Dáil Éireann debate -
Tuesday, 25 Nov 1958

Vol. 171 No. 7

Committee on Finance. - Health and Mental Treatment (Amendment) Bill, 1958—Second Stage.

Minister for Health (Mr. MacEntee)

I move that the Bill be now read a Second Time. This Bill is concomitant with the Social Welfare (Amendment) Bill and the basic reason for introducing it is the same, namely, to give entitlement to approximately the same number of persons, to the benefit of services under the Health Act, 1953, as were so entitled when the Act was introduced. It will be recalled that the Bill to provide these services was introduced in 1952 and became law, not without opposition, in 1953. Under it general institutional and specialist services, the maternity and child health service and the mental treatment service, became available to persons and their dependants in one or other of four categories. Roughly speaking, these categories, which together make up what have become known as the lower and middle income groups, at the moment are composed of persons insured under the Social Welfare Act, 1952; other adult-persons whose yearly means are less than £600; farmers the rateable valuation of whose holdings is £50 or less; and persons outside these three categories who cannot, without undue hardship, provide the services for themselves and their dependants.

The number of landowners with properties not exceeding £50 in valuation has not sensibly changed since 1952. On the other hand, the number of persons within the remaining categories who were eligible for health services in 1953 has contracted substantially, because so many people are earning so much more. The effect of this has been that many wage-earners for whose benefit the 1953 Act was enacted have ceased to be eligible for an important group of services which it was intended should be made available for them. The aim of this Bill is to restore to those thus extruded the benefits which under the original Act they were entitled to. Perhaps at this point I should stress that irrespective of the level of their earnings persons who can demonstrate hardship will, as heretofore, be eligible for the institutional and specialist services.

Apart from the intrinsic justice of reinstating all those for whose benefit these health services were originally provided, I should like to point out that the amendments of the Social Welfare Acts proposed by the Social Welfare (Amendment) Bill would make the assessment of entitlement a more complicated matter than it is at present if we did not make the income limitations under both codes coincide. At present, in so far as insured persons seeking health services are concerned, it is necessary only to establish that the appropriate contributions have been paid under the Social Welfare Acts. Once this fact has been established, it is not necessary to make further inquiries into the person's means or into the means of the members of his family residing with him. Eligibility in this context is related to insurance under the Social Welfare Act of 1952. Unless the Health Act is amended to change this reference to cover the 1952 Act as extended by the Social Welfare (Amendment) Bill, which the House has just passed, those within the £600 to £800 limits would not become entitled, as insured persons to Health Act benefits. It would, therefore, be necessary to establish, in relation to each person in non-manual employment insured under the Social Welfare Acts, whether or not his annual income were above or below the old level of £600. To attempt so to distinguish between the persons paying insurance contributions under the Social Welfare Acts would be administratively difficult and costly.

In the case of the second category —non-insured adult persons whose yearly means are less than £600 and their dependents—the case for increasing the limit is, if anything, stronger than for the insured. In the case of a person claiming entitlement under this, the assessment of eligibility is made on a family basis, which is not the case under the Social Welfare Act. This, of course, makes it relatively more difficult for a non-insured person to establish his entitlement to the services; and it would be indefensible further to disimprove his position vis-a-vis the insured by not making a corresponding easing of the income limit.

In the Health Act, 1953, yearly means for the purpose of determining eligibility for the "under £600" group includes the means of any unmarried son or daughter, stepson or stepdaughter living with the applicant. It has been represented to me that it is unfair to take all the income of such persons into account. A typical case might prove the point. Take for example, a married couple. The husband retired with a pension of, say, £3 a week. Living with their parents are a son and daughter who are working and earning, say, £9 a week. Because the family income under the law as it stands is £12 a week, or £612 a year, the parents are ineligible for services under the Act while the children, if they are in insurable employment are eligible. Both the children might be saving to get married and, reasonably enough in those circumstances, not handing up all or even the major part of their earnings. It is hard, I think the House will admit, to justify refusing services to the parents in such circumstances. The extension of the family income limit from £600 to £800 will no doubt improve the position in such cases, but I feel that something more is required and, consequently, sub-section (4) of Section 1 provides that wherever the family includes more than one member with an income, the first £100 of each son's or daughter's income will be disregarded in calculating the aggregate of the family income. I feel that the figure of £100 is a fair compromise between the interests of the family on the one hand and of the ratepayers and taxpayers on the other. It is not unreasonable, however, to put a limit on the number of hundred pounds to be disregarded in this fashion and the limitation imposed in the Bill is £300.

It is difficult to say how many people will be covered by the new provisions or what the additional cost will be, but it is estimated that the benefits of the Act may be extended to about 80,000 additional persons and that the additional cost will be of the order of £120,000, half of which will be borne by the Exchequer and half by the ratepayers. I am reluctant, as I have made clear in the past, to add substantially to the public expenditure on health services, but I feel that the additional charge must be accepted.

This Bill, as I said at the outset, will in effect bring back within the scope of the services provided under the Health Acts a considerable number of persons for whom it was intended to provide such services when the 1953 Act was passed. Clearly it involves no departure in principle from legislation which has already had the approval of the Oireachtas. In those circumstances I trust the House will see its way to give the Bill a Second Reading.

Mr. T.F. O'Higgins

One cannot help feeling that when the Minister went to the trouble of introducing this Bill into the Dáil—a Bill which involves an amendment of our Health Act code—it was a pity he did not decide to deal with more than is dealt with in this Bill. This is an insignificant measure designed to deal with, comparatively speaking, a very small category of persons. Indeed, I would have thought that what this Bill is designed to do could already have been done by the Minister by appropriate regulations dealing with the hardship classes under Section 15 of the Act. I cannot help feeling that the Minister introducing this Bill is adopting the slogan "much ado about nothing". Perhaps the Minister finds a Bill of this kind a welcome relief from writing letters to the newspapers.

Mr. Corish

He enjoys that, too.

Mr. T.F. O'Higgins

What the Minister proposes here is to adjust the charges of the Health Act, 1953, in accordance with what has already been done by this House a few minutes ago by amendment to the Social Welfare Act. Since, under the Social Welfare Act, a limit for insurable purposes of £800 was laid down, it was obviously felt by the Minister that there should be written into the Health Act £800 instead of £600, although there is rather a non sequitur there because the £600 in the Health Act refers largely to self-employed persons.

