It is rather difficult in a debate on an Estimate which covers such wide ground and upon which so many matters of detail have been raised to make what would be described, perhaps, as a composed and shapely reply. So I can only take the principal points seriatim giving, as I think I should, precedence to the points raised by my predecessor, Deputy Tom O'Higgins. I should like to say here that I found his speech very helpful and gratifying because, quite clearly, he appreciates the difficulties under which a Minister for Health has to labour in present circumstances.
In the course of his speech Deputy O'Higgins inquired what progress had been made in the provision of a rehabilitation service. The position is that an interim report has been received from the National Organisation for Rehabilitation which Deputy O'Higgins, as Minister for Health, set up in November, 1955. This report contained a considerable number of recommendations in relation to various aspects of a rehabilitation service. The recommendations, which affect a number of Government Departments, have been circulated to those concerned and at the same time they are being examined in the Department of Health. We hope that a submission— which is in preparation—on the report will be available for my consideration within the next few weeks.
Deputy O'Higgins referred to another matter and perhaps I should quote, or at least paraphrase, his remarks. He said it had come to his notice that in some cases doctors on the staff of voluntary hospitals are seeking to charge fees in respect of the treatment of patients in the public wards of their hospitals and in that connection he said this was a practice which he completely condemned. He said: "I should like to express my complete condemnation of any person who seeks to impose any such charge". Of course, the Deputy has expressed my attitude towards that practice. It is perhaps difficult to see what we can do to curb it but, if necessary, legislation will not be ruled out because it would be quite wrong to permit the clear intention of the Legislature to be defected by those who have entered into an agreement with the State to provide these medical services free of charge in public wards. I do not want to say any more than that, but I certainly do not wish any of those who may be engaging in this practice to feel that they are likely to get away with it.
Deputy O'Higgins also raised the question of providing for those who were in the lower income group a choice of doctor. The matter was mentioned also, I think, by Deputy Coburn, by Deputy Loughman and others. I suppose it would be a desirable thing, if it could be done without any undue administrative difficulty or greatly increased expense, to provide those who are in the lower income group with the same choice in regard to their general practitioner as is provided for them under the maternity scheme. But examinations which have been made in the Department— a preliminary examination under Dr. Ryan and further examinations when Deputy O'Higgins was Minister for Health—have indicated that there are many difficulties involved.
The first difficulty is that it is highly doubtful whether it would be possible to provide this choice of doctor for the lower income group outside the larger centres of population so that we should be put—not that I would regard it as being of any very great moment—in a position in which we would have, perhaps, some very eminent people coming along and telling us how the Government were discriminating between town and country. If it were possible to provide a general practitioner panel service for the larger centres of population and if we found ourselves unable to do that in the rural areas we would probably be charged by some people in high places with discriminating between town and country. Enough attempts have been made to create—so to speak—bad blood between the inhabitants of urban and rural districts for me, at any rate, not to give further cause for complaint in that respect.
Apart from this there would be the question of expense, and this, in regard to the schemes which were examined when Deputy O'Higgins was Minister, would be quite considerable. I am informed that a modified proposal, which he suggested should be examined, would not be so expensive but it is doubtful whether, in our present circumstances, we could undertake to provide this additional right for those in the lower income group. However, I shall ask that the matter be examined further and it may, perhaps, be possible to do something. Candidly, I do not think it will.
Deputy O'Higgins also urged that there should not be undue caution— that is not precisely what he said: he put it rather the other way and urged that there was a danger that there might be undue caution in curtailing hospital building—because of the condition of the Hospitals Trust Fund. I do not think any Minister for Health, continually bombarded as he is with requests for money to finance the continuance of hospital programmes, would be permitted to be unduly cautious, but I am concerned, and it is my first concern, to see that the Hospitals Trust Fund is put on a fairly substantial basis again, because I do not think that we can, in the circumstances of the world around us, afford to build up heavy, uncovered commitments in respect of building contracts. I would certainly like to be sure that if any project is started it will have a reasonable chance of being carried through to completion even if the worst should happen and we found ourselves in such a position that the income which the Hospitals Trust Fund derives from sweepstakes was suddenly reduced or perhaps cut off entirely.
Deputy Dr. Browne criticised me very severely for the policy which I have adopted in regard to vaccination against poliomyelitis. He held that it was a retrograde step to expect parents —this was the burden of his criticism— to pay for the vaccinating of their children against poliomyelitis, even if they could afford to do so. I do not think there is anything retrograde in asking a parent to shoulder his parental responsibilities, when he is in a financial position to undertake that obligation. On the contrary, it would be, in my view, a grave and indeed unjustifiable retrogression to permit a parent who can well afford to look after the health of his children to unload his obligations and impose them on his neighbours.
