Has the Minister finished?
Committee on Finance - Vote 64—Health (Resumed).
Debate resumed on the following motion:—
That a supplementary sum not exceeding £119,400, be granted to defray the Charge which will come in course of payment during the year ending on the 31st day of March, 1960, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Ard-Chlaraitheora), and certain services administered by that Office, including Grants to Local Authorities and miscellaneous Grants.—(Minister for Health.)
Yes.
In this Estimate the Minister is seeking an increase of £118,000 approximately from the Central Fund and, naturally, added to that will be the same amount from local authority funds, because of underestimation of the amounts required for the administration of health services. The Minister's statement was a full and comprehensive one and he explained fully the financial implications as they applied to the necessity for this particular Estimate. Several things in his statement struck me as significant. The Estimate would have been considerably higher but for the fact that there were savings of nearly £50,000 on tuberculosis administration and as I read the Minister's statement, this is the last year in which it is likely that any funds will come back to the Central Fund as a result of economies in the tuberculosis administration. The actual sum, I think, was £48,000 for the years 1957-58. It is estimated that there will be very little saving from now on. From now on we must at least have the possibility of facing increased charges for the administration of health services each year, both in regard to the Central Fund and the local authority funds. In other words, there will be increased taxation to meet existing health services and there will be an increase in the rates.
I note in today's paper that Dublin Corporation expect an increase of 1/1d. in the present rates bringing the current rates over £2 in the £1. It is stated that this is solely due to the administration of health services.
The Minister gives several reasons for this increase, one of the main causes being the extra charges that fell on the local authorities in the administration of health services due to the fact that more money was required for patients that were being admitted to voluntary hospitals. He said this was due to increased awareness on the part of patients that they were entitled to services in the voluntary hospitals. This poses a very serious question. In the administration of the health services throughout the country the aim has been under this Act to make available in all rural areas whether regional or definitely inter-county, specialist services of all kinds. But the fact is that, according to the Minister's statement, more people are going to the voluntary hospitals and that means that more patients are going to central hospitals situated in Dublin, Cork and Limerick—the only places in which you find voluntary hospitals nowadays. That goes to prove that the administration is not really a success. In 1957 and 1958 people were availing of local services and since then more specialist services have been available in local authority hospitals; yet, even though there are more specialist services so available more people have availed of the opportunity of going to the voluntary hospitals for treatment. That seems to suggest to me that we are having duplication of administration which is, of course, unavoidable. It means that the money that is being provided for health services is not only providing local hospital treatment and providing specialist services which are not really being availed of but it also has to pay for the administration of the voluntary hospitals. I should like to submit to the House that in the administration of this Act we should not go too fast. Perhaps there has been a little too much wishful thinking on the part of those who were so keen on this particular administration.
To prove that case more concretely, I want to refer again to the Minister's statement. The Minister said that a certain amount of this money was due to the fact that more money was being spent on mental administration than before. I do not think there is a Deputy who would not welcome that statement. Every Deputy agrees that more money should be spent on mental administration. However, I want to go further into the Minister's statement. In that statement the Minister says that the increases in the mental hospitals are mainly under the following headings: food, repairs, maintenance, salaries and medicines. He does not say that there is an increase in those particular lines in the ordinary hospitals; it is only in the mental hospitals. That means that these increases which have to be levied on the tax-payer, be they for central or local administration, are due to those particular reasons. But there is no mention of their being due in the ordinary local authority hospitals for the ordinary specialist services. This again proves the point and verifies what the Minister says, that the people are not availing of the local authority hospitals and that they are availing of the voluntary hospitals.
I did not say that.
I shall withdraw if the Minister wishes to explain.
Read what I said. I did not say people are not availing of the local authority hospitals.
Not actually in those words.
