that obligation here. If we pass this section, Bill or amendment in the form in which it is at the moment, a county manager may—I do not say that he will, but he may, and we give him the power to do it—completely ignore any of them. But may I point this out to Deputy Allen: we are purporting in this amendment to provide something not there at the moment, namely, weare purporting to give a choice of institution and service and a choice of doctor and hospital? We are not, in fact, of course, giving a choice of hospital. I think the Minister cannot gainsay this.

As the amendment is before us at the moment, what it means in effect is a choice of doctor subject to the approval of the county manager, or the county manager in consultation with the county medical officer of health, if he chooses to consult him. There is no question whatever about that. If a patient elects to choose his own, or her own doctor, and in the opinion of that doctor who probably knows the whole—if I may say and I think I am using the medical term correctly—case history of the patient and is therefore in a much better position than any county medical man could be to determine to where or to whom the patient should be sent to get the best possible treatment for his ailments, he cannot do that. He has to get the authority of the county manager.

Mr. Allen

He has to get someone's authority.

Mr. Morrissey

I am not going to pretend it is not a difficult problem but it is not insoluble. At the same time I am not going to lend myself to the pretence that we are giving a free choice of hospital and doctor to the patient when in fact we are not doing any such thing.

Mr. L.J. Walsh

I am one of the many Deputies in this House who are also members of local public health authorities and in my experience I have never known—and I have experience of five of them in the past —our managers to take it upon themselves to direct any patient to any institution or to take responsibility for recommending treatment. In the first instance, a patient goes to the dispensary doctor who examines his case and may possibly direct him to the county medical officer of health. I have known cases where the county medical officer of health recommended patients to the T.B. home and other cases where he recommended them for surgical treatment. All of these thingsare done by the public health authority and it is the function of the public health authority to formulate policy and it is not the function of the manager.

Mr. Morrissey

But the manager is the public health authority.

Mr. Walsh

County managers do not formulate policy.

Dr. Ryan

The county manager is not mentioned in this Bill.

Mr. Walsh

The public health authority provides the treatment. I have known where we have taken accommodation from outside our own health authority and got accommodation from neighbouring health authorities. The manager did not do this on his own initiative. It was discussed by the public health authority. They decided to take certain accommodation in neighbouring institutions and then the manager arranged for the transfer of such patients. My understanding of Deputy Dr. Esmonde's attitude is this: that the county manager is the alpha and omega of all things in relation to public health. That is not so, and nobody knows it better than a doctor and especially a doctor associated with a public health authority. I cannot understand the attitude of anybody who says that no one counts in this matter but the county manager. That is not so. We, as the public authority elected by the people, have the right to formulate policy and to direct where our services are to be made available. I must repeat, after an experience of five different county managers, that not in one single case have they directed a patient to any institution. That is a well-known fact to every Deputy who is a member of a local authority.

Dr. Esmonde

May I point out that the principle we are fighting for is the right of a doctor to decide where his patients may go for treatment? We are making no imputation against any county manager in this State. It is the principle we object to, the principle of the health authority being the final arbiter in deciding where a patient is to be treated. Deputy Allenhas mentioned the point of view of the local authority. I think in the few words I said just now, I met the question very fairly. I agree that as the object of the Bill is to extend medical facilities in this country and to get local authorities to provide for further treatment they have the right to some safeguard. I think I met that very fairly by suggesting that the medical officer of health, who is more or less an official of such a body, should, in consultation with the local medical practitioner, decide where the patient is to go.

The medical officer of health may not be in active practice; he may not have been treating cases for a certain number of years but at least he is a fully qualified registered medical practitioner and he would know and understand medical conversation. He would understand what the local doctor meant when he said the patient should go to such and such a hospital for treatment. I think the State or the local authority would be safeguarded if the medical officer of health was included in the consultation.

I cannot for the life of me see how any Deputy can suggest that we are more or less attacking county managers as a body. We are not. We are attacking the principle of the thing. We are defending the right, and it is a sacred right, of a doctor who has a moral contract with a patient, be it a male or a female, to give him or her the best treatment possible and he cannot do that if he is subservient to a State official who is a layman.

As to the question as to whether or not the county manager is the health authority, every Deputy knows that under the existing managerial system the county manager more or less has the final say in local administration. We must accept the fact that if we implement this legislation we are going to hand over the rights that exist at present between a doctor and patient to a lay authority and a State authority. I said before that we believe in the freedom of the individual so I would ask the Minister to meet us on this point. If the Minister agrees that the medical officer ofhealth is to be included in this amendment in consultation with a general practitioner, that does not cover everything we want, but at least it provides a further protection inasmuch as it will permit of the moral contract between the medical practitioner and his patient being upheld and fulfilled.

Dr. Ryan

To get back to the amendment Deputy Morrissey thinks that the patient has no choice of hospital. Of course he has a choice of hospital.

Mr. Morrissey

Subject to the health authority.

Dr. Ryan

Subject to the local authority agreeing that he is either in the lower income group or in the middle income group. There is no other "subject." So far as this amendment is concerned, we are dealing with a choice of hospitals. A doctor says to a patient: "I want to send you to hospital," and the patient says: "I should like to choose my own hospital." The doctor then will say: "That can be arranged, but you will have to pay a certain amount." The patient says: "All right," and names a hospital. The doctor then says: "Right. Off you go." He then notifies the local authority that this patient has chosen his own hospital.

Mr. Morrissey

Supposing the hospital is chosen by the medical officer?

Dr. Ryan

It is, of course, the medical officer who will do it. In any case the local authority does not come into the hospital part of it. They come only into the means part of it. They will inquire about his means and, of course, if a person or his family is insured, that is decided for them. Again if the person is a farmer under £50 valuation that is also decided, and there is no inquiry necessary. The only possible case in which there can be an inquiry is the case of a person who is not insured or who is not a person under £50 valuation. Then the question will arise whether his income is under £600 or not. It is altogether wrong for Deputy Morrissey to say that he has no choice of hospital. Hehas an absolute choice if he agrees to pay a certain amount, and if he is able to get the hospital to take £3 10s. That is all he will get towards his hospital expenses. It is only the other case we are talking about, where the patient says: "I cannot afford to pay anything; in any case I do not mind what hospital I am sent to." Then, of course, if the doctor says: "I do mind because I think you should be sent to a Dublin hospital," if where the local authority is going to pay the whole lot, then somebody must decide whether it is an unreasonable request of the doctor or the patient that this patient should go to an outside hospital.

Just to get the thing clear in the only case that is to be decided by the amendment, as Deputies have pointed out, the practice has been for many years, both since the county managers were introduced and before county managers were introduced under the board of health, where a doctor made a recommendation of that kind whether it was to the secretary of the board of health or to the county manager they got advice from some medical officer who either agreed or disagreed with the recommendation of the family doctor. I do not think we can change that system.

Mr. Morrissey

Why not provide for its continuance?

Dr. Ryan

The thing has worked so smoothly for all these years that I do not see why you should put in all these restrictions. Let us take another example. A county manager is authorised by the local authority to build houses. Does he build these himself or does he pay an engineer or an architect to carry out that work? It is ridiculous to talk about sending a patient to hospital on the advice of a county manager. Of course we know that a man in that position must get advice on the technical aspects of the matter. There is another amendment to be moved to this Bill later setting up a local advisory committee. On that local advisory committee there would be four members, two appointed by the doctors and two others can be appointed from outside or any way youlike. That is the type of case these people will be dealing with. That is the object of providing that committee in response, first of all, to representations of the Irish Medical Association, and secondly to a representation from some of the religious authorities. The Irish Medical Association were very keen on that local council where doctors would be represented because so many things might arise that it was considered advisable to have a local advisory council. Everybody knows that if a county manager was, let us say, so ill-advised as to turn down a recommendation supported by medical advice, that this local advisory council could make a desperate row about it sufficient to keep the county manager from doing anything like that again in future.

Dr. Esmonde

We have got to the position now that if a doctor advises a patient to go to a hospital, normally speaking, the subvention only will be paid.

Dr. Ryan

Yes, under this section.

Dr. Esmonde

But if the patient says he cannot pay anything, the local authority may pay it all.

Dr. Ryan

No.

Dr. Esmonde

That is what I understood the Minister to say.

Dr. Ryan

No. If the patient says: "I want no help," there will be no recourse to the local authority. The doctor will send the patient up and the local authority will never hear about it. Where, however, a patient says that he would like to get some help, the doctor may say: "Under the Health Act, you will get some help. You pay a certain amount yourself and you come in under this section." If the patient says he can pay nothing, he cannot choose his hospital. That is all.

Dr. Esmonde

The position really is that if there is a free choice of hospital, such as the amendment purports to give, in all cases there will only be a subvention of £3 10s. as against £5 12s.?

Dr. Ryan

That would be the present arrangement. The amount may vary, but there will always be a difference of £2 2s.

Dr. Esmonde

That is in relation to the middle income group in the case of specialist treatment.

Dr. Ryan

Or even the lower income group. They are not likely to do it, but they can, if they wish.