Deputy Dr. Browne painted a harrowing picture of the distressing condition of children who have been stricken by this terrible disease. None of us who has any knowledge of the disease will attempt to minimise the suffering of the afflicted or the anguish of their parents; but we are not arguing about the nature of the disease or about its terrible characteristics. There is no controversy about that. We are in agreement about it and it is not an issue. What is in issue is whether it is just and equitable to use the limited resources at our disposal to help those who are in the greatest need of assistance and to expect of others, whose circumstances enable them to do so, that they should look after themselves. That, I think, is the issue, and the only issue, between Deputy Dr. Browne and myself.
The weakness of the case he has made is proven by the devices to which he has resorted in order to support it. First, we had this high-pitched appeal to the emotions. Then we were told that we were condemning children to death, or at least to be maimed and crippled for life—thousands and thousands of them, until hyperbole could soar no further. Then, the case was cited of a white-collar worker in the middle income group with a family of 12 children. A graphic picture was painted of his struggle to determine whether he would have only six of them, or none of them, vaccinated. I should like very much to have further particulars of this white-collar worker whose marriage has been so fruitful and so blest. One would like to know, for instance, the ages of his eldest and his youngest child. It would be interesting to know also what his occupation is, and whether he is insured. All this would be helpful and I should be glad to have the information and other specific particulars of the financial and general circumstances of the gentleman whom Deputy Dr. Browne has in mind. We can then see if there is any need in the particular circumstances to make special provision to meet his, and similar cases.
As I have said, we are providing vaccination against poliomyelitis free for the children over six months and under ten years in the lower income group. If our means permitted it, I should prefer to enlarge the group not by relating its range to the economic circumstances, but by relating it to the ages of the children concerned. In any event, most parents outside the lower income group should be able to carry and should, in my view, carry, their parental responsibilities. God forbid that any act of mine should result in any child being stricken with the disease. I would not carry such a responsibility lightly; but I do not think that we should carry paternalism so far as to relieve parents, who can carry their responsibilities, of the obligations which God and nature have imposed upon them in relation to their children.
The children belong to them. They are theirs to nurse and care for and, so far as the care of the children is concerned, if they are not in a position to provide it, if they cannot afford to look after their children, then the community comes generously to their aid. But if the parents are in a position to provide for the physical care of their children, why should the community be asked to provide it? Even if it does involve the parents in some little self-deprivation for the sake of the children why should they not accept it as duty? It is a very easy declension from providing services for others, and caring and rearing for others, to arrogating to oneself a proprietary right in regard to those for whom we care. And that is where, I think, unnecessary and intrusive eleemosynary action on the part of the State would eventually lead us.
I have never accepted the position in relation to those things which, as I have said, parents or other people are bound in their natural duty to do, that they are entitled as of right, even if their circumstances do not justify it, to demand that others should carry the burden for them. If we were to enlarge this scheme in the way Deputy Dr. Browne suggested, and if everybody covered by it were to take advantage of it, it would cost the State the better part of £500,000—that is, if everybody were to take advantage of it—and that £500,000 could be found, in general, only by imposing additional burdens upon the lower income group and the middle income group for whom Deputy Dr. Browne is so concerned. The burden would be passed on to these groups in order to relieve those who should rightfully carry it of the obligation of doing so.
Deputy Dr. Browne also criticised the voluntary health insurance scheme. There may be aspects of that scheme which may perhaps be criticised; I do not know. I am only assuming that, like every other thing of man's devisiting, it has its imperfections. However, there is no substance in a criticism which takes the worst possible case, enlarges on it and then says: "That is the sort of thing you are doing by providing this voluntary health insurance scheme!" The main criticism by Deputy Dr. Browne of the scheme were (1) that the scheme is expensive; (2) that it is not sufficiently comprehensive and is unlikely ever to cover more than 20 per cent. of all those not eligible for free or subsidised health services and (3) that the correct basic fundamental principle upon which a health service should be based is that there should be a comprehensive no-means-test scheme financed by taxation. I have already stated my position in regard to the last point and perhaps I should go on to consider the others.
We have to remember that, as conceived, the Voluntary Health Insurance Board and the schemes it operates are expected to be self-supporting and self financed. The State has provided the board with certain money to enable it to commence its operations. I think the general theory behind it is that the scheme will be operated for the mutual benefit of those who are organised within it and that they, themselves, will provide the income to finance the operation of the board and to finance the benefits which the members are expected to derive from it. Outside that, the Voluntary Health insurance Board conducts schemes which are non-profit making. Any surplus which may accrue from year to year or from time to time as a result of the board's operations will be given back to the policy holders, the subscribers to the scheme, in the form of enhanced and improved benefits.
In the example which he cited, in criticism of the operations of the board, Deputy Dr. Browne quoted the highest possible rates chargeable, that is, the rates chargeable to a married couple with four or more children joining the scheme as individual subscribers. First of all, let me say that rather lower rates are chargeable to people with fewer children. Secondly, even still lower rates are chargeable to those who join the scheme not as individual subscribers but as members of a group.