I understand and appreciate the Deputy's great concern with the subject, but we shall not get very far if the Deputy ascribes to me something which I did not say and a concept which is far from my mind. I did say that one considerable factor in the increase was the fact that people were availing more readily of the services of the ordinary general hospitals. That does not mean to say that people are flocking to Dublin and Cork from the local authority hospitals.
I shall quote the Minister. The reference is Col. 932 of the Dáil Debates for Thursday, 25th February, 1960:
The occupancy of voluntary hospitals appears to have increased significantly over the years 1958 and 1959. Many of the additional days of occupancy are attributable to the patients receiving Health Act services, and also the increasing awareness of patients of their right under the Acts, and consequently the proportion of the services provided in voluntary hospitals which results in claims on health authorities, may be assumed to have been growing over those years, and, indeed, to be still growing.
That is quite correct, but the Deputy is putting a gloss on that which is not mine.
I did not intend to embarrass the Minister. He has told us there are increased charges in the mental hospitals due to certain things. The point I was making was that he did not mention there were increased charges in the ordinary local authority specialist hospitals due to the same causes. The reason those increased charges do not take place in the local authority hospitals is that there are not more people in them. It goes to show there are fewer people availing of the local authority hospitals for specialist services than previously. I have imputed nothing else to the Minister, only what he said. I do not think the Minister can accuse me of trying to put words into his mouth he did not say. If he thinks I said anything, I would be happy to withdraw it. I do not think he made a clear case against me. I am only quoting him fairly in the two instances.
I want to go back to the mental hospitals. The Minister said the increase in the mental hospitals was due to food, repairs, maintenance, salaries, and medicines. The increase in 1958-59 was £123,000, and the increase in 1959-60 was £55,000. Due to modern treatments, expenses were higher. I cannot conceive, even taking the lower figure for 1959-60, how the medicine bill could be £50,000 up. That, to my mind, is impossible, even with the advent of modern drugs and scientific treatment. Though these drugs cost a considerable amount when they first come out, the general tendency is, when more and more come on the market and are easier to produce, that they rather tend to fall in prices. We must come to the conclusion that the real increases in charges in the health services are due to other things. One is that it is defeating its own end. That is a point I made before: that the patients are not availing of the local authority hospitals and, therefore, the whole scheme is, in my opinion, a failure. They are turning back to the original centres of treatment where they went before. The other increase is due to the general rise in the cost of living. I do not want to labour in the House the reason for the rise in the cost of living. The Minister knows that as well as I do. Every Deputy knows it. There is pressure for increased wages, and that is due to the fact that there has been an almost illimitable increase in the cost of living. While I say it is necessary that this amount of money should be voted as necessary to maintain the health services, the reason I intervened was to make it quite clear that, in my opinion, no matter what arguments are used, the health services as at present administered will cost more to the tax-payer each year.
I think the proof of that is that the Minister himself has stated you cannot expect much more reduction in savings under the heading of T.B. At the moment I have a letter in my pocket from a working man who suffers from chronic asthma, and who is just able to carry on working himself. His wife is a chronic invalid. He is earning just under £7 per week. He had to send his wife into hospital because he could not look after her himself. She is in hospital for 42 days and he now has a bill for £21, which he has brought to me. He cannot pay it. He says he never had, and is never likely to have, £21 in his possession in his life.
It is not only yesterday or to-day I have got letters like that. I have been getting such letters regularly over the past couple of years. We are spending huge sums of money on the health services. I submit that we are not getting the return that we should. The very people who should get a return from the health services are not getting it. They are waiting at the end of the queue. I said that in 1952 and the facts have proved I was right, and I repeat it here.
I think the Minister cannot be blamed for the health administration that he is faced with at the moment, and I am grateful to him for the comprehensive statement he made the last day when introducing this Estimate but, anyone who reads it carefully, will see it is an admission of failure in regard to the money spent. I suppose the Dáil will have to vote more money in future but I submit that the country, and the people who should get a fair return from health administration, are not getting it.