To appreciate the small scope of this Bill, Deputies must remember that those entitled under the Health Act code to institutional and other services, apart from general medical services, are covered by the definition of eligible farmers up to £50 and an insurable person under the Social Welfare code. Those who come in by reason of the fact that the family income is less than £600 must be a very small number, but it is sought to provide in this Bill that in relation to that small category of persons the family income limit shall in future be £800.

To the extent that the Minister feels that the scope of the Health Act should be extended to deal with persons of that kind, certainly he is entitled to this measure. I do not think anyone here could have the view that a person whose family income does not exceed £800 is a person in no need of some assistance from the State.

In relation to health legislation we are all of the view that where a case of need has been established there is not only a necessity but also an obligation on the State to assist. The State assists the people in the class dubbed the middle income group because there is a gap between what they can provide themselves and what the actual cost is to them.

Undoubtedly, there are persons whose family means might exceed £800 who are equally in need of State assistance by way of aided hospital and institutional services. I should not like the Minister to feel that, while we agree with his Bill, we are doing anything of a notable kind for persons who might need assistance from the local authorities. We are merely adjusting the £600 figure in the Health Act, 1953, in relation to the falling value of money over the past five years. We are doing no more.

We intend to affect by this legislation a very small percentage of those who need some form of State assistance in relation to health services. This is a very insignificant measure. If the Minister has thought about it he might have been able to do this by a regulation or by a circular letter to the health authorities telling them to arrange in their treatment of cases of hardship in future for those whose family means did not exceed £800. The Minister finds it necessary to bring a Bill in here and I would not deprive him of the satisfaction which that undoubtedly means to him.

Mr. Corish

In the White Paper the Minister described this as being a corollary to the Social Welfare Bill which we have just passed. As Deputy O'Higgins said, if one examines it it will be seen that it is an insignificant Bill. I do not know whether or not that arises out of the fact that the Social Welfare Bill was introduced first when the Minister was not here. I do not know who took the initiative. I am not aware whether it was the Minister for Health or the Minister for Social Welfare.

Mr. MacEntee

Both simultaneously.

Mr. Corish

The Minister appears to occupy the role of Pooh Bah. I think it is the Minister for Social Welfare we should blame. This Bill is a corollary to the Social Welfare Bill. The Minister has gone just a little further. For that he ought to be congratulated. He says that the first £100 of the son or daughter, subject to a limit of £300 in the case of any family, is to be disregarded when treatment is suggested for those in the middle income group and whose income now must not exceed £800. That is a very good departure and for that I should like to congratulate the Minister.

He has done that in respect of the middle income group. I do not know whether or not it would be appropriate to suggest on this Bill that the Minister ought to examine the case of the lower income group. As far as my experience goes, all the income going into the one house is taken into consideration for the purpose of assessing means to establish entitlement or otherwise to Government health services. If the Minister concerns himself about the proposal in respect of the lower income group and makes a change somewhat on the lines suggested, I think he would be doing something to eliminate a big number of grievances in regard to the Health Act services as far as that particular group is concerned.

However, that may not be entirely a matter for the Minister. As far as I am aware, he can only advise and not direct because I do not think he has power within the parent Act to lay down means in respect of the lower income group to the local authorities. I can assure the Minister that it is operated very harshly indeed by the local authorities who in all cases happen to be county managers or somebody appointed or designated by them.

The Minister also stated that this amendment does not debar a local authority, a county or city manager from assisting or providing health services for people with an income of over £800 per year where he is satisfied that they could not afford hospital maintenance, hospital treatment or specialist treatment. In actual practice, the local authorities or the managers stick rigidly to the formula of the £600 per annum now and will stick rigidly to the ceiling of £800 per year in the future.

As far as I am aware, that was not the intention of the Act. Various Ministers have given it as their opinion that there should be some sort of elasticity in approaching problems where families with an income of £800 per year cannot afford to pay big hospital bills, specialist or surgical fees.

I should like to ask the Minister what effect this measure will have on the voluntary health insurance scheme. As far as my information goes, it seems that the voluntary health insurance scheme has been an outstanding success but whether or not it has reached the zenith of its success I do not know nor do I know whether it is deemed to be an economic scheme. I should like to know what, if any, effect this amendment will have on the voluntary health insurance scheme.

The Minister apologises and says that this scheme is going to cost £120,000; that £60,000 will be borne by the State and £60,000 by the local authorities. I do not think he need worry to any great extent about the burden this £60,000 will place on the local authorities throughout the country when one remembers that 80,000 people, as I think the Minister said, will, benefit by it. I do not mind telling the Minister that the local authorities have devised ways and means of extracting money from him under the Health Act.

I can give him one very good example. It is one he should look into. Tens of thousands of people in this country had been drawing what is described as home assistance for a number of years past until the introduction of the disabled persons maintenance allowance. The practice of some local authorities in the past two or three years has been to transfer many of these people from home assistance to the disabled persons maintenance allowance. Any person who can prove by the production of a medical certificate that he or she is not fit to work is transferred to the disabled persons maintenance allowance. There is thus qualification for recoupment to the extent of 50 per cent. from the Minister for Health.

In my opinion many of these are purely home assistance cases. The local authority saves money by taking them on home assistance and qualifies for the 50 per cent. refund from the Department of Health.

An Leas-Cheann Comhairle

The matter of administration would not be relevant on this Bill.

Mr. Corish

I am talking not so much about administration as I am about the cost. The Minister told us that this was going to cost the ratepayers £60,000. I am trying to tell him where the ratepayers will get more from the Minister for Health than they should.

Major de Valera

There are two questions I wished to ask, the first of which has in a sense been asked—the effect of this measure on voluntary health insurance. The second matter arises on the amendment that is proposed in regard to the allowance of £100 for certain members of the family up to a total of £300. If I understand the thinking behind that section it is that if there is a relation, within the categories mentioned, in a family earning, £100 of the earnings of any one of those can be disregarded up to a total of £300. That means that if there is only one such relation in a family a benefit of only £100 is given whereas if there are three or more such relations a benefit of £300 would be given. It seems to me that the case which would more nearly require it would be the case where there was only one such person in the family. That is what leads me to ask the Minister whether he has considered a flat ceiling of £300 irrespective of how many are in the family. I am just asking that in the form of a question at this stage and the necessary amendment could be considered later.