Dr. Esmonde

There is, then, the other point. If a practitioner wishes to recommend a patient for treatment in an institution other than the local institution, to whom is the case to be referred? Does the Minister still maintain that it should be the county surgeon or county physician?

Dr. Ryan

The county manager will have to be left discretion, but he will get advice. Certain county managers may think the county physician the best adviser and others, the county medical officer.

Dr. Esmonde

Being a doctor and a Deputy, I will be asked by doctors what the actual position is. The Minister has said that the county manager will act on the advice of the county surgeon or the county physician, as the case may be. Suppose I propose to send a patient to a hospital other than the local rate-aided hospital, what is the procedure I adopt? Do I send that patient to the local hospital from which he will be subsequently transferred or do I send him directly to Dublin and report the condition afterwards?

Brendán Mac Fheórais

I was reluctant to enter into this discussion because the section appeared to me to be pretty simple. Under the first sub-section, it seems clear to me that, in the first instance, the doctor is treating a patient and decides that hospital treatment is necessary. The patient elects, unless the doctor advises otherwise, to go to the local institution or an extern institution from a panel of institutions approved of by the Minister. The only other case is the case of a doctor saying definitely to a patient: "I do not think you can get adequate treatment in the localinstitution; you ought to go to an extern institution in Dublin or in Cork," where ordinarily better services will be available. I cannot understand why, therefore, there should be any question of consultation either with the county manager or the county medical officer of health. It is a matter entirely between the patient and the doctor. The patient elects to go to the local institution or to an extern institution. On the other hand, if it is the doctor's advice that he cannot get the required treatment in the local institution, he goes to some extern institution. I agree, of course, that, by default, in the greater portion of this Bill, the local authority is the county manager.

Mr. Morrissey

Surely Deputy Corish realises that, if he is going to an extern institution in Dublin or Cork, in order to avail of the terms of the contract between the local health authority and the hospital, the patient must go through the local health authority machinery. Otherwise, any doctor could send any private patient direct to the hospital. The Minister in his reply tried to establish that the points we were raising were trivial points which amounted to nothing, but he immediately proceeded to show that they were anything but trivial, because apparently, according to himself, the very points that we are making here in relation to the local health authority, that authority in the ultimate being the county manager, were considered so important that very strong representations were made to him not merely by the medical authorities but by the religious authorities. In response to those representations, he has agreed in a later amendment to set up a local advisory council, half of the members of which will be nominated by the medical authorities.

Dr. Ryan

Two out of eight.

Mr. Morrissey

Whatever the number, the Minister is doing that in response to recommendations made to him for exactly the same reason as we are advancing here. Let me say, so that there will not be any misrepresentation, that what we have to keep inmind here is not what has been done up to now and what may continue to be done. I am not casting any reflection on any local health authority or county manager, but we cannot divest ourselves of the responsibility that we are legislating for the future. We do not know whether the system or the custom operated up to the present will continue. Nobody sitting on these benches can say definitely that there will not or cannot be a change. It is quite on the cards that you might get amongst county managers, as we have amongst T.D.s some very peculiar fellow who would not be prepared to take advice from anybody.

Dr. Ryan

They would not be as bad as that.

Mr. Morrissey

I hope that they would not be as peculiar as some members of the House, but generally it is not as easy to get rid of county managers as it is to get rid of T.D.s, although it is being made rather difficult these days. I am making the point that we are not concerned with the present position or with what the position has been in the past but with the system which may operate in the future. We have to keep our eye on the legislation passing through here and remember that once it passes out of the Oireachtas its operation, administration and interpretation pass entirely from our hands into outside hands.

Mr. McQuillan

It is an important aspect that Deputy Morrissey has dealt with that we are not concerned with what has happened in the past, but in order to understand the measure at all we must look at what has happened in the past and go on the experience we have gained. I have been a member of a local authority for a short period and my experience has been that never did the county manager take it on himself to make decisions with regard to patients or hospitals without the advice of a competent medical authority— either the county surgeon or county physician. I should like to know why Deputy Morrissey believes that the position that has obtained in the past is likely to change all of a sudden, within the next six months or twoyears. I want to make it clear that I think this section is an improvement on the present situation. It is nothing like what I would really like to see but it is an improvement to the extent that in future more people, especially those in the middle income group who up to the present could not take advantage of specialist treatment because they had to pay for it themselves, will be given a chance at least in future of getting this specialist treatment.

The position that obtained in the past with regard to the lower income group has not been referred to here at all. As far as that group is concerned, when we talk about a choice of hospital and so on I wonder how many Deputies have criticised the fact that the people in the lower income group who, according to Deputy McGilligan, number practically 1,000,000, have had no choice whatever with regard to either specialist treatment or hospital treatment in the past. There was no choice whatsoever. I cannot understand what Deputy Dr. Esmonde is talking about when he speaks of a moral bond between the doctor and his patient; that the doctor must in conscience ensure that the patient under his care goes into whatever hospital that doctor thinks is the best for him. That situation has never existed in the past. The only place that situation existed was where a patient had a big income and had no need whatever to go near any local authority. In that connection the man in the middle income group, the man who is able to pay portion of his hospital and specialist treatment, can in future take advantage of the assistance that is being made available under this section. He will be in a position to choose his own hospital and the local authority will pay portion of his costs. To me the section is quite clear. It is an advance on previous legislation and it will be a great help to the middle income group.

Mr. Kyne

I am in the same position as Deputy Mac Fheórais. Possibly the Fine Gael Party sees something in this section that I do not. It strikes me that the only matterthat the county manager will have to be advised on is the question of means. That having been disposed of, then the choice of hospital or doctor is the responsibility of the patient and his own doctor. In the past that was not so. The county manager had to satisfy himself as to whether or not a recommendation of the doctor's would justify him in incurring expense on behalf of the ratepayers in sending a patient to a hospital in Dublin or Cork, or somewhere else, away from the hospital services supplied in the county. In the past the question of the hospital was primarily the function of the health authority or the county manager, acting on the recommendation of the county surgeon. Under this section no question of that arises at all. Is not that actually the case?

Dr. Ryan

That is true.

Dr. Esmonde

I think Deputy McQuillan's point in relation to the lower income group should have a reply. Deputy McQuillan says that heretofore the lower income group had no choice of specific specialist treatment. That is entirely wrong. I am not a dispensary doctor myself, but Deputy McQuillan should know as a representative of a local authority that practically every local authority throughout the county has an agreement with certain hospitals in Dublin In the majority of cases they have agreements with three, four or five hospitals—I am speaking now of the big voluntary hospitals—to which their patients can be sent. If a doctor is treating a private patient and that patient is in the lower income group and unable to pay, up to a few years ago it was comparatively simple to get such a patient into a public ward in a Dublin hospital at a maximum of £2 2s. Let it be said to the credit of the hospitals that in many instances they took patients for nothing. If a private practitioner could not send a patient for a particular type of treatment, he could have that patient transferred through the local dispensary doctor. It is quite untrue, therefore, to say that the lower income grouphave not available to them the specialist or hospital services that are available to others in the country.

Mr. McQuillan

But there was no choice.

Mr. Kyne

There was no choice.

Mr. McQuillan

The Deputy would want to be a dispensary doctor to understand this Bill.

Dr. Esmonde

Local authorities in the majority of cases have an agreement with several Dublin hospitals. I have confirmed that fact over the last few weeks. Patients can be sent to any one of these several hospitals. If that is not a choice of hospital, what is? In each of those hospitals there is a multiplicity of specialists. The dispensary doctor can pick any one of these hospitals to send his patient to.

Mr. McQuillan

Then the Deputy is knocking the bottom out of his own argument. Why are you arguing against this if all that choice is there? What are you arguing against?

Dr. Esmonde

The Deputy made the point that the lower income group had no choice of hospital before. I am telling him that those in that group had a choice. It stands to reason that if one goes to a different hospital one gets a different doctor. Is not that right? One is a corollary of the other. Deputy Kyne made the same point more or less.

Mr. Kyne

You have not convinced me in the slightest. In the local authority we have an agreement in connection with certain diseases with a hospital in Cork and with a hospital in Dublin. Assume I am ill and my doctor tells me I am suffering from a certain disease; I get specific advice from someone else that a certain doctor in a different hospital would be ideal for me. At the moment I cannot say I want to go to that hospital. Under this section in future I can. I have a choice. I had no choice before.

Dr. Esmonde

You have not a real choice to go anywhere you want tounder this amendment as I read it. You have a choice to a limited extent.

An Ceann Comhairle

Will the Deputy please drop the second person? Let us have the third person.

Dr. Esmonde

I am using "you" as indicative of the patient. I am not referring to the Deputy.

An Ceann Comhairle

It sounded very like it.

Dr. Esmonde

The Deputy said that if a patient is being sent to a hospital he has a choice of hospital. He has not really got a choice of hospital now without the sanction of the manager.

Mr. Kyne

The Minister has said that is not so. I am satisfied it is not so either.