In this Supplementary Estimate the Minister requires something like £120,000 for the administration of the health services generally. I know this is not the main Estimate and therefore my remarks will be fairly brief, but I think it would be wrong if I allowed this opportunity to go without making a comment on the administration of certain parts of the health services at present. I suppose the Minister must be aware, as are most of us in this House, that there is a certain amount of dissatisfaction with regard to the administration of certain sections of the Health Act. In particular there is grave dissatisfaction on the question of the issuing of medical service cards. I suppose the great bulk of the people are served pretty well so far as the lower income group services are concerned but there is a pretty big fringe who, in my opinion, are done a very severe injustice. By whom I do not know. I must confess that, and one does not seem to get much satisfaction when one inquires why this or that person did not get a medical service card.
That brings us down to the question that has been often addressed to the Minister in this House: who is entitled to medical service cards? As yet there has been no definite reply given, either by the Minister or by the various executives, who are the county managers in most cases. If any Deputy were asked, as many have been asked by their constituents and other people "Deputy, am I entitled to a medical service card?", the Deputy must reply "I do not know." The Deputy or member of a county council who is asked that question feels pretty foolish because he can only say "The manager decides whether or not you are entitled to a card and it depends on your circumstances." The man then tells you his circumstances but still you cannot tell him.
I appreciate that there is some difficulty in laying down a means test in respect of services given by either local authorities or the State, but I wonder are the medical services vastly different from the ordinary social welfare services administered for many years? If a person were to ask anybody in this House, or any member of a local authority "Am I entitled to an old age pension?" one has only to ask one or two questions and immediately one can say whether or not that person would be entitled to an old age pension, and one would be right 99 times out of a 100.
When someone asks me "Am I entitled to home assistance?" knowing the rules as laid down by the Minister for Social Welfare, and included in the Department of Social Welfare's Booklet, after asking two or three questions I can tell that person whether he is entitled to home assistance. With a fair degree of accuracy I can tell a widow whether she is entitled to a widow's pension, and so on with regard to the other social services administered by the Minister for Social Welfare and his officials, but, even though we are told there is a means test with regard to medical service cards, nobody knows it. The Deputies do not know it and I do not think the Minister knows it, and how it is operated by the local authorities I do not know.
Again, when a person is refused a medical service card one might as well be idle as to ask for the reason. No reason is given beyond the vague reply that the circumstances of the applicant are such as would not warrant him receiving the services generally applied to the lower income group. That is one of the principal reasons why there is grave dissatisfaction with regard to the administration of the health services, that even though certain services are refused no good reason is given as to why they were refused.
I know very many deserving people who, in my opinion, are deserving of the services generally applied to the lower income group and I wonder whether or not there could be a system whereby even a part of these services would be applied to those who would be on the border line. There is tremendous expense on a person who is ill pretty often and who has not got a medical service card, who is just on the border line and who has to pay £1 or 25/- for one particular drug that he himself must have, or that some member of his family must have. Such a person is in the unfortunate position of being more or less chronically ill and of having to have particular drugs and, as Deputy Sir Anthony Esmonde said a moment ago, drugs can be pretty expensive in these times.
Therefore, I think a general review is called for and I think the Minister who introduced the Health Act said at that time that we would have to see how we got on over the years. That Act has been administered for the last five or six years and I think it is about time there was a review. We should not leave it like other Acts, for 20, 30 or 40 years and then only after persistent criticism attempt to make a review of it. Possibly the Minister himself makes a periodical review.
Again in reference to the issuing of medical service cards it seems to me that each local authority is in competition with the others. Periodically the Minister gives information to the House as to the percentages of population covered by medical service cards and they range between 28 per cent. up to 40 per cent. of the population. The local authority which covers 40 per cent. of its population rightly does so because that 40 per cent. are deserving of the services available to the lower income group, but it seems to me that when local authorities see figures ranging from 28 per cent. up to 40 per cent. they all try to get down to an average, or to get below the figure which is covered by other local authorities and which is below their own.