Mr. O'Donnell

There is just one matter I should like to mention to the Minister at this stage although it would probably be more appropriate on Committee. I represent a constituency, as do many other Deputies where a number of our constituents have to depend on emigration and migration, particularly the latter, for a livelihood. I know a number of families in West Donegal where five or six members of the family migrate to Britain for 11 months of the year and return to this country for only two or three weeks during the summer when the public works on which they are engaged in Britain are closed down. Their residence for all practical purposes is in Britain; they contribute very little to the household "kitty" or fund at home and pay their income-tax in Britain. But when the father or mother of the household wishes to take advantage of the Health Act, the earnings of those unfortunate migrants who cannot procure employment here are taken into account in assessing the means.

Mr. MacEntee

They must be living with them.

Mr. O'Donnell

That is just the point. I know cases where the local authority take into account the earnings of the entire household. They may be migratory workers in England who are here for only a month at the very most during the summer and possibly another week at Christmas, but their earnings are taken into account in assessing the entire family income and very often these people are debarred from the benefit of the Health Act as a result of that. If the Minister inquires from my local authority in County Donegal he will find out that not only must they give the names of the members of the household but the names of their employers in Britain; we all know the very large percentage of earnings which goes into the British Exchequer by way of income-tax, but that is not even taken into account. The gross earnings of the members of the household in Britain are assessed for the purpose of the Health Act. That is something the Minister should look into.

Mr. Corish

It is something the county council should look into.

Mr. O'Donnell

At the direction of the Minister, because we can do nothing about it. You are very well aware of the situation, a Leas-Cheann Comhairle, as are other Deputies from West Donegal, Galway and Mayo who represent constituencies where there are migrants. Some directive should go down from the Minister. The Minister, of course, will say that is a matter for the local authority.

Mr. Corish

They should read the Health Act, what few local authorities do.

Mr. O'Donnell

They should read the amendment to Section 15 (6) (b), that is one thing that would be read out by every county manager. I am quoting from the White Paper, paragraph 3 of which says:—

"Section 15 (6) (b) of the Health Act, 1953, provides that the yearly means of an applicant for the services referred to at (b) in paragraph 1 above, are taken to include the full annual income of the spouse and of any unmarried son, daughter, stepson or stepdaughter normally resident with the applicant..."

That is simply because they come home here. It is their residence. They retain their Irish citizenship and hope they will continue to retain it and that they will be able to come back and live here permanently if they find employment at home. So far as we are concerned their residence is here. It is not their normal residence, which is in Britain.

Mr. Corish

How long are they at home in Donegal?

Mr. O'Donnell

A month. They are on the voters' register and the Fianna Fáil Cumainn make sure they are on the voters' register.

Mr. Corish

Why is the Deputy concerned about the Fianna Fáil supporters?

Mr. O'Donnell

I am concerned about all the families in my constituency. I never ask them what their politics are, and I hope to continue in that way.

An Leas-Cheann Comhairle

The Deputy is getting away from the Bill.

Mr. O'Donnell

I am glad you have reminded me of that. I would ask the Minister to consider the following amendment which might cover the point I am making. I am quoting again from paragraph 3 of the White Paper:—

"...Section 1 (4) of the Bill proposes to modify this provision in favour of applicants by disregarding the first £100 of the yearly means of a son, daughter, stepson or stepdaughter, subject to a limit of £300 in the case of any family."

If the words "earned within the State" were put in at the end of that paragraph I think it would meet the point, that is, if we refer to the £800 as money earned within the State and disregard moneys earned outside the State.

Mr. Corish

Does the phrase "normally resident" not cover that?

Mr. MacEntee

Of course it does.

Mr. O'Donnell

You cannot say that for the simple reason they are on the voters' register. If the Minister would give a directive——

Mr. MacEntee

It merely means they were there on a certain night in the year.

Mr. O'Donnell

They would not become entitled to vote if they were there only on a certain night. They must be normally resident here on a certain night. Would the Minister say the £800 should be earned in this State?

Mr. MacEntee

No.

Mr. O'Donnell

I think he would go a long way towards helping these people if he would say that. We drive them out of the country to earn a livelihood in Britain. They are taxed in Britain and we delve into their pockets when they come back, which is very unfair. We have the same thing in investigating the means for the supplementary housing grants. The earnings they make in Great Britain are out of proportion in relation to this country but the cost of living in Britain is completely different. I would ask the Minister to look into the matter.

Mr. Moloney

I was rather amused at Deputy O'Higgins describing this Bill as an insignificant little measure. It is a very significant measure and one that will save us many headaches particularly the part which deals with the raising of the ceiling limit from £600 to £800 and also the question of exclusion of a certain income of members of the family up to a maximum of £300. Unfortunately it has been rather difficult to get the county health authorities to consider favourably the claims, in cases of hardship, of those who were outside the statutory limit in the past. I myself have some experience in that connection and the only way I could make any reasonable headway was either to get the person concerned to appeal, if an appeal is appropriate or, alternatively, to ask the Department of Health to use their good offices with the local authority.

I found that, on a number of occasions when steps of that kind were taken, some appreciable measure of relief was given. I am inclined to agree with Deputy Corish who said that the county managers are inclined to stick hard and fast to the rule. My experience was that, in the first instance, when I generally tried to settle the question through the local authority the latter would always insist that when the ceiling was exceeded there was no case of hardship and no matter how strongly you built up your case it was very difficult to get it accepted. I think that was one good reason why the Minister thought fit to increase this limit. I am glad he accepted that principle and generally accepted, I am sure, various representations made to him over the past couple of years.

A very important addition to this measure is the fact that certain family income may now be excluded up to a limit of £300. I think it is unnecessary for me to say why that should be the case because, in the course of his speech, the Minister pin-pointed the particular reason.

There are just a few points, arising out of the Minister's introductory speech, to which I should like to refer. The first concerns insured persons who are now raised to a ceiling of £800 and the special treatment to which that category of persons is entitled. I have never been able to get clear whether they had a free choice of hospital. I always assumed that insured persons were entitled to treatment in any hospital of their choice and that, because they were insured——

An Leas-Cheann Comhairle

Is that relevant now?