Mr. L. Walsh

I think we could pinpoint Deputy Dr. Esmonde's argument if he would answer a specific question: Does Deputy Dr. Esmonde claim the right for every medical practitioner in the country to send his patients to any institution he chooses? That is my interpretation of Deputy Dr. Esmonde's argument. If that is so, what is to prevent a dispensary doctor in County Louth recommending that his patient be sent to a particular specialist in Cork? As I see it, that is the argument that is being put up. In my opinion it is an argument merely to waste time rather than an attempt to be constructive.

Dr. Esmonde

If a doctor is attending a patient—I have said all this before—he ought to be in a position to recommend that patient to whatever hosptial he thinks is the most suitable; in other words, the hospital in which that patient will get the best treatment available. If the local authority—I have stated this more than once—is providing a certain sum for the treatment of that patient, I suggest that the medical officer for health, being a duly qualified medical practitioner, should have the right in consultation with the patient's own doctor to decide where that patient should go. In stating that, I consider I am defending the rights of theattending doctor and also the rights of the local authority.

Dr. Ryan

As far as this amendment is concerned there is an absolute choice of hospital. There is no question of the family doctor not having a perfect right to send the patient to any hospital he likes. That does not arise under this amendment.

Dr. Esmonde

Would the Minister answer the specific question I asked before and would he indicate to whom does a patient apply in the event of the practitioner sending that patient to a particular hospital?

Dr. Ryan

I should have said also that this follows to some extent the present system with regard to insured patients. In fact, what happens with insured patients is that the doctor sends the patient to hospital very often before he applies at all. The same will happen here, particularly if the case is in any way urgent. The point is that permission can be refused by the local authority. If the patient is sent to a hospital he can get a note for the local authority and that would be all right.

Dr. Esmonde

The doctor can send the patient direct to hospital?

Dr. Ryan

Yes. Under this section there is a choice of hospital. The local authority cannot refuse to pay except on grounds of means. If the person is insured or belongs to a family which is insured or if he is a farmer under £50 valuation or a member of that family then he is quite safe. The third class embraces those with an income of under £600 a year.

Mr. Kyne

Is that up to the full amount of the subvention?

Dr. Ryan

The subvention is the same as always.

General Mulcahy

The Minister's amendment has a very important effect on a part of Section 15 about which we had such considerable discussion. I refer to the £1 clause. All those people who are above the lower income group and above the special circumstances group referred to in sub-section(3) who would normally be able to pay, could get full institutional and specialist treatment in the local authority institution at a cost of two guineas a week if they opted to go to an institution other than that to which they are being sent by the local authority and the local authority will pay the normal £5 10s. less the two guineas.

Under Section 15 a woman availing of the maternity care would receive complete free treatment in the local institution, and if sent by the local authority to any institution outside would receive free treatment too, but there is a proviso. If a woman availing of the maternity care wishes to go outside the local institution or the facilities normally provided by the local authority outside, and if she wants to go to a doctor other than one of her own choice outside, then the assistance given will be the normal kind of health or surgical assistance and not maternity and the local authority will pay the £3 10s.—that is, £5 10s. less the two guineas.

The Minister makes provision under Section 15, sub-section (3), in relation to persons outside the groups referred to in Section 14—that is, the remainder of the community, the people other than those in the lower income group and the middle income group. The Minister sets out a special scheme which will operate on the payment of £1. That was later changed to "the appropriate amount" and is now something which has yet to be specified. He invites women in the higher income group to come into a scheme but the Minister's disclosure on this amendment would seem to indicate that his idea in regard to this particular matter is very fantastic. We have already referred to the Minister's reply in regard to the accommodation in connection with maternity beds throughout the country. In Carlow you have eight, in Cavan 15, in Leitrim seven and in Longford five for the normal institutional treatment for maternity cases in regard to persons who are now in the lower income group. What is the idea at all of making provision for the £1 or the "appropriate amount" group if they aregoing to be invited to pay this £1 for the purpose of going to the crowded and ill-equipped local institution so far as bed capacity is concerned? The Minister tells these that under this amendment, even though they belong to the appropriate fee-paying group, if they go to an outside institution or to a doctor of their own choice they can get no accommodation at all. That is the only interpretation I can put on the amendment. I would like to ask the Minister whether my interpretation of the amendment in relation to sub-section (3) of Section 15 is right or not or what would happen persons who were fee-paying persons under sub-section (3) of Section 15 if they elected to go to an institution of their choice outside?

Dr. Ryan

It is obvious that, as the section stands, anybody coming under Section 15 will have a choice of hospital and will get the subvention of £3 10s. a week, under certain circumstances. It is true, of course, that, under Section 15, the women in the middle income group get free hospital and specialist services in regard to maternity, but they are not guaranteed that outside maternity. In fact, we are treating the women in the case of maternity more favourably under Section 15 than people in the same family who suffer from other diseases. To that extent the Deputy has a case, that we should not, therefore, treat them the same. In other words, that we should treat maternity cases more generously.

My principal reply to that is we guarantee as far as we can that a woman will get the best possible treatment when she goes to her own doctor and he says that she is a case for specialist treatment. She will get that treatment in the county hospital or she will be sent to some specialist hospital for better treatment still. She may even be put into a private room or ward in that hospital because she happens to be a very particular case. All that will be done free if it is on medical grounds and in the best hospitals to be found in the country if necessary. Of course, if she makes adecision on social grounds we will say: "Well, if you want to make a choice like that you will have to pay a certain amount of the cost." That is really what we are discussing here.

The Deputy made a case for those who will contribute. Perhaps, a case can be made for them but I would like to consider that further. I do not really know whether you can make a very strong case for those who contribute. After all, if we say to people who contribute: "We guarantee as far as the local authorities can do so that you will get the very best possible care. You have a choice of doctor in the first instance and if he recommends special or institutional treatment beyond that you will get it," I think that is promising a great deal even to those who contribute. I do, however, undertake to re-examine the case of those who are contributing to see if they should not get perhaps even more favourable treatment than the others.

General Mulcahy

When the Minister mentions medical treatment, does he mean medical treatment arising specially out of maternity conditions, or does he mean medical conditions that simply are a casual occurrence in maternity cases?

Dr. Ryan

No. The distinction that I meant to make was this. A person might like to go to a certain hospital because she believed that it gave the best possible treatment—that would be for medical reasons—or a person might like to go to a home because it was a good address for the baby to be born—that is socially. I made a distinction between medical and social in that sense. She could have no complaint for medical reasons, because the local authority would say that they were sending the patient to the best institution in the country. I therefore, hold that the patient will be influenced entirely by social reasons in choosing a private home in this case.

General Mulcahy

I must say that I consider that as a rather remarkable suggestion coming from the Minister for Health—that a person, say, in the upper income group when she looks around to see where shecan be treated for maternity purposes, will think in terms of the society tone of it, rather than the efficiency and standard of treatment.

Dr. Ryan

A good many do.

General Mulcahy

It is a rather peculiar outlook on the mentality of our people with regard to maternity and child work. I do not believe that there is any foundation for it at all. However, I will leave it at that though I disagree entirely with what the Minister has said on that.

I would like to be clear as to what the Minister's suggestion now is in regard to sub-section (3) of Section 15. In cases where people are invited to become fee-paying contributors to a scheme and are looking for medical, surgical, midwifery, hospital and specialist services without charge under the section, am I to understand that what they are offered is—if I have not misjudged what the Minister has said—that if they go to a hospital of their own choice they will be assisted to the extent of £3 10s. a week for two weeks?

Dr. Ryan

Two weeks or maybe longer.

General Mulcahy

Or such certified period, I take it, as their own doctor considers necessary? Am I to understand that what they are offered as an alternative is that they will be dealt with in the local institution or, if their cases are exceptional cases requiring specialist treatment, they will be sent to such institutions as the local authority thinks can give the most up-to-date specialist treatment for that particular type of case, and, secondly, that if there is any medical treatment that requires to be dealt with concurrently with the maternity, either leading up to it or following it, they will have the benefit of being brought in under Section 14—that is to say, they will have a guarantee of the service available under Section 14 because they are covered by the fee?

Dr. Esmonde

The Minister mentioned just now that, if it was thoughtby the doctor that it was necessary for the patient to get this maternity treatment in a particular hospital, that would be allowed. He then went on to refer to social reasons. I could not follow him on that. I think that is unlikely to arise. If it should, who is to be the determining factor, whether a person is going to a home for social reasons or not? That would seem to me to be an extremely difficult matter to decide. It would amount to accusing a patient of wanting to go to a particular hospital or institution for social reasons.

Dr. Ryan

I do not think the Deputy's question is a practical one or that it will arise.

Amendment agreed to.

Brendán Mac Fheórais

I move amendment No. 46:—

In sub-section (1), page 8, lines 26 and 27, to delete "the charges approved of or directed by the Minister".

I am moving this amendment for the same reasons as we put forward when we moved a similar amendment to a previous section because I believe that the Minister should not have the power to direct or lay down the charges to be made by a health authority for the institutional services which are to be made available. The section says: "The charges approved of or directed by the Minister". I think that is a matter which should be left entirely to the local authority.