I know, as the Minister said here last week, that money is a very important factor and I suppose to some extent we must cut our cloth according to our measure, but it would be interesting if the Minister could give us a break down of the expenses of the health services. It would be interesting to see how the money is spent. I do not think that information is given in the Estimate. I think the Estimate merely reads "Grants to health authorities" but it would be interesting if the Minister could give us that information on the main Estimate. What part of the money goes to the voluntary hospitals, to local authorities, to dispensary doctors, what part goes for maternity services, for drugs, for medicines and all the other things included under the general heading of "Grants to health authorities"? It is true, of course, that some local authorities are more progressive than others.
I know the Minister's hands are tied to a large extent on a matter about which I feel very strongly, the extension of the health services as allowed under the Health Act, 1953. For instance, some local authorities have a dental service for adults. Others have not. I agree with the Minister and his predecessor that the concentration should be on school children in the matter of dental care but it is also very important that elderly people should have good teeth. Some elderly people are under the impression that if they had teeth extracted the local authority would provide dentures. That was done prior to the Health Act, 1953, under a heading in the Vote. Whether it was under the public assistance heading or not, I do not know, but people were provided with dentures under some heading, prior to the introduction of the present Act and there is provision for it in the Act. I would ask the Minister for Health to encourage every local authority to go as far as they can to provide a dental service for adults in the lower income group.
Deputy Dr. Esmonde referred to hospital charges. I am afraid that in that respect there is room for very detailed examination. In my constituency, at least, people who would ordinarily be entitled to a medical service card have discovered that the local authority have now checked up on hospital accounts and have sent out bills for fantastic amounts for maintenance in hospital. The local authority should be reasonable in that respect. A man whose income is £8 or £9 a week, who has a wife and one child and who would not be entitled to a medical service card, would find it very difficult to pay a hospital charge of 10/- per day for 30 or 40 days in respect of his wife.
There is another criticism one can make of the administration of the Act by the local authorities, namely, that, invariably, the 10/- per day is charged. The Act says, and the Minister said when he introduced the Bill, that a charge up to a maximum of 10/- a day may be made but the intention of the House was that the local authority would use discretion and grade the daily charge having regard to the circumstances of the family. I do not want to be unfair to any local authority, particularly to the local authority about which I know most. They invariably charge 10/- a day but, on representations being made, in some cases—not in all cases—the charge is reduced and sometimes waived completely. There should be a special officer of the local authority who would act as almoner and whose function would be to investigate the means of a family in circumstances where they are required to pay a lot of money for hospital expenses or for drugs or medicines. That would go a good deal of the way towards satisfying people who are critical of the administration of the health services, particularly in regard to the issue of medical service cards.
As I have said, my remarks would be more appropriate on the main Estimate. I trust the Minister will have regard to what I have said in respect of medical service cards. I do not wish to give a comprehensive survey of the health services now but perhaps the Minister will consider some of the points I have raised on this Supplementary Estimate.
There is only one point to which I wish to draw particular attention. Deputies are naturally interested in providing the service at as low a cost as possible. I should like to draw the attention of the Minister to the case of persons who require artificial limbs or medical appliances. In the first instance they are provided but, in the case of renewals, unless the person concerned enters a hospital, he can be charged the full cost of the appliance by the local authority. That applies in Cork city and county. It is an extraordinary situation that by becoming a patient in a hospital while awaiting the replacement of the appliance the expense is covered whereas, if he were to stay at home, it would not be covered. It should be possible, under the Health Act, to make such appliances available without the necessity of the person being admitted to hospital. That would mean a saving to the State and to the local authority and would be more convenient for the person concerned.
Such cases have arisen in Cork and the matter was discussed at a recent meeting of the South Cork Board of Public Assistance, arising out of a case in which a person was presented with a very high bill because of the fact that he did not re-enter hospital for the purpose of having an artificial limb fitted.