Mr. T.F. O'Higgins

It is in the Act.

Mr. Moloney

It is important that it should be cleared up.

An Leas-Cheann Comhairle

It may be important but the Deputy might get a more relevant opportunity of raising the matter.

Mr. Moloney

Sir, I accept your ruling and shall avail, I suppose, of another occasion to try to bring this matter to light.

With regard to the other provisions in the Bill, what is very important is that it will facilitate particularly people who are subjects for treatment of mental disease. There was a very significant drawback in the existing legislation, particularly for that type of person, because the admission to and the cost of treatment in mental hospitals was a great bone of contention. Patients were subject to being billed by the hospital authority for treatment and, in the case of some mental illnesses which were unfortunately likely to last a long time, the people who were responsible for the patient—the parents or members of the family who might normally be responsible for him—were placed in a very difficult position. The health authorities, in cases of that kind, were rather insistent on some contribution. Very often, an exorbitant contribution was demanded. From that point of view, I think the measure is a very marked advance and something that will help in no small way to get over that particular difficulty.

A point arises out of a matter raised by Deputy O'Donnell. I am rather surprised to hear that in his local authority the income of members of the family employed abroad was taken into account when making assessments in relation to the Health Act. Our general experience in our local authority was that only the income of those members of the family employed in the State and who were normally living in the household for some period of the year was taken into account. There may be a different system in every local authority. I agree that there should be uniformity on this matter. If there is any way in which the Minister could put that problem right, it would be a step in the right direction.

Mr. Rooney

This Bill mainly tries to follow the lines set already by the Social Welfare (Amendment) Act, 1958, in relation to the extension of the income limit from £600 to £800. A very significant omission in this Bill which is entitled.

"An Act to amend and extend the Health Acts, 1947 to 1957, and the Mental Treatment Acts, 1945 to 1957,"

is that it omits any relief whatsoever for persons with a valuation limit of £50. That valuation of £50 was written into the previous Acts.

Are we to assume that this Bill was brought in here to come to the rescue of people who were deprived of any advantages available under the previous Health and Mental Treatment Acts because their incomes went up over £600, which is approximately £11 10s. per week? Because their incomes when up over £11 10s. a week, they were left without the benefits which can be provided under this Bill now if their incomes will not exceed £15 15s. a week. Surely the Minister does not contend that costs for the holders of agricultural land and farmers whose valuations were £50, to which the existing legislation applies, have not gone up? It is obvious that their costs have also gone up but there is not provision in this Bill to increase by 33? per cent. the valuation limit, which we ought to expect.

A £50 valuation in certain parts of the country may seem a high figure but, particularly in the counties of Leinster, £50 is a very modest valuation. The man trying to live on land with a valuation of £50 is getting a very bare living. The statistics can show the average earnings of such farmers. It is obvious from those statistics that they should not have been omitted from the provisions of this Bill and that they should have been given the benefit of an extension of 33? per cent. in relation to the income which applied when the previous legislation was passed.

Another matter which I should like to mention is that when it was listed for the First Reading, when we did not know what we might expect in this Bill, it was thought it would be designed to meet many of the hardships which wage-earners are obliged to face at the present time. We know, for instance, that the Minister increased the maximum daily hospital charge from 6/- per day up to 10/- per day. In addition to that, those people are obliged to pay for X-rays and specialist fees. No consideration has been given to those people. Many of them, on £6 or £7 a week, are frequently being turned down by the various local authorities who contribute the balance of the hospital maintenance charges on their behalf.

These people, and I mention people who might only be earning £5 or £6 a week, are obliged to pay anything up to 10/- per day for their maintenance in hospital, in addition to X-ray and specialist charges. Nothing whatsoever has been done for them. The county manager has the discretion to hear their cases but he follows the regulations, and he sends them a notice saying that people who, by their own industry cannot provide for themselves and their families, are the only people who will escape this daily charge for hospital maintenance.

Those are people who meet real hardships, and they are frequently compelled by county councils and county managers to pay a bill that mounts up against them, owing to an unfortunate illness over a prolonged period. That large bill has to be met by the payment of instalments over a long period, just because the county manager finds it necessary to interpret the Bill pointing out that they do not belong to the assistance classes. If they were wage earners, and if they were receiving over £5 a week, they were immediately liable for the payment of these hospital maintenance charges because the county manager, according to existing regulations, cannot see his way to remit them.

This Bill has stepped a little further towards the relief of families who are obliged to undergo hospital treatment, but this £100 allowance for any wage earner in the family, in addition to the head of the household, could lead to a position where the head of the house would be earning £799, and there might be three members of his family earning wages, which would mean that the limit, for all practical purposes, would be raised, not from £600 to £800, but from £800 to £1,100. I feel that this Bill was necessary, and it did not come before its time as far as it brings advantages to the people who were disqualified from the benefit provided by the existing Acts, when their earnings went up over £600 a year, which is slightly over £11 10s. a week.

Rising costs obviously made it necessary for their incomes to be increased and now benefit will apply to people whose earnings do not exceed approximately £15 15s. per week. However, I think that when people with these scales were being considered the Minister should also have paid attention to the other end of the scale, in relation to the persons who were on low wage levels, apart from the assistance classes who are, of course, entitled to full and free services.

Here, again, we have the example where a family may have the tragedy of an invalid child to look after and, of course, under the existing legislation if they are earning more than £11 10s. per week it would be necessary for them to meet the full cost of maintaining such an invalid child in an institution, or elsewhere. I believe this will be a great advantage for those people because the maintenance of an invalid child, at the present time, in appropriate institutions is very high. I think in these times we ought to give consideration, as far as the State is concerned, to ensure that families who are unfortunate enough to have an invalid child, which is unmanageable at home by reason of mental illness or physical defect, should have proper institutions provided for them.

At the present time the existing institutions for such children are managed and controlled by voluntary or religious organisations. It is very humane work. It is, if you like, the utmost for the highest, realising the real difficulties which would be caused in the home if people were compelled to keep those children. I would like to mention that many of those families find it difficult to find a suitable place for such invalid children. I feel that, within the health code, we ought to make an organised effort to ensure that proper attention can be given to those invalid children, and that their parents and families should be relieved of the hardship of trying to maintain them, or the worry of trying to find a place for them, because there is limited accommodation and a limited number of institutions dealing with patients of that type.