Dr. Ryan

Deputies will realise, of course, that local authorities, in laying down their charges, will be influenced to some extent, I suppose, by the financial consideration of what treatment in an institution will cost. They may say that there are limits beyond which they cannot go. The Minister will also have the same consideration in mind because he will have to pay half of whatever the cost in these institutions may be. I think it is fair, therefore, that the Minister should approve of the charges put up by the local authority as well as from the point of view of getting uniformity. I do not say that we can hope toget perfect uniformity as between cities and counties, but I think there should not be a big discrepancy as regards the charges between one county and another. First of all, the Minister, as I say, is paying half the cost and, secondly, it is desirable to get a fair amount of uniformity. Therefore, I think the Minister should have these powers.

Brendán Mac Fheórais

I appreciate the reasons given by the Minister. I would ask him, however, to consider between now and Report Stage deleting the words "or directed by the Minister". Their deletion will not make much difference, but, at least, if that change is made it will leave the initiative to the local authority in fixing the charges. The Minister will still have power under the section to approve or disapprove. In doing that, he can have regard to charges made by other local bodies. I should like to know the significance of the words "directed by the Minister".

Dr. Ryan

Personally, I have never come across a case where it was necessary to do that. The Deputy is aware that we have these powers already. It has never been more than a question of giving approval. My experience of local authorities is that they have always been as reasonable as the Minister himself.

Brendán Mac Fheórais

The words seem to me to be unnecessary.

Dr. Ryan

If one local authority were inclined to make very much lower charges than other local authorities, then the Minister might say that he would not approve of them. In that case, there would be no charge at all. The only way the Minister could meet that would be by directing that authority to make a higher charge. I do not undertake to bring in an amendment on Report Stage, but I will consider the matter in the meantime in the light of our experience in the past.

Brendán Mac Fheórais

It is hardly likely that the local authority will not impose any charge inasmuch as theywill be responsible for the upkeep and the general maintenance of the institution.

Dr. Ryan

That is true.

General Mulcahy

I think it would help us in this matter if the Minister would give us an idea as to what is the general intention of the section.

Dr. Ryan

There are paying patients' regulations in existence for years. I cannot say offhand what the charges are but the general intention is that patients who can afford to pay—in this case they would be people above the middle income group—should be charged at least the cost of a bed in the hospital whatever that may be.

Mr. McGilligan

Merely maintenance?

Dr. Ryan

All charges.

Mr. McGilligan

But not medical?

Dr. Ryan

The local authority will pay a proportion of the medical charges as well. Perhaps they would be entitled to go beyond that but I cannot say definitely at the moment. Anyway, this section is only carrying on what has been done in the past.

Mr. McGilligan

Section 14 (3) enables the health authority to extend the group of persons for whom certain institutional services are to be made available. That is left to the health authority.

Dr. Ryan

This refers to those outside Section 14.

Mr. McGilligan

I know. I am only making the contrast. Under Section 14 it is the health authority which is given the power to extend the category or the number of people for whom institutional services may be provided. In that instance it is left to the health authority. Is it necessary to bring in the Minister in respect of charges under this section? The same matter comes in under sub-section (3) of this. If the health authority is to be the body to determine the group of people to whom certain services under Section 14 are to be made available, why notleave this? I would have thought the determining of the group of people should have been more properly left to some central group because the Minister speaks as if an occurrence that ought to be deplored might easily happen under Section 14. I understood the Minister to make the objection that one local authority might make charges of a certain type and they might be different in a neighbouring area but would there not be the same possibility of differentiation in regard to people who are to be provided with the services under Section 14? One authority may make the services open very widely to certain people and others may restrict them. In fact, under that section I pointed to that as a flaw in the measure because it would mean the poorer county with low valuation would be more likely to restrict. That would particularly be the case where the services ought to be more widely available because of the poverty of the neighourhood. There may be discrimination by different local authorities; one may make it wide and another may make it very narrow. The Minister says the charges might be very low. It would depend entirely on the type of area and the amount of money to be raised over the rateable valuation.

Dr. Ryan

The Deputy referred to Section 14 (d).

Mr. McGilligan

No. Section 14 (3) says:—

"Institutional services under sub-section (1) of this section shall be made available without charge for the persons specified in sub-section (2) of Section 13 of this Act and to such other persons specified in sub-section (2) of this section as may be determined by the health authority."

Dr. Ryan

That is right. The Deputy will see that (a), (b) and (c) are very well defined and it is only under (d) that there is a discretion. I do not know if I explained this when the section was under consideration. It was extremely difficult; there is always the trouble of drawing the line between those who must get a certain benefit and those who will not. Whenit came to £600 and the £50 valuation limits it was pointed out that you might have a certain man fairly well off with, say, £49 valuation; on the other hand you could have a man with a big family not too well off with £51 valuation. It appeared unfair and the suggestion was made that we might have the higher valuation according to the circumstances of the family. It was the same with regard to the £600. I thought it was better to keep these limits as simple as possible and to give discretion to the local authority to bring in those that could be considered as hard cases. That is what is dealt with in sub-section 2 (d). The man who is over £50 valuation and who has a large family, or the man over £600 who has a large or delicate family and is not too well off could be brought in. These are cases that must be considered locally and there can be no general guide, I am afraid, as to who should be taken in and who should not. It must be left to the discretion of the local authority.

This, however, is a different matter. This is a question that can be generalised. You are above the middle income group, and they are presumed to be able to pay. I think it is possible to make fairly general rules with regard to the amount of payment. I presume the rule to be made will be that the patient will pay the cost of his bed in the hospital and will pay his share of the maintenance and attendance.

Mr. McGilligan

It is quite clear that there can be no standard for the whole country laid down——

Dr. Ryan

Except that type of standard.

Mr. McGilligan

——except the general type such as that. May I return to Section 14, sub-section (2) of which specifies people who are to have institutional and specialist services made available to them? There are three categories of people which are definitely limited. The (d) category is a bit indefinite. It applies to:—

"Persons not specified in the foregoing paragraphs who, in the opinion of the health authority, would beunable, without undue hardship, to provide institutional and specialist services for themselves or their dependents."

Therefore, right away the decision is left to the health authority. They will decide with regard to the persons who will be unable, without undue hardship, to provide those services for themselves. In relation to that, sub-section (3) says:—

"Institutional services under sub-section (1) of this section shall be made available without charge for the persons specified in sub-section (2) of Section 13 of this Act and to such other persons specified in sub-section (2) of this section as may be determined by the health authority."

I do not know whether that is mere repetition of what is in (d) or a mere gathering up of what is in (d), or whether that is another right of the health authority to add other people over and above those that a particular health authority may have added under sub-section (d). Whether it is repetition or not the point I am asking is that it is the health authority which by this sub-section is empowered to make the decision. Once the health authority is empowered there is the possibility of different treatment under different health authorities. One health authority may take a liberal view as to the people who will be caused undue hardship; they may take an exact standard while others may take a low standard, say that the people can pay and that they will not extend the list. There is to be contemplated a possibility of divergence as between different health authorities. I make that point to fortify what Deputy Corish said on this section.

An Leas-Cheann Comhairle

Amendment No. 46.

Mr. McGilligan

Amendment No. 46, Section 24. The Minister took the objection that unless he had power to direct and approve there might be varying charges made to people who are to get the institutional services and who are not entitled under Section 14. Does it matter whether thecharges would be different or not? I suggest that rigid uniformity is very bad. Even on the Minister's general standard—he said that you will pay more or less the cost of the bed, the cost of the bed meaning the cost of the medical attendance and the cost of maintenance in a bed in a particular hospital. That will be paid.

That is going to vary not merely from health authority to health authority but even between institutions where there are more than one inside the health authority. That is no objection. Why the necessity? Why not leave this to the health authority? Why does the Minister require the power to approve and to direct the charges? I take the approval to mean that in case a health authority puts up certain charges the Minister will approve of these but the direction will mean that where the health authority made certain charges not approved of, the Minister wants power to say: "No, not merely will I not approve of the charges proposed but I insist on you charging something else." I think that is the purpose.

Dr. Ryan

Yes. That is the purpose.

Mr. McGilligan

I wonder why that power is required.

Dr. Ryan

The Minister has to pay half the expenses.

Mr. McGilligan

Yes. Even so, the health authority has to pay half.

Dr. Ryan

They have.

Mr. McGilligan

Is not that going to be a fairly sufficient handicap, so to speak, as against them making small charges and, therefore, increasing the State contribution? That is the way it will work out. The fact that they have to shoulder the burden as to 50 per cent. ought to make them responsible. They are not going to go mad and give institutional services without very much in the way of charge. In the end I would say—I do not think the Minister would agree—the more that is left to the initiative of the subordinate body and the less that is taken over to the centralised authority thesooner one is getting to the real teaching on morals in these matters.

Dr. Ryan

I should remind the Deputy that I have in these cases to refer back to Section 14. In previous legislation, like the infectious diseases regulations, the tendency was to have an appeal to the Minister. We are dropping this appeal in this Bill. In other words, we are leaving the local authority the sole authority with regard to who they will give treatment to or refuse treatment to. This is a sort of general thing, however.