On the occasion of this Supplementary Estimate it would not be appropriate to have a general discussion of the health services but I should like to say that Deputies find it embarrassing at times when people ask them whether or not they are entitled to medical cards. In my opinion, a great deal of the difficulty has arisen because the yardstick by which the manager or local authority decided whether or not a person was entitled to a medical card, namely, his income of a few years back, has not since been altered in respect of increases in wages in certain categories over the last few years. The difficulty is that no allowance is made for the increase in the cost of living or in wage rates. That is causing a lot of the trouble.
It is only fair to say that in south Cork the officials of the local authority are doing their utmost to co-operate in the matter of charges for patients in local authority hospitals or other hospitals coming under the Health Act. From my own experience, I know that they do go out of their way to examine carefully the financial position of the family before deciding on any particular charge. I think it is right that we should issue cards to assist them in making as favourable an approach as possible to patients and patients' families. On the other hand the discrepancies exising at the present time, based on the wage rate now as against what it was a few years ago, are I believe causing undue upsets in the minds of people who had, a few years ago, been favoured with medical cards. These cards have since been taken from them. As I say this is a Supplementary Estimate and it would perhaps be more suitable that we should confine ourselves to the item in it. But I would ask the Minister to examine the cases of persons who are not re-entering hospital and who are at a disadvantage if they have to replace medical appliances.
I appreciate the points raised by the Deputies who have spoken on the Estimate. I merely want to say that there is no person more conscious than I of the imperfections of our health service and if a point of substance is made in this House by a Deputy in regard to these services I shall endeavour to ensure that, so far as I can, the matter is rectified. But here we must have a very clear realisation of what the powers of the Minister are under the Health Act. He is bound by the statutes, particularly in relation to the issue of medical cards to persons on the general medical services register. That is an Act of the Oireachtas and it is a decision which the Oireachtas took on very substantial grounds because, unlike the case of social assistance as distinct from home assistance, the whole cost of the health services is not met by moneys provided by the Oireachtas.
The Exchequer pays 50 per cent. of the cost, and the local community, the local ratepayers, pay the remaining 50 per cent. It is only just and proper that the local community on whom the payment of 50 per cent. may fall very heavily in its immediate incidence, should have the right to determine who, in their judgment, are by reason of their economic conditions entitled to secure free services at every level from the general practitioners up to the higher specialist services at a considerable charge to the local community.
I think we cannot, in the nature of things, deprive the local authority of the right and responsibility to control the issue of medical cards. In the case of the social assistance code, the position is very different. With the exception of home assistance, the full charge arising out of the existence of that code and its administration is borne by the Exchequer and you have social welfare officers and other who are competent to determine whether or not a person fulfils the conditions which entitle him to the qualification certificate under the Social Welfare Acts. There you are up against the other difficulty which I think Deputies must consider. That is that there is no flexibility in the administration of the social assistance code. Either your income exceeds in rural districts £72 16s. and in county boroughs and other urban districts, I think £92—I am speaking from recollection—or it does not. If it happens to exceed that figure you are out for unemployment assistance and everything that derives from unemployment assistance.
In the case of health services on the other hand, there is a great degree of flexibility built into the code which allows the responsible officers of the local authority to consider the case of every applicant and the question of his need to secure a medical services card is determined ultimately by the economic circumstances of himself and his family. Here, of course, there is room for infinite variation and infinite flexibility which you have not got in the case of social services under the social assistance schemes. Taking it by and large I would say that it is highly probable that, if we were to depart from the existing scheme, a great deal of hardship which at the moment is avoided would be imposed upon individuals and upon families who are at the present moment enjoying the benefits of the Health Act—and they are justly entitled to enjoy them.