I am glad that this Bill has been introduced, particularly as it deals with the invalid side as well as the normal health services. Finally, I am disappointed that this Bill did not embrace more aspects of our existing health services. Anybody who has anything to do with the administration of our health regulations, at the present time, knows that there is a considerable amount of confusion and disappointment caused when the regulations are being implemented and interpreted. It is hard to know whether the cause of that confusion is owing to misinterpretation, or to a defect in the existing health legislation, but anybody who has reason to avail of the services under these Acts usually find they get the wrong end of the stick, and the existing Acts do not provide for them the services which they had expected. The health department of every county council is probably the busiest department, and it is busy because they are trying to administer the existing health legislation and interpret it for so many people who find they completely misunderstood it, and who find it does not apply to them in the way they had expected.

Mr. Larkin

I want to make one or two brief comments on this Bill. While I welcome the Bill it is a fact that mainly it is restoring the position that existed previously, and is now bringing the income limit more in line with the reduced value of money. The Minister for Health, possibly, may be commended in his capacity as Minister for Social Welfare. In practice it is extending to people with an income up to £800 benefits which were enjoyed by them when we had a somewhat lower cost of living and their income was £600. The Minister, however, in referring to Section 1 (4) where he indicates his proposal to disregard the income of members of the family, a son or a daughter, stated in the course of his remarks that in his view such additional wage earners or salary earners in the family do not normally contribute the whole——

Mr. MacEntee

No, I did not say that. I am sorry. I shall tell the Deputy what I said. I was giving an example. I was pointing out it was possible that there might be a house with parents who had low incomes and there might be a son and a daughter living there and both the son and the daughter were contemplating marriage. I said that in those circumstances it would not be reasonable to expect that they gave up all or the major part of their income because they would be saving up for themselves.

Mr. Larkin

I am sorry if I misunderstood the Minister but I will just refer to those particular circumstances. In no circumstances that I am aware of does the son or daughter give up all his or her income. In fact, I think it fair to say that in the majority of cases they would not give up the major part of their income and I am not even alluding to those contemplating marriage. If the Minister is concerned, as he said he was, with the family in which the son or daughter is contemplating marriage, I wonder if he will examine this aspect of the matter. Frequently the position, particularly in the classes mentioned in the Bill—non-manual workers who come within the middle income group —the practice is that, by arrangement with the parents, the son or daughter, for a fairly considerable period prior to marriage, give up not the whole or major portion of their income but none of their salary. That is quite a common practice and in that regard the parents recognise the need for, and are prepared to make, sacrifices in order to try and assist their children who are contemplating marriage. Consequently, if the Minister accepts that as a more than common position perhaps he might look again at the new steps he proposes to take. This step of disregarding some of the earnings is a new step, even though I may be permitted to describe it as a very weak and faltering step, but nevertheless it is a step in the right direction.

While the provisions of the Bill are an improvement and because they are an improvement in the Health Act, they should be welcomed generally in the Dáil. In many cases when Acts of the House come to be implemented, both in rural areas and in constituencies in the City of Dublin, the intentions behind the introduction of an Act are frequently not given effect. For instance, reference has been made to the special maintenance allowance and, in effect, as has been mentioned by Deputy Corish, instead of those maintenance regulations being of value all that has occurred when it came to operating these regulations in many cases was that they were substituted for home assistance for persons suffering from diseases which prevented them from earning a livelihood or providing for themselves. This was an Act of this House which was specifically designed to assist in a more concrete way people confined to bed, confined to the house, or people who, because of ill health, were unable to follow a vocation and provide for themselves.

Instead of getting additional help what happened because of the way these things are implemented was that the recipient in many cases instead of receiving 10/- or 12/- home assistance got the equivalent in maintenance assistance. The same thing can occur generally in the application of benefits even under this Bill. The intention of the House in passing the Health Act was to assist the people whether they were of the lower income class, or whether they were covered in the insured sections of the Bill or whether they would come under the middle income group, but when it comes to implementing the benefits then there is another story.

I had a recent case where it was only possible after prolonged representations, to get the manager or his representatives, to mitigate payments for institutional services. It was a case where they were aware of all the facts for some months and yet it took quite a considerable amount of representation before they saw the justification of mitigating the charge for institutional treatment. I would ask the Minister to consider the position where there are a number of salary earners in the family of a person covered under this Bill, a non-manual worker or a person in the middle income group. Many are at present earning a salary of £10 or £12 a week. If they have one or two grown-up children also earning they may well be, because of the combined income, completely outside the scope of this Bill.

In many cases—and I am sure the Minister is aware of the fact—where people are covered by the health regulations and fall ill, not only do they have to face the normal expenditure, the normal hardships consequent on such illness but in many cases they must suffer additional economic hardship arising from the necessity, in the case of fathers of families to employ housekeepers to look after the house during the course of the illness.

So far as the Bill is a small step forward it is welcome, but I would ask the Minister to consider the cases he mentioned himself, cases of young people intending to get married. I would ask him to take into consideration that in many such cases the boy or girl concerned may make little or no contribution to the family expenses in the two years before the marriage.

Mr. Sherwin

I wish to say a few words regarding the operation of the Health Act. The people were led to believe that if they earned less than £600 per annum they could get certain benefits under the Act but in actual practice they were turned down while earning as little as £450 in many cases. There is, in fact, a means test. Families with five or six children have been turned down where the income was only £9 per week, whereas £600 per annum would represent £11 10s. per week. Some of these people have come to me frantic with worry because they get hospital bills for £30 or £40, as if they could afford to meet them.

I know that this Act has done more harm than good to the health of children. Formerly the children could go to the local dispensary and get treatment for colds and other childish ailments. Now they are not treated unless they have a blue card. The parents would have to get a private doctor and pay for medicine. Those families that are just able to live cannot afford to pay out 10/- or 15/- for a child's cold in any week. I have the experience, being a member of Dublin Corporation, of dealing with a large number of rent cases. One of the excuses I got—and they gave evidence of it—was that they could not pay the rent because they had to pay the doctor in the same week.