Mr. McGilligan

That is a pretty serious matter to leave to the local authority. I would say much more serious than the charges for people who are not entitled to institutional services. Surely it is a much more important discretion to give the local authority that they should say: "You can get services" and "You cannot" instead of saying to all: "You have to pay for your services. We will charge so much."

Dr. Ryan

I do not know what the Deputy is arguing. I am only just answering the point where he says we should give the local authorities as much power as possible. I say, yes, we are moving in that direction. I am not surprised if I am moving in the wrong direction as far as the Deputy is concerned. However, we are moving in that direction. The Deputy, having been Minister for Finance for some time, surely understands the mentality, if you like, of saying to a local authority that not only must we approve of their charges, we must also have power to say: "You are not charging enough" because, if they are not charging enough, the Department of Health has to pay half anyway.

Mr. McGilligan

Half the deficit.

Dr. Ryan

Half of the deficit, as it were.

Brendán Mac Fheórais

The Minister hangs most of the case on the fact that he will be paying half the charge. Would he not consider amending it so that the sub-section might read: "They shall charge for any institutionalservices the charges agreed between the local authority and the Minister?"

Dr. Ryan

That would be quite all right. "Agreed between them" would be quite all right but it is not just the word that is usually used.

Brendán Mac Fheórais

I do not suggest that would be the legal phaseology but the responsibility is equal.

Mr. McGilligan

"Agreed between them" would have the same effect.

Dr. Ryan

Yes.

Mr. McGilligan

Only it would be more politely phrased. The weapon would still be there, the Minister's power.

Dr. Ryan

We can consider it on Report Stage.

Amendment, by leave, withdrawn.

Dr. Ryan

I move amendment No. 47:—

To delete sub-section (3).

An Leas-Cheann Comhairle

Amendment No. 47 is consequential on No. 45.

Dr. Ryan

Amendment No. 45 makes this sub-section (3) superfluous, so it must come out.

General Mulcahy

I should like to understand amendment No. 47 more, Sir.

Mr. McGilligan

What part of amendment No. 45 directly affects sub-section (3) of Section 24?

Dr. Ryan

This sub-section (3) was covering the case of a patient who got institutional services at his own request. Of course, amendment No. 45 is dealing very fully now with the person who chooses his own hospital, or goes to hospital at his own request, as the case may be.

Amendment agreed to.

Dr. Ryan

I move amendment No. 48:—

In sub-section (7), page 8, line 57, to insert "the operation of Section13 or Sections 15 to 20 of this Act or of" before "Section 31".

We are moving to insert words in sub-section (7) so as to make it read:—

Nothing in this section shall affect the operation of Section 13 or Sections 15 to 20 of this Act or of Section 31 of the Principal Act or any regulations under that section.

It is described to me as a drafting amendment. At any rate, it is designed to make it clear that the reference in this section, 24, to the making of charges for institutional services does not apply to services provided under the various other provisions of this part of the Bill. In other words, it applies only to institutional services.

Dr. Esmonde

It applies only to institutional services?

Dr. Ryan

Institutional services for paying patients—that is what this section deals with.

Amendment agreed to.

Section 24, as amended, agreed to.

SECTION 25.

Question proposed: "That Section 25 stand part of the Bill."

General Mulcahy

We should like to hear something about it.

Mr. McGilligan

Is not this the iniquitous means test?

Dr. Browne

Go and make a speech against it.

Mr. McGilligan

Is not this the iniquitous means test? Is not this the means test?

Dr. Ryan

The means test, yes. I do not think I ever made a speech on the White Paper or the Health Bill that I did not say there were several means tests in it.

Mr. McGilligan

I always understood that but apparently some people did not.

Dr. Ryan

I always understood it too.

Mr. McGilligan

This is just themethod of securing the information so that the means tests can be properly applied throughout the Bill?

Dr. Ryan

You must get the information.

Mr. McGilligan

This is what would be described as inquisitorial procedure in relation to means tests.

Dr. Browne

So acceptable to the Fine Gael Party.

Mr. McGilligan

That is what it is.

Dr. Browne

Insisted upon by the Fine Gael Party.

General Mulcahy

Is it proposed that regulations will be framed or what machinery is intended to be used for deciding, say, the form by which a declaration will be made or the means that may be taken to varify the accuracy of the information given by the person?

Dr. Ryan

I do not think there is anything about this in the regulations.

Mr. McGilligan

Is there anything in the Public Assistance Act?

Dr. Ryan

I do not think so. All this section does is to say that the local authority may require a person to give information regarding his means and I suppose if you have a means test that is necessary.

General Mulcahy

Can we take it that the local authority is the county manager and that this section proposes that the county manager may take such steps as he thinks fit to varify the information given with regard to means —that the matter is left entirely in the hands of the county manager as regards the steps he will take?

Dr. Ryan

If the local authority gives the power to the county manager he may.

Brendán Mac Fheórais

I assume that in respect of the different classes who are described under Sections 13 and 14, those people will have to declare their means at some particular time of the year so that the medical officers and the medical staff generallywill be able to know at a glance, or say at a day's or a moment's notice, that they belong to such and such a class and that they are entitled to such and such services and that those who belong to the middle income group are entitled to such and such a service. Will there be a general round-up of all those people in the county, or will there be a check by him as to their means? Will forms be issued or available? Are those to be filled in or will the information be collected by, say, the home assistance officer or by some officers appointed by the local authority to carry out such an investigation as to means? What are the actual mechanics of finding out the means and putting the people into the different classes?

Dr. Ryan

With regard to the lower income group the same definition will be there which has been there for many years back—a person not able to provide by his own ordinary and lawful means for medical treatment, and so on. With regard to the middle income group, as I mentioned a few minutes ago, there are two classes there, well defined. A person insured or any member of his family has only to produce the insurance card if asked to do so; and a farmer of £50 valuation requiring treatment for himself or any member of his family has only to produce his assessment for rates. You have left then a rather small class, I believe, of those on salaries, whether under £600 or not, and I take it that it will be quite easy to determine in many cases, where you have public servants or allied services like teachers, the Gardaí, and so on, what their means are. The only difficulty I see about means is in the case of people in business, like small shopkeepers, who may claim that they have less than £600 net per annum from their business. The county manager, I suppose, if he is acting for the local authority, will probably ask them for a declaration and if he is not satisfied he may ask for some further proof that such a person has under £600.

Mr. Kyne

What about the person in the first group, in the lower income group? As it operates at present is itnot worked under a system of giving a red ticket? My experience of dispensary doctors is this: that unless a doctor is perfectly satisfied that the person is not the type who should get a ticket he accepts their statement of means.

Dr. Ryan

Yes, he does.

Mr. Kyne

That is the system. Will there not now be somebody who will do the allocation or will it be the doctor who will give a white card instead of the warden giving a red ticket?

Dr. Ryan

As far as this Bill is concerned the same system will continue. The person will go to the warden for his red ticket, but Deputies of course realise that not all people who go to the dispensary have a red ticket. Many of them have not a ticket at all but the doctor takes them without question though he is entitled to question them. It was suggested to me and I think to my predecessor, though I am not sure about that, that we should try to substitute the red ticket by something more convenient. Now there is no use in anybody saying that we want to remove the pauper idea, the idea of looking for a ticket, merely by substituting a card. My idea was that it would be more convenient to have a card because if a man is in the lower income group and gets this card current for 12 months, let us say, which certifies that he is in the lower income group them he or any member of his family can produce this card at the dispensary or to the doctor during a domiciliary visit or for any other purpose, showing that they are entitled to the benefits for the lower income group and that there is no further necessity to go for a red ticket at the same time. I want to stress that it was for convenience that it was suggested that this card should be produced, but it was made use of the people to ridicule the whole idea, of saying that we were doing away with the red ticket and substituting a white card and in that way doing away with poverty. Of course it makes no difference whatever about poverty. If people are in this group we shouldmake it more convenient for them if we can. However, these things, if the Bill passes, can be done by regulation.

Mr. Kyne

Perhaps I did not explain myself. I am not trying to get in any political point.

Dr. Ryan

I know.

Mr. Kyne

What I am trying to say in this. This white card for convenience is issued at the discretion of the warden or by people acting as wardens. I have no objection to that. Instead of going every second week they may get a continuation certificate that they are entitled to medical attention. What I am afraid of is that if the relieving officer takes on the responsibility he may have a different outlook altogether about the question of medical services. My experience of relieving officers is this, that they have to account to a county manager pretty regularly or to their council and they are inclined to be rather severe on the people. They are not liberal. The warden has not responsibility to the county manager at all when a man goes to him and he is inclined to be a more liberal than the relieving officer. What I want to know is, is the relieving officer the person who will have the duty?

Dr. Ryan

I could not answer that, but I presume it would be. I think that the county manager would operate that system naturally. He probably would operate it through the home assistance officer. We could not immediately say that the red ticket system is withdrawn, because you may be sure that there are many people in the country who would not bother going for the white card and then they would get sick, maybe rather suddenly, and have to do something about it, so we must have the red ticket issued probably for some years.