We cannot have it both ways—the human approach to the particular circumstances of a family which we have under the Health Act and, at the same time, the automatic determination of whether a person is entitled, say, to a non-contributory widow's pension or unemployment assistance which we have under the social assistance code. And, of course, we could not possibly cover the number of families who are deriving full advantages of Section 14 of the Health Act if we were to employ some method of automatic regulation such as is built in in the social assistance code. We would certainly have to set our targets more modestly; if we were setting a target in that way, our sights would have to be set very much lower than under the Health Act. I think that a consideration which Deputies should bear in mind.
The moment we withdraw the power and discretion and, of course, the responsibility that goes with discretion, from the local authorities, we begin to exclude from the benefits of the health services a very large number of people who are on the margin or whose circumstances, although apparently good, by reason of things which are not known to the public and can only be made known to an investigating officer, from the point of view of health—the demands which the provisions of health services for themselves or their families make—are far from being good. I think we must not dwell all the time upon the fact, that sometime or other, this flexible approach is bound to pinch a few toes.
By and large, having regard to the number of people who possess medical service cards throughout the country, I think the position must be from the medical point of view reasonably satisfactory—in fact so reasonably satisfactory that there would appear to be many people who, although they have medical service cards, are not taking the full advantages of them. I find to my astonishment cases of persons who are in possession of medical service cards writing to me to complain that they have gone to this or that hopsital which is not a recognised institution for the purpose of the Acts and that they have been sent by their own medical attendants.
They have gone, instead of availing of the local authority hospitals, into the voluntary health hospitals and then they have to suffer the consequences. How it happens that, instead of going to the local authority hospitals and availing of the great skill and competence of the persons now staffing the county hospitals, they come up to Dublin or to Cork just astonishes me. I often wonder whether, in fact, these unfortunate patients find themselves subsequently in the position in which to their surprise they are confronted with substantial bills because they have been wrongly advised in respect of hospital facilities by the practitioners whom they consulted in the first instance.
I should be gratified if Deputies like Deputy Corish and Deputy Esmonde, who have just made these complaints, would communicate with me. If they do so, I shall endeavour to have the situation cleared up to their satisfaction. I can try to get the local authority to ameliorate the position of the people who have been caught in this way. I shall endeavour to bring the facts before the notice of the local authority and ask them to reconsider the position. That is as far as I can go.
Deputy Esmonde argued from certain statements I made in my opening speech that people were flocking to the voluntary general hospitals in Dublin because they did not get the treatment they required in the ordinary county medical hospitals. May I say that the general complaint in relation to the county hospitals is that they have not enough beds for the patients anxious to avail of them? If people do come to the voluntary general hospitals in Dublin it is perhaps most generally because there is not a sufficiency of beds available locally. There may be the second consideration that perhaps some people are being sent by their local medical advisers quite unnecessarily to the voluntary general hospitals in Dublin and elsewhere. I shall not enter into the reasons why this might be done but I am afraid it is being done in some instances. I deprecate it and I am sure that Deputy Corish and Deputy Esmonde would also deprecate it.
Another reason why such a large number of people are availing of the voluntary general hospital service is that many people, particularly in Dublin city and county where you have over 25 per cent. of the population of the whole country, are now becoming aware of the great benefit which they may derive from the Health Act of 1953 and are availing themselves of the hospital services which are more or less freely available under that Act. These are the reasons there is now greater occupancy of the voluntary general hospitals than in 1956 or 1957 when the Act was only beginning to come into operation.
To come back to the reason for the Estimate, which should really be the only thing discussed at this stage, may I say that the reason is a very simple one? It is just that the local authorities, no more than I am, are not prophets. When they were preparing their estimates for the year 1958-'59 they were not in a position to see for a year ahead, how many people would avail themselves of the services provided under the Health Act. In some relative measure they were not able, in 1959-'60, to foresee the future in any great detail. It was because they under-estimated the number of people and the charges which would fall upon them and on the Exchequer in 1958-'59 and 1959-'60 that we are bringing in this Supplementary Estimate today.
Vote put and agreed to.