If it is understood that those with less than £600 get certain benefits, then that should be the case. We put the question to our city manager on many occasions but no one answered. He says he will treat a case on its merits. Whatever that means I do not know, but we do know that people come down there and cannot get a blue card. They are not sending their children to doctors. Formerly they could get a bottle for the child but now the child is allowed to suffer on. These regulations have done considerable harm.

Last year during the 'flu period people had two or three children down with 'flu. These people could afford to have the doctor only once and the children had to suffer on. That is the effect of the Health Act. I would ask the Minister to consider this matter further and to remember that families with £8 or £9 cannot afford to go to the doctor every time a child has a cold. I would ask the Minister to ensure that at least they can get dispensary treatment even if they must pay for hospital treatment, and in that case that they should be able to pay on an instalment system so that they would not get these demands for £30 or £40. I know of some people who ran away to England on account of them. This Act is not operating as well as the Minister thinks and more harm than good is being done at present.

Mr. Carty

This Bill to extend the limit from £600 to £800 for purposes of institutional and specialist services under the Health Act will be welcomed generally throughout the country. In some cases the limit may be up to £1,100. I want to know for my own information what percentage of the population will be covered in the lower income and middle income groups by the extension of the limit from £600 to £1,100. We know that the percentage generally for the lower income group is 30 per cent. of the population but what percentage will now come under the Health Act as a result of the new limit? It would be very enlightening to know that.

I wonder what the effect of this Bill will be on the Voluntary Health Insurance Act? I hope it is not intended to torpedo that scheme. If the limit is raised to £800 and in some cases to £1,100 the income that the Voluntary Health Insurance Board expected will be seriously curtailed because I believe a large proportion of the population will be covered and what will be left to the Voluntary Health Board will be very little.

I would also like some information regarding the conditions on which doctors were employed in recent years and who were given certain private practice. Under the conditions of their appointment they were given private beds in hospitals. How will they be affected by the extension of the income limit to £800? I hope the Minister, when replying, will be able to give some information on these points.

Mr. Lindsay

The provisions of this Bill must be welcomed by everybody as not alone in their nature acceptable but as highly desirable, having regard to the economic conditions in which we live and the rapidity with which they change, that change having in its turn, an adverse effect on static incomes.

Apart from that welcoming statement I rise as a seeker after uniformity. Some Deputies seem to think on reading paragraph 4 and its sub-paragraphs that an income can go as far as £1,100 per annum, that is, the total income of a household, before that family is excluded from the provisions of this Bill. I may be wrong, and this is a matter that has given rise to query on each side of the House—Deputy Vivion de Valera raised it and it was also mentioned by other Deputies— but I take a different view of this provision and I am afraid it is a view which will be taken by those responsible for the implementation of these provisions. Take a man with an income of say £501 per annum with two children earning between them £600. Of that £600, I take it that £300 will be disregarded for the purpose of computing——

Mr. MacEntee

Only £100 per child.

Mr. Lindsay

Then let us take it that there are three children earning among them £600. Of that £600, £300 will be disregarded bringing the total income of the household—the £300 that is taken into consideration from the earnings of the three children and the £501 from the earnings of the parent—to £801 thereby putting him outside the scope of the benefits intended by this Bill. That is the meaning I take out of it. Other people have taken the meaning that the ceiling must be £1,100 before anything happens. I think that is something upon which the Minister should be quite specific in his reply before members of his own Party in particular are let loose on the country over the weekend to praise him for this wonderful lift in relation to the new health scheme. It is essential that there should be clarification of this matter and what is intended should be perfectly clear. Uniformity should prevail in the implementation of measures of this kind. All too often it is the experience of Deputies on both sides to find two people in rural areas, with similar holdings, similar incomes, similar stock, and A has his medical card while B has been refused it. It is that kind of thing which leads people into the belief that they have to belong to some camp or other before they can qualify.

Mr. J. Brennan

Maybe A can tell more lies than B.

Mr. Lindsay

There is also the corollary, following from Deputy Brennan's interjection, that A's lies may be more acceptable than B's or, to go a step further, that the telling of the truth may be less effective than the telling of lies.

In matters of this kind uniformity of implementation is most desirable. The Minister should concede that principle straightway. Deputy Sherwin has told us that he knows people with £450 income who were denied the benefits of this type of legislation. It is all very well for local authorities to say that each case is considered on its merits and certain people have to be rejected because their means exceed the statutory limit. What amazes me is that people are not more challenging in relation to the rights they should enjoy under the various provisions of these enactments.

Dr. Browne

Even though this is clearly just another patch on the patchwork quilt we call health services, I suppose it must be welcomed. It is clear to anybody who has any experience of the operation of health services at the moment that it cannot possibly answer the needs of the people for a properly organised health service based on a completely free and no-means-test principle. The raising of the income level from £600 to £800—and even if it is extended to £1,100—will not be an answer to the real needs of the people for a proper health service. As long as the means test persists we will have different standards of health services. We will have the best that money can buy for those who can afford it and a lower standard for those in the lower income groups subject to means test. There is no doubt about that from a medical point of view.

Anybody who has any experience knows that, when there is a choice as between private medicine and means-test medicine, the best service is available to those who can pay as against those who are subject to a means test. We have plenty of examples to show that the proper solution will only be found by getting rid of the means test altogether. That has been proved in our own country in relation to the tuberculosis service and the fever hospital service. We have the example then of the British health service which probably is the finest in the world and in which there is no means test. That is the only kind of service which will give equity of treatment.

In 1951, when we had this crisis and all the discussion on the means test or no-means-test, people were slightly confused on the issue as to what precisely was meant by a means test at that time. One constructive and useful purpose achieved by the legislation which has been passed since then is that it has educated the people in a most acute and painful way into the real meaning of what a means test constitutes in health services. When the time comes for us to have another national debate on health services, one thing is certain; the ordinary people will be unanimous in their understanding of the real implications and the injustices inevitable in a means test and the need for its complete elimination from our health services.

I welcome this small advance since it will help to continue the education of our people and ensure that we will have in time a free health service similar to the T.B. service and the fever hospital service now. At the moment there is no general practitioner service so far as the lower income and middle groups are concerned. A mother with even one child is often in dire need of such a service when she is not sure whether the child is suffering from some simple ailment or in the early stages of pneumonia. Her problem is a grave one and her position has motivated the legislators in more progressive countries into ensuring that health is something which is above the market place, something for which the community must provide so that nobody need worry unduly should ill health strike.