Mr. McGrath

At the present time a member of a public assistance authority can give a ticket. Will he be able to do so in the future?

Dr. Ryan

Yes, the red ticket system will continue as far as that is concerned.

Dr. ffrench-O'Carroll

I am interestedin Deputy Kyne's point on the definition of what exactly is the public assistance group. I can sympathise with the Minister. I have never known what the old definition actually means. I think the defination is: "A person who is able to provide for himself by his own efforts or by other lawful means." I think it might be to their disadvantage if it were more carefully defined or set out exactly what should be done, because I think the relieving officers and the district medical officers have various interpretations of that. My experience is that many district medical officers do not ask for the red ticket at all now. I think it is a great pity that in this particular part of the Bill the Minister did not try to put what we call the public assistance group to-day and the middle income group into one section of the Bill.

General Mulcahy

They are put into one section here.

Dr. ffrench-O'Carroll

It is a pity that when we produce assistance to the middle income group which is going to be of some benefit to that particular group we do not put that group and the persons in the public assistance group into the one group.

General Mulcahy

They can all be grouped together.

Dr. ffrench-O'Carroll

There are many sections where there are differences in the treatment they will receive. The point that Deputy Kyne was discussing was the way relieving officers would treat cases to decide whether any person was in the public assistance group or was not. I think that, rather than try to define the public assistance group, he should work for the abolition of whatever differences there are between the public assistance group and the middle income group and try to make them all one throughout the Bill.

Mr. McGilligan

I do not think we can appreciate Section 25 without having a look at Section 26, since we are getting well away from the old easy-going method of the red ticket and getting into rather difficult territory for the future. Section 25 gives the health authority power to requirefrom a person a declaration. That declaration is to discover whether a person is or is not entitled to any service provided under this part of the Bill. They can also ask him to make that declaration in such form as the health authority considers appropriate and the health authority is empowered to take such steps as they think fit to verify the declaration. All that adds up to considerable power. Such power might easily be brought under review in the courts in a case where it was sought to surcharge people for giving services to people who were not entitled to them. If there were any reliance on the old easy-going attitude, the court might say: "You started off again in 1953 and the legislative body took care to ensure that the health authority was empowered to get this declaration and could take steps to verify the declaration."

You go on to Section 26 which I ask to be allowed to look at, at least in this connection. Section 26 says that if a person is recorded for the purpose of the section by a health authority as entitled on account of specified circumstances to a service provided by the health authority, he is to inform the health authority of any change in the circumstances. In the next sub-section there is a fine of £20 for which he is made liable if he does not notify the change in circumstances. Let us apply that to Sections 13 and 14.

Section 13 is the old "destitute" section—the health authority is to make available without charge for certain people certain services that they are unable to provide for themselves. Who are the people? That is defined. It is the old definition under the Public Assistance Act—I do not think there is any change—those who are unable to provide "by their own industry or other lawful means the medical, surgical, opthalmic or dental treatment or medicines or medical, surgical or dental appliances necessary for themselves or their dependents". A person may be in that class but if his circumstances change to the point that he move out of that class and does not notify the health authority, the health authority may come down on him and he maybe fined £20. There is an amendment to take that out but it is still there.

Services may also be rendered under Section 14. The Minister says that some of these groups will more or less define themselves. There are four categories, the first of which is people insured under the Social Welfare Act. The Minister thinks it easy to find out who they are. There is also those given under (c)—adult persons whose yearly means are derived from farming, the rateable valuation of the farm or farms being £50 or less. In that there is a little bit of choice— people whose means are "in the opinion of the health authority" so derived. May I accept for a moment the Minister's view that that class will define itself pretty easily and there will not be any reason for a declaration? I am not so sure about that. It may be said that a local authority was not efficient or attending to its duties if it did not demand an declaration. There is also the class of people whose income is under £600. The Minister thinks it is a small group. It is adult people whose yearly means of are under £600. This whole matter is defined afterward in sub-section (6)— that it includes the yearly means of the spouse, where such spouse is resident, and the annual means of any unmarried son or daughter of the person or of the spouse or deceased spouse, where the son or daughter is normally resident with such person.

The Minister might get some clarification if he asked the Dublin authority regarding their difficulties on the differential rents, which goes down to a means test and to getting information to enable that means test properly to be applied. It seems to me that there could be considerable difficulty, unless we are going to adopt a very easy-going attitude in regard to the middle income group in defining people under paragraph (b). Those are the difficulties that are ahead.

Section 25 is now starting a new system and is no doubt to be taken that it will be represented hereafter that the legislative body was turning back on the old easy-going method of the red ticket and, now that they wereannouncing what were to be better benefits, there was going to be better regulation of the class entitled to the particular benefits. The red light is shown in the next section. If a person's circumstances change so that he shifts from the destitute group to the middle income group or from the middle income group out of that group, and does not notify the authority, he may be fined. There is an air of complete illegality about this. There is definitely a more disciplined system where services are going to be provided, but provided with more rigidity and more regard to the points of entitlement. It is a pity we could not get that matter clarified, as to what the health authority intends to do. The Minister talks about a declaration. There are two types of declaration. There is that called a statutory declaration, and falsehood in respect of it may get a person hauled before the courts and fined. I do not know whether a declaration is going to be much good otherwise. I can see the ordinary declaration where a health authority says it believes, from its view of a man, that the man is inside a particular group and entitled to get certain services. I believe they are going to demand a statutory declaration.

Dr. Browne

I naturally, of course, am impressed by the argument put forward by Deputy McGilligan against this proposed system which is implicit in this part of the Bill. There are two objections which fall to the section, the insistance on the declaration of of means. Deputy McGilligan has made the case which is universally recognised against the imposition of means tests, particularly in health services. Inevitably, one must run up against these terribly complex tedious attempts by the draftsman—with the best intention in the world, I have no doubt—to cover every contingency and all the contingencies mentioned by Deputy McGilligan. Even if one did not have other objections to the means test and the attempt to cover all the likely eventualities which must flow from this very complicated legislationin relation to the means test, one would have to be moved by the appalling prospects which this opens up. This is an attempt to keep control as to the people who are within particular income groups, the people who have moved out of those groups and the people who move in, to follow the change of their financial circumstances in cities, towns or in the country. There is no doubt that in order to meet the wishes of the people who are in favour of a means test in relation to health schemes, this tremendously elaborate administrative machine must be engaged in the local authority service. It is most regrettable that this should have to arise and that it should have to be created. The ideal would have been to jump all these fences in one and have a scheme in which there was no necessity for a means declaration or means test of any kind.

If, however, one does accept the necessity for a means test—and I must confess, of course, that I accept it as a temporary measure in view of the fact that it appears to be the wishes of the majority of the House—I feel absolutely certain that there will eventually be an extension of the T.B. no means test service, the neo-natal no means test service and the infectious diseases no means test service and the maternity services included in this Bill itself. I think that is the one bright part of the Bill—that that principle has been maintained, possibly slightly vitiated but I do not think in effect vitiated. That principle will be extended over the years and eventually we shall be able to rid ourselves of this rather frightening incubus which must be created in order to help the various local authority officials who must be guided by the very rigid rules created by the Minister under this legislation. The ideal arrangement would be for us to dispense with the assessment of means and to decide that the health service shall be available to all, either because they need it due to economic circumstances or because they are paying rates or taxation, the need being decided on purely medical considerations.

The main objection to the meanstest is not any doctrinaire political objection at all. As far as I am concerned, it is an objection based on medical grounds that you can have an even type of service with a means test running through it. I think you can get different levels—two-tier, three-tier levels—and I think that the lower income group can come off least well in the contest for the health services. If one does insist on the retention of a means test in our health services, that heritage of years gone by, then I am afraid that all these sections for which you create this very involved and complicated series of regulations are simply consequent on your insistence on the retention of a means test.

Deputy McGilligan talks about the free-and-easy red ticket days, and so forth. It is no use telling a relieving officer or a public official that he can use his discretion. Unfortunately, I do not think the average official feels free to do it. He must be bound by the letter of the laws we create. Therefore, if we insist on keeping this means test we must impose this very expensive administrative machine on our local authorities.

From conversations I have had with visitors who, in their own country have valuable no means test health services, I found that one of the main arguments put forward by them for these types of services, particularly in Great Britain, was that the means test was administratively terribly complicated and very expensive to carry out and that, for that reason alone, it was thoroughly undesirable.

The Minister cannot be accused of having introduced these things particularly willingly. We know quite well that this legislation is amending the 1947 legislation for which he won the authority of the House for a free no means test scheme and which would be a much bigger bite at the whole cherry which, in reality, would be a free no means test health service.

General Mulcahy

The outrage that I find here is that whereas this section plans to deal with the means tests that will define the lower income group, the middle income group and the deservingcases in between, and the higher income group, we are told in this section that the health authority shall take such steps as they think fit to deal with the matter—that is, that the machinery and the method of distinguishing between the different groups in the spectrum will be such steps as the local authority think fit.