The examples mentioned by Deputy Dr. Browne are to be found on page 7 of the board's brochure. There, it will be found that a married couple with four or more children can participate in scheme "A" for an annual premium of £13 10s. 0d., in scheme "B" for an annual premium of £17 10s. 0d. and in scheme "C" for an annual premium of £23 10s. 0d. Therefore in that particular group, at least six individuals are covered by the premium paid. On that basis, if we divide the £13 10s. 0d. payable under scheme "A" by six we shall see that it comes to a payment of £2 5s. 0d. in respect of each person in that family. If we divide the £17 10s. 0d. payable under scheme "B" by six we shall see that it comes to a payment of £2 18s. 4d. per person in that family. In the case of the six persons covered by scheme "C", in respect of whom a total payment of £23 10s. 0d. would be asked, the payment amounts to £3 18s. 4d. per person. Contrast those figures with the £5 10s. 0d. per person which Deputy Dr. Browne mentioned in his criticism. I think it will be found that, on the whole—and taking into consideration the benefits given under the voluntary health insurance scheme—members of the scheme are getting what is reasonably fair value. I have not mentioned anything about the reduction of about 10 per cent., on the premiums which would be secured by a member of a group insuring his family under the scheme or anything about the rebate in income-tax which is obtainable on the premiums, because the amount of the rebate would vary with the circumstances of the subscriber.
The second criticism which Deputy Dr. Browne launched against the scheme is that subscribers are not covered for appliances, dental treatment, maternity and general practitioner care. The fact is that cover is given for appliances in respect of two-thirds of the cost over £2 10s. 0d. up to a maximum of £50 under scheme "A", £60 under scheme "B" and £75 under scheme "C". I think that that is quite substantial cover having regard, again, to the circumstances of the individuals who are expected to avail of the scheme.
Deputy Dr. Browne also criticised the scheme because there is no provision in it for dental benefits. No recommendation to include dental benefits in their schemes was received from the Voluntary Health Insurance Board. The arguments against including dental benefits in a scheme of this sort are set out in the report of the advisory body which considered the practicability of setting up a scheme of voluntary health insurance. Briefly they are: firstly, that the cost of dental treatment is not normally excessive. Secondly, since such treatment as a general rule can be postponed, any scheme of dental insurance would be presented with many claims arising out of postponed treatment. Therefore, such an insurance is not a practicable proposition.
As regards the insurance against maternity costs, the board made no recommendation for the inclusion of cover under this head. Of course, the question was considered at lenght, and it is true that the advisory body did consider and recommend, even though the costs of confinement were predictable as to time and amount, the inclusion of some provision to meet such costs in the scheme of voluntary insurance. As I have said, however, the board did not accept this. Any person joining the voluntary insurance scheme, who is eligible for institutional and specialist services under Section 15 of the Health Act, 1953, is entitled to all the benefits of the maternity services, if the person so desires, which are provided under the Health Acts.
As to the other point of criticism that the scheme does not provide for general practitioner care, as a rule, this is, and generally should be, met out of income.
The next type of criticism Deputy Dr. Browne made was this. He suggested that in time the number of people who would be covered by the scheme would settle down at from 80,000 to 100,000, and that against this there are 300,000 or 400,000 people who would be eligible to join the scheme, to whom it might be advantageous to join the scheme but who would remain outside it. How many of the people who are not covered by the present health services will eventually join the scheme is anybody's guess. So far, 50,000 persons have joined it within the short period the scheme has been in operation. Scarcely a day passes but I receive one or two letters from people down the country asking me how they may join the scheme. So that, as the knowledge of it is becoming more widespread, people are becoming more anxious to know what it is all about; and presumably when they are told what it is all about, they will become, in due time, subscribers. The main justification for the scheme is that it provides a service which can be availed of by those who are in a position to take it, and who are not covered in any other way. They are free to join or not to join, as they so desire, provided, of course, that their general physical condition and health is not such as would impose an undue burden upon the scheme.
Deputy Kyne raised a great number of points. Many of them were referred to by other Deputies. If I fail to mention by name any of the Deputies who brought these matters to my attention, I can assure them I listened to what they had to say, even though I shall just have to deal with the points as they were mentioned by the speakers who raised them in the first instance. Deputy Kyne suggested that appeal machinery should be provided under the Health Acts. That has been considered from time to time in the Department. Indeed, the Health Act of 1947 did grant a right of appeal to the Minister by persons aggrieved by decisions of health authorities in relation to the granting of infectious diseases maintenance allowances.
That right subsisted for a period of six years. During that period, about 1,700 appeals were considered. The vast majority of them, however, were refused. They were not sustainable appeals. In view of that, the 1953 Act abolished that right of appeal. I do not see that, so far, a substantial case has been made for setting up an appeal board to consider cases where persons have been refused the grant of a medical card. I fear, having regard to the great number of persons involved, that the difficulty of assessing the means and general circumstances in every case would make the work of an appeal board exceedingly onerous, exceedingly difficult and exceedingly expensive.