This Bill, I suppose, is just another short step towards the just society that we all hope to see established in time. It is quite clear that administering a means test is a very difficult task. Local authority officials are themselves confused. They try to interpret the laws we pass and we cannot blame them if they adhere to a rigidly literal interpretation of what we enact. Their interpretation may be strictly legal and very parsimonious indeed. The Minister should consider this question of the administration of means tests. First of all, there is the tremendous cost involved in keeping the bureaucracy needed to inquire into means and to changes of means by improvement in salary and improvement in conditions, which are extremely complicated things to assess.

That was put to me as one of the biggest objections by some members of the British Labour Party who were over here eight, nine or ten years ago when we were discussing the whole question of means test. Obviously, they had an ideological objection to a means test but they said that probably the biggest objection to the inclusion of a means test in that service was the necessity to retain the very expensive and complicated bureaucracies in order to try to assess means.

Anybody who has any close contact with his constituents will know that there are difficult borderline cases, people who are certain they should be included in the scheme and who are not included and who have a great sense of grievance against people who, they think, have £15 or £20 a week and who get the blue card, the red ticket or whatever it may be. There is this sense of real or imagined injustice as a result of the very variable interpretation of the legislation that passes through the House.

These are the main considerations, the medical consideration, clearly, being the most important. We have shown in our legislation that you will get the most just, equitable and efficient form of health service where you get rid of the means test altogether.

A second point is that where you have a means test there are borderline cases which create so much discordance amongst neighbours and a sense of grievance, real or imaginary, and because of that the means test is undesirable. Further, there is the needless expense of the administration of a means test which is involved in the retention of a very considerable bureaucracy by each local authority. There is the further consideration that the inquiry into means, which, no doubt, in most cases is done in as tactful a way as possible, is a thing which leads to a great deal of hardship where there are young people trying to save up to marry, and so on, who find as members of families that they are suddenly billed for the sickness of a member of the family.

It is bad enough in a family to have the awful worry of one of the members being sick without having in addition the responsibility of having to try to find the money to pay the bills at the end of the person's illness. It is a matter which I would ask the Minister seriously to consider. There was a time when he had the most progressive views on these questions. I should like him to think about it again because if he were to go around the average mothers in the poorer areas of his constituency, those who are not in benefit, he would find that there is a considerable amount of hardship and a lot of distress amongst people who do not come under the existing health schemes.

The only other consideration that the Minister might bear in mind is that in the whole question of the treatment of the sick early diagnosis is of considerable importance. Where people are faced with the ordeal of going through a means test in order to get access to the benefits of a health service they tend to defer going to the doctor, in which case, by the time they go they are very much more in need, very much more sick than if they could have ready access to the health service. We found in the tuberculosis service that one of the greatest aids to early diagnosis was the ready access to a health service. It is a most important consideration.

I am sure the Minister will understand from his own experience that people naturally will tend to defer as long as they can committing themselves, first of all, to finding out if they are seriously sick and to defer the treatment of serious illness until they are, possibly, incurable or in such a condition that it will take a very much longer time to cure them than would have been necessary if they had a health service readily and easily available and did not have the overriding fear that when the time came to pay for treatment they would not have the money. The only solution is, not merely to shift up the means test level —which, of course is always welcome and I welcome this as an improvement in the level—but to get rid of it altogether. If the Minister does that, he will make a real contribution towards the betterment of the health services.

Mr. MacEntee

Deputy Browne will, I hope, appreciate that it is not out of any discourtesy to him that I do not propose to discuss the principle of the means test upon a measure of this kind. This is a Bill to amend the Act of 1953 and the principle of the means test is embodied in that Act, so I do not think it is really germane to the present measure to discuss it at length.

Deputy O'Higgins described it as an insignificant measure. I am sorry if a letter of mine has caused him to look at this Bill through the large end of the telescope and, therefore, rather to whittle down its significance; but you cannot so describe a measure which is going to give to 80,000 persons the benefit of the services provided under Section 15 of the Act of 1953. Of course, it is not by any means as comprehensive in its scope as some Deputies would like, but it does represent an attempt, at any rate, to retrieve the position and to bring back again within the ambit of the Act all of those whom the Act was originally intended to serve.

The people who have been displaced in their entitlement by reason of the change in the level of prices over the past five years have been mainly those engaged in trade and industry and commerce. Farmers' valuations have not changed. I would say that the vast majority of landholders, or even every surviving farmer, who was entitled to the benefit of Section 15 when the Act was passed remains entitled to it; and I cannot see any justification in present circumstances for raising the valuation limit so far as they are concerned. That is my answer to the criticism which Deputy Rooney made of the Bill.

Deputy O'Higgins suggested that it would have been possible to do what the Bill proposes by having resort to the hardship provisions of the Principal Act. It is suggested that we could do it by regulation. I doubt whether we could do it by regulation. He went further and suggested that a circular letter to the county managers would bring within the scope of this measure those whom it is intended to benefit. There are 80,000 persons who will benefit under this Bill. They will be entitled to the institutional and specialist services which are provided under Section 15 of the Act. I think it would be a very irregular procedure and certainly a very deplorable one if, without resort to or sanction of Dáil Éireann, we were to widen the scope of the existing services to that extent. It would be undesirable also from another point of view. After all, if we tried to do it in the way the Deputy has suggested, it would mean that those 80,000 persons would be getting their entitlement at the sole discretion of the county manager. I think it is very much better to give them legal entitlement to the services under Section 15.

Deputy Corish and Deputy Vivion de Valera, and subsequently Deputy Carty, asked how the voluntary health insurance scheme would be affected by this measure. I do not think it will be affected to any significant degree. One cannot say how many of the 80,000 persons who will be brought again within the scope of the Act of 1953 might have covered themselves now or in the future under the voluntary health insurance scheme. It is reasonably clear, however, that the larger proportion of those who have availed themselves of the schemes of the Voluntary Health Insurance Board are people who would be above the £800 limit. That is the opinion which I think it is fair to form from the facts which have been submitted to me.