Deputy Dr. ffrench-O'Carroll suggested that it is better not to define too clearly how this will be done. Here is an inquiry section and we find that the approach is: Better not inquire too deeply how this inquiry is going to be carried out.

Deputy Dr. Browne's appreciation of what will arise here is that very rigid rules must be created by the Minister to deal with the matter. He implies that the local authority officers who, more and more, have to deal with these matters are getting into the position that they are not able to use their own discretion in connection with this matter.

The outrage that I find here is that, in a very complicated and very vital work, that is, discriminating between the lower income group, the middle income group and the higher income group, and fairly assessing the rights of every particular person, all we are told is that, in the administration of this matter, the health authority shall take such steps as they think fit. I think we ought to be told to what extent, if any, the Gardaí will be called upon to carry out inquiries or to take steps in the matter, or any other class of officials, or whether or not new machinery is going to be brought into existence.

It appears to me that it is an outrage to tell the House that, in a matter like this, the local authority—in other words, the county manager—may take such steps as he thinks fit.

Brendán Mac Fheórais

I hope the Minister will not lose sight of one of the observations made by Deputy McGilligan with regard to those people who might, from time to time, drift under the heading of "persons insured under the Social Welfare Act, 1952" and thus become participants in the middle income group services.

Every Deputy in the House knows that we have thousands and thousands of these people who cannot, as sub-section (2) of Section 13 specifies "... provide by their own industry or other lawful means the medical, surgical, ophthalmic or dental treatment or medicines, or medical, surgical or dental appliances necessary for themselves or their dependents." I have in mind people who would be unemployed for 11 months of the year and who, say around Christmas, might get relief work under the local authority or get some temporary job around Christmas but would be unemployed for the other 11 months of the year. What is their position? What change is there to be if, strictly, they and their families are to be regarded as person insured under the Social Welfare Act, 1952, and, coming under the heading of the middle income group, would thus be deprived of certain services and appliances, particularly dental treatment, to which they would not be entitled under the middle income grouping although they are services which they certainly could not afford themselves?

Dr. Ryan

I must say that it was not intended at first, whatever way the Deputy might have read it, that everybody in the insured class would be in the middle income group. Many insured people would be in the lower income group if they "are unable to provide by their own industry or other lawful means the medical, surgical ophthalmic or dental treatment, or medicines, or medical, surgical or dental appliances necessary for themselves or their dependents." There are many people insured who have not a bigger income than, say, £4 a week. I have in mind farm labourers, and so forth, and perhaps other people even lower than that. Naturally, they would be the lower income group. I should say that probably half the insured people would be in the lower income group. An insured person can, however, claim to be in the middle income group.

Mr. McGilligan

This ought to be taken seriously. A section of this typeis needed of course once there is to be a means test or a number of means tests, and there are quite a number throughout these proposals. May I take the points made by Deputy Mulcahy first? This certainly is extremely wide. There was a point that, apparently, was of some significance to the Minister when discussing amendment No. 46 and certainly the same sort of difficulty arises here. In discussing amendment No. 46, that is, that the charges were to be approved or directed by the Minister, because the Minister thought it necessary to regularise the charges, to make them more or less uniform or at least to have the power to keep some near approach to uniformity, the Minister apparently regarded it as objectionable that these matters should be left to each separate health authority because you might get a series of charges with very wide divergencies between them. Similarly here in regard to this rather special matter of finding out a person's means, when there is attached to the means, test a penalty—because the matter is to become an offence under certain circumstances rendering a person liable on summary conviction to a fine not exceeding £20—the form of the declaration would surely be a matter in which the Minister should intervene and give us a specimen type of declaration or a ruling generally with regard to the declaration. That would appear to be the way out of this, that a statutory declaration would be the one which would be imposed on people in the end.

It is said that where there has been an insistence on the means test there has been an insistance on objectionable inquiries of this type. An inquiry is particularly necessary if one has to discriminate between people and if one has to supplement what people are able to provide out of their own resources for these medical services. But if you cross the borderline you get into rather dangerous territory if you want to do what people should morally be required to do for themselves. An inquiry is necessary but it is wrong to leave it in this vague form: "A health authority may require that person to make a declaration in such form as they considerappropriate." Deputy Mulcahy pointed out that the matter is still wider when you say: "May take such steps as they think fit to verify the declaration." In the end it would work out that there will be a declaration required, and if there are circumstances breeding suspicion a person will be taken to court and the declaration will be produced and some evidence given which will establish prima faciethat the person is getting aid to which he is not entitled.

We are getting into a new system. I do not think it can be denied that it is a new system. Up to date these services were provided on what is called the red ticket system. I always understood from my acquaintance with medical practitioners that the administration of public assistance through the red ticket system was carried out in what was described as a very charitable way. Apparently there is some objection taken to having a service rendered on grounds of charity. I do not think there is anything wrong with that. But when you get to another point, when you come to something that people are entitled by legislation to demand as a right, even though the right is limited by certain circumstances, there is no use blinking the fact or trying to pretend that you can render services of this kind on a charitable basis. You simply cannot. You must have a real inquiry about means. It may not be developed too rigidly. It may be that only, so to speak, exceptionally bad cases, really fraudulent cases, will be brought to court. But there must be some definite discrimination made as between the categories and much more court activity in bringing defaulters and defrauders to book if persons try to get into a class in which they will get freer benefit or better services than they are entitled to.

I think it is necessary to accept that we should have a means tests in this legislation and, having a means test, we must have some procedure by way of declaration, something that has been described as an inquisitorial procedure. That is a necessary adjunct to the provision of a means test. I am glad we have a means test. I think itis necessary. I think it divides people into different groups and that we can give the aid required instead of putting every grade on a charitable footing.

Dr. ffrench-O'Carroll

I understood Deputy McGilligan to say that the administration of the red ticket system was done in a charitable way. I do not agree with that, because the red ticket at present is issued by wardens and, in my experience, a lot of the wardens, particularly in the country, are local shopkeepers, and the position in practice is that if a person wants to obtain a red ticket under the dispensary service very often he has to go into a shop and ask for that red ticket.

Mr. McGilligan

Many a doctor has treated a person without a red ticket, and without inquiring whether he was entitled to it or not. That is charitable.

Dr. ffrench-O'Carroll

A lot of medical officers never bother about a red ticket. There are circumstances where a doctor can request a red ticket and, if a person comes without a red ticket, he is within his rights in saying to the patient: "You must go back and get a red ticket." The vast majority of them do not do that. I should like to come back to the point of the means tests as far as this section is concerned. I hope the Minister will see that it will be carried out by the relieving officers under more decent conditions and in circumstances where there will be some privacy so that the disclosures made by the applicant will be confidential. If there is to be a means test, I hope the Minister will do away with the wardens.

Dr. Esmonde

As regards this means test, Deputy Dr. Browne is consistent in maintaining that there should be no means test. He also stated that there would be an imposition of the means test under this particular section and that in due course there would be built up in every area a considerable amount of administrative expenses. I agree with that. I think it is an argument against the whole principle of the sections with which we are dealing from beginning to end. It also I think brings us back to the point thatthe only satisfactory solution in this case is to have contributory insurance. If you have contributory insurance, you do away with all question of means tests. The argument as to whether you require a means test or do not require one does not arise. Simply, people who are not able to provide for themselves with the present high standard of living are able to meet the expenses that will come their way when they are unfortunate enough to be in the hands of medical attendants or going to hospital, if they are aided by contributory insurance. The only means test is as to whether the money is utilised for the purposes of treating them for whatever ailments they may have.

An Leas-Cheann Comhairle

That would not arise on this section. We are dealing with the declaration as to means and nothing else.

Dr. Esmonde

I am arguing that if you have contributory insurance you will not require a means test. Deputy Dr. Browne says we should not have a means tests, but the Minister is introducing a means test. I am maintaining that you will do away with the means tests if you have contributory insurance. You will not need a means test or a big administrative staff, which is what you are going to have. You can start in a small way with a few officials. The outcry in this country is in the case of every Department: we have too many officials; we are paying too many taxes; we cannot afford to pay those taxes. If you are going to have a means test you are going to have more officials, more expenses and the administrative cost is going to be considerable. Therefore, I think the only reasonable solution is if you abolish this section altogether, have no means test and introduce contributory insurance. If you do that, you are going to remove expenses and ensure that money taken out of the pockets of the people is used for the purpose for which it was intended and goes into the health services and not into administrative costs. I asked the Minister the other day what he estimated administrative would cost——

An Leas-Cheann Comhairle

TheDeputy is getting far away from the section. Section 25 deals with the declaration as to means.

General Mulcahy

It is going to cost something if some of the remarks we heard mean anything.

Dr. Esmonde

With respect, Sir, would you not agree that a means test is going to produce increased administrative costs? That is the point I am arguing. I will read the section:—

"For the purpose of determining whether a person is or is not entitled to any service provided by them under this part of this Act, a health authority may require that person to make a declaration in such form as they consider appropriate in relation to his means and may take such steps as they think fit to verify the declaration."

Surely, Sir, you agree that you must have some sort of administrative staff to deal with that. That is going to cost a certain amount of money. That is the case I am going to make.

An Leas-Cheann Comhairle

The Deputy could argue some of these points on earlier sections. The Deputy cannot argue the merits or demerits of some of these points on Section 25.

Dr. Esmonde

Perhaps the Minister would tell us—in fairness I must say he has tried to explain it—how this means test will be implemented? I can see some considerable difficulty with it. We have three sections of the community to deal with. We have the lower income group in which we are going to have perpetuation of the red ticket to which some Deputies have strong objection. We are going to have also white cards and if a person has a white card which says he is under continuing treatment, it will obviate the necessity for him to get a red ticket. I think I agree with Deputy Dr. ffrench-O'Carroll that the majority of doctors do not look for red tickets.

Mr. Kyne

And for a very good reason. It is not for the welfare of the patient.

Dr. Esmonde

Would the Deputy care to give me the reason?

Mr. Kyne

So that if he does choose to charge later on he can but if he gets a red ticket then he cannot.

Dr. Esmonde

I am afraid the Deputy has a very poor opinion of the medical profession.

Mr. Kyne

The Deputy is no fool.

Dr. Esmonde

A doctor is entitled to refuse under existing law to attend a patient or to visit a patient unless that patient brings a red ticket. Is not that so?

Mr. Kyne

Yes.

Dr. Esmonde

Does the Deputy know many cases where doctors have refused to do so and sent them back for tickets?

Mr. Kyne

That is not the point.

Dr. Esmonde

Then I have not got the point, I am afraid.

Mr. Corish

It is good practice for some of the doctors not to ask for red tickets so that if they want to charge the patient later they can do so.

Dr. Esmonde

I do not agree with the suggestion that the majority of doctors do not look for red tickets at all.

Mr. Corish

Not the majority—they are in the minority.

An Leas-Cheann Comhairle

Deputy Dr. Esmonde on Section 25.

Dr. Esmonde

We are on the lower income group. Now let us take the middle income group. As the Minister said difficulties will not arise with regard to the farming community because it will be quite easy for the county manager or a health authority—I assume we are agreed now that the county health authority is the county manager—to refer to the rate book and he can easily find out what means are there. But I think in the big centres such as Dublin, Cork and so on, there will be considerable difficulty in ascertaining the means of intending participants in this health scheme, and I would like the Minister to give us some idea of how the county manager, or therelieving officer or whoever else is there, is going to find out this means. Has he the right to go to the employer and find out what he is paying his employees? Has he the right to insist on getting a declaration on oath as to the means? I think you will agree with me that the thing is not as simple as it sounds. There is going to be considerable expense and in the final analysis you are going to have a lot more civil servants under this Health Bill, or under Section 25 alone than you have at present, and a lot more taxes and expenses thrown on the country.

General Mulcahy

I think we have rather thrown emphasis on the red tickets in the discussion on this section and that is unwise and unnecessary. I think it has tended to obscure the enormity of this section. Section 13 deals with the lower income group but Section 14 definitely deals with a number of classes that add up to about the middle million of our population. The first million contains the lower income group and the second million contains various classes, and according to this Bill entitles them to certain services, medical and otherwise. But in order to define what services they are entitled to, they will require to be classified. The person who is the authority, the sole authority to classify them is the county manager. We are told here in Section 25 that he shall take such steps as he thinks fit to classify them and classify them in relation to their means. He can require them to make a declaration in such form as the county manager considers necessary. If the county manager, having received such a declaration as to their means does not exactly believe that it is a true account, then he can take such steps as he thinks fit to see to what extent the details of that statement are right or wrong. That is all we have been told about this and I suggest that the talk about red tickets, about wardens, the relieving officer and all that, has nothing to do with providing us with information with regard to the scheme. Deputy Dr. ffrench-O'Carroll thinks that the relieving officer should have his powers extended to cover the whole spectrum of our population in this matter.

Dr. ffrench-O'Carroll

Did I say that?

General Mulcahy

I understood the Deputy to say that the warden should be abolished and that the relieving officer should do this work and do it with a little more privacy than the warden did it.

Dr. ffrench-O'Carroll

I said that we should have as little investigation as possible and that we should put all these sections into one.

General Mulcahy

I say this section does put them all into one——

Mr. McGilligan

There is no doubt about that.

General Mulcahy

——to the extent that it says to the county manager: "You can make any individual make any declaration in any form you think fit and then you can take such steps as you like to verify what they have stated." They are all put into one there. If I did not misunderstand Deputy ffrench-O'Carroll, the suggestion that the Deputy made was that the machinery should be the relieving officers, acting a little more delicately and with a greater sense of privacy than a shopkeeper who might be authorised to give red tickets. I do not know if the machinery is to be the relieving officer but if it is to be the relieving officer, I think it should be put into the section here.

I want to suggest that the Minister has not given us the slighest information in relation to the section. There are so many things here that the Minister is required to do and so many regulations that the Minister is asked to make that there is a remarkable shyness departmentally and ministerially about having anything to do with the section. The lack of information is what I can only describe as a legislative outrage. Surely the Minister does not think that it is reasonable to give sole power to an official such as the county manager to decide what steps he should take to find out whether the information given about a person's means is right or wrong. Is the county manager going to have power to refer say to bank managersin case somebody with an income of £550 may have a thrift account or is he entitled to approach shopkeepers to see to what extent information regarding the debts, which the statement says a family owes, is correct? Is he entitled to approach the Guards to ascertain what they know of a man's general mode of life or anything like that? I submit that it is not sufficient to say that the county manager shall take such steps as he thinks fit to do all the things that he may decide are necessary to enable him to come to a decision as to what part of the income spectrum a person belongs. There is a dividing line as between the first million of the population, the second million and the third million and this section enables a county manager to conduct an inquiry to ascertain to what section an individual may belong.

Dr. Ryan

The only thing that arises here is the making of an inquiry into the declaration of means. It must be quite obvious to everybody what the section means. The county manager will, first of all, ask for the declaration if he thinks it necessary to do so and, secondly, will follow that up by any steps he thinks necessary to verify it. I think Deputies will agree that the investigation that takes place is necessary only in a very small proportion of cases. There is no doubt about most cases. This investigation will, therefore, arise only occasionally. If there is a means test, as some Deputies say and as I have admitted, then you must have power to investigate. The section enables the county manager to take whatever steps he thinks fit to verify a declaration but it is obvious that under the law he cannot compel a bank manager to give him information.

Mr. McGilligan

This will be the law when it is passed.

Dr. Ryan

The Deputy knows more about law than I do but I am quite sure that under the law or under this Bill he cannot compel a bank manager to give him information. Will the Deputy stake his reputation that that is not so?

Mr. McGilligan

When this is passed?

Dr. Ryan

Will he have power to compel a bank manager?

Mr. McGilligan

I believe he could.

Dr. Ryan

I should like to have that noted as a legal opinion because it is the most ridiculous legal opinion I ever heard in all my life. It is absolutely ridiculous.

Mr. McGilligan

Can he not approach the bank manager?

Dr. Ryan

He can, if he is foolish enough, just as he can now. There is nothing to prevent him going to the bank manager if he is foolish enough to do so.

Dr. ffrench-O'Carroll

It is done under the differential rents scheme.

Mr. McGilligan

Deputy Dr. ffrench-O'Carroll says it is done under the differential rents scheme.

Dr. Ryan

There is no power here to do it. I remember a section of some Bill introduced here on one occasion where it was suggested that a bank manager should be made supply information and it took several sections to say that. Everybody knows that.

Mr. McGilligan

Everybody knows what?

Dr. Ryan

That if we wanted a Bill compelling a bank manager to give information, there would be several sections necessary to cover the point.

Mr. McGilligan

And there would be riots in the House, I hope.

Dr. Ryan

I hope there would, but the Deputy is not beyond misleading the House by saying that the power is given here.

Mr. McGilligan

Have a look at it and will you advert to the practice of the Revenue Commissioners?

Dr. Ryan

Is the Deputy prepared to say that this section compels the bank manager to give information?

Mr. McGilligan

I shall answer that in a minute.

Dr. Ryan

Do not go on with it because Deputy Costello would be appalled at such a suggestion. This is a simple section. We have a means test and we must give the local authority power at least to ask for information. Having got the information, we say let them verify it by any means in their power which means any means legally in their power.

Mr. McGilligan

It is rather late in the day to have any Deputy in this House on legislation of this type, appealing for privacy, when the whole purpose of the Bill is to stuff into the public ward all the various people who are going to get service under this Bill. Let the Deputy who is so disturbed about privacy consider this aspect of the matter. In the public ward of a hospital you are to have the various people who are destitute and who cannot by their own industry or other lawful means provide for their medical services. In another bed in the same ward you will have a farmer whose valuation is under £50. In a third bed will be the person whose family resources are not more than £600 a year, and in still another bed a person who is insured under the Social Welfare Act. All these people are going to know all about the position of their neighbours. There used to be a cant in this country about 2½d. looking down on 2d. Now we are going to give these people plenty of opportunity of looking down on one another by placing them in neighbouring beds in the same public ward. In that situation the Deputy pleads for privacy.