When the voluntary scheme was originally in contemplation, it was assumed that about 500,000 persons represented the maximum number which in all circumstances might be covered by the schemes of the board. That was an absolute maximum. The actual number who would cover themselves by agreements with the board would normally be very much less than this. According to the board's first annual report, there are two categories of persons covered by its schemes. The first comprises those who have insured themselves under the basic scheme—they number 8,000 persons. Those who have covered themselves by the more expensive schemes amount to 15,000 persons. It is clear from those figures that the general tendency has been to accept the more expensive schemes. For that reason, I assume that by far the greater portion of the 80,000 who would be covered by this amending Bill are persons who would not be insured at all under the voluntary health insurance scheme. I do not think that the board itself would differ greatly with me in that opinion.

Another point was raised by Deputy Vivion de Valera in the first instance, and referred to again by Deputy Lindsay. I think both Deputies were labouring under a misapprehension. Deputy Lindsay was nearer the mark than Deputy de Valera was, because Deputy Lindsay assumed that there could be a case of a parent who had an income of £501 and had three children each of whom was earning £200 a year. He said, of course, that only £100 of the earnings of each child— that is, £300 in all—would be disregarded from the point of view of calculating the family income. That is quite correct; but because we disregard the first £100 of each child's income when we are calculating the total family income, it does not follow that the family income is only £801. The total income earned by all the members of the family normally resident in that one household remains at £1,101, in the case which Deputy Lindsay cited, even if for the purpose of this scheme we are aggregating that at only £801. Of course, it looks a terrible hardship to say that a man is to be excluded from the benefit of this scheme because his income is £801, but I would suggest that if he takes one Saturday morning off in the year he would very quickly get rid of that impediment to participation in the scheme.

Mr. Lindsay

The sum is correct?

Mr. MacEntee

I think my explanation has also answered Deputy Vivion de Valera's criticism. The real point is that while we are prepared to assume and are assuming for the purpose of the concession that every child will earn more than £100, it is not necessary to assume that at all. We are assuming that the income of the family will be the income of the parent plus the income of up to three children who may earn £100 or more than £100. If each child should happen to be earning more than £100, then the income of the family, whether we make the allowance or not, is the larger the more the children earn. If there is only one child earning, there is no reason for saying that that child should be treated, so far as the assessment of his income is concerned for the purposes of this legislation, as if he were three children—which is, I think, the point Deputy de Valera was making, that we should give £300 in the case of the one child because he was the only earner in the household who was not a parent and was not the head of the household. On that aspect, surely it will be understood that the other children have no income and therefore their earnings cannot go in any way to swell the total of the family income.

Mr. Lindsay

The operative figure is £800 per annum.

Mr. MacEntee

The operative figure is £800, plus the sum——

Mr. Lindsay

Not £1,100.

Mr. MacEntee

Wait a moment, we must not confuse the issue here.

Mr. Lindsay

I do not want to be confused.

Mr. MacEntee

No, I understand that. What we are talking about here is not the personal income of any one individual: what we are discussing is the income of a family treated as a unit. For that purpose the operative limit of income under the legislation is £800; but it is quite correct to say that in certain circumstances it may be £1,100—the £800 plus £100 for each of the three children. There is no use in trying to ring the changes on this. For all practical purposes we take the £100 as the norm and we say that if by any chance a child earns £100 or under, even though the aggregate family income may be in fact £900, it is still treated as £800.

I must say I am sorry I cannot have very much sympathy with the point which Deputy Larkin made. After all, the Constitution provides and I think the canons of Christianity also regard the family as a unit. Children are bound as a matter of natural duty to care for and assist their parents. That is a fundamental principle. If those children are to get married or something like that and the parents decide they will not ask them to contribute to the support of the household, I do not think those parents have any right to pass portion of the burden of maintaining the household on to other persons quite outside the family. That is my answer to Deputy Larkin.

I did cite the case of children saving up to get married as a justification of what I was proposing to do. As an example, I said it might happen that there would be circumstances in which it was not equitable, having regard by and large to general considerations, to regard the whole of a child's earning as inuring to the benefit of the family as a unit. Deputy Larkin said they would probably spend quite an amount upon themselves, but if they do that they do so with the permission of their parents; and if parents permit their children to spend every penny they earn and to disregard their responsibility to the family as a whole, as I say, that is the look out of the parents. They cannot expect that other people will bear the burden the children of the household are not prepared to accept.

Deputy Carty wanted to know how this Bill would affect the position of doctors. The position of doctors will remain unchanged under this Bill, the only thing being that if any of those 80,000 persons require the services concerned they will be entitled to them. Otherwise the position so far as the medical profession is concerned will be quite unchanged.

Deputy O'Donnell cited the case of persons in Donegal who were earning their livelihood abroad. He did not make a very good case because he mentioned that these people only returned home perhaps for a month during the summer and perhaps a week at Christmas, making five weeks in all; but they were regarded as being "normally resident" and therefore their income was aggregated with that of the members of the family who remained at home. Of course, I cannot be responsible for the way which the term "normally resident" is interpreted but it would seem to me that that certainly was not a case of normally resident, even if they did happen to appear on the electoral register. There is another way of dealing with that which I will not suggest to Deputy O'Donnell because he probably knows it. I am sure if he were to adopt the remedy he has in mind it would be found to cut both ways.

Mr. Lindsay

You would not need proportional representation in West Donegal; there would be only one seat.

Mr. MacEntee

But he made a suggestion which at first sight appears to be a very facile solution. He says we should exclude from the calculation of family income income not earned within the State. I can see many objections to that argument. I can think of a person making a trip on an ocean liner. The income made during that period would not be income earned within the State. If he happened to be sailing with a master's ticket or a first mate's ticket and making very substantial income and maintaining a home here he would still under those circumstances appear to qualify for a medical card. In the same way you might have a person selling on commission, going abroad and securing a very substantial contract on which he would be paid very substantial commission. That would not be income earned within the State but still he would become entitled in certain circumstances to have his name entered in the medical register. I suggest the more you would examine that remedy for the problem Deputy O'Donnell has in mind, the less you would find it to be administratively possible or an equitable solution.

I do not think there was any other point arising from the Bill I should deal with.

Question put and agreed to.

Agreed to take remaining stages today.