I move:—
"That in view of the fact that the cost of ill health among middle-income families is a serious financial burden and a dangerous impediment to their getting ready access to a first class health service, and since the dispensary medical service does not make available an efficient or equitable service with free choice of doctor to the lower-income group, Dáil Éireann is of opinion that the present blue card medical system, subject to a means test, should be abolished and replaced by a no means test national health service based on the principle underlying the present tuberculosis medical services."
I think it is some time since we had a serious debate on health services. We felt that sufficient time has elapsed for us to face the problems which are created by providing State health services and that we are also in a position to judge by the results of different services by Governments over the years. From that judgment we must try to find out what would be the wisest way to progress in future.
The position at the moment is that our health service is a sort of uneven patchwork, broadly based on the century-old pauper laws imposed on our people by the British which successive native Governments have left virtually unchanged, particulary in regard to the dispensary service. The British have long since discarded the poor law. We appear to feel no sense of shame that nearly one-third of our people still enjoy, if that is the word, the use of services under the stigma of the pauper laws of the middle of the last century. Also, many thousands of citizens in the middle income group are faced with the great worry and fear not only of falling ill, as might happen anybody—it is completely unpredictable in the life of anybody or any family—but of being unemployed. They have also the fear of meeting doctors', chemists' and hospital bills.
I think the time is long overdue when we should reconsider the whole gamut of our health services and establish them on the lines suggested in the motion—that is on what is called the free, no means test principle on which the infectious diseases health schemes are based. The health schemes which are available cover the national health insurance schemes, maternity schemes, mother and infant schemes under the 1953 Act, school medical services, the dispensary services and the voluntary health insurance scheme. Then, there is the private health service which is a fee for service type of medical scheme under which the majority of the people in the middle income group in particular must get their health cared for.
Those are the main services available. Of course, there are the infectious diseases health services and the fever hospital services. They are included. It is quite clear that all these are based on varying principles. The principle of the free, no means test scheme in the infectious diseases health services goes right over to the voluntary contributory schemes of the voluntary health insurance scheme. Then, there is the compulsory national health insurance, the free school medical service and the poor law type of dispensary service which is based on the means test.
While there are all these varying kinds of service, there is the basic difference between them of the means test covering a number of the services and the no means test principle covering the infectious diseases services. That is the basic principle which divides us in the House. It has divided us in the House for a number of years. I want to show the House that it is this basic principle, the principle of the means test, particularly in the dispensary service, which makes it virtually impossible for our people to get an even level high standard of health service.
The means test in regard to the dispensary service is based on the payment of a lump sum to the doctor to care for anything between 1,500 and 2,200 patients. He gets a lump sum for caring all these patients. At the same time, he is permitted to run a private practice. This curious amalgamation of two kinds of service, under which he has a fixed sum for the dispensary patient and is allowed fees for services in regard to private patients, creates a situation which is not invariable. There are some dispensary doctors who honour the general hopes that underlay the whole idea of the dispensary service that for a fixed block grant he would give exactly the same standard of treatment to the dispensary patient as he would give to a fee-for-service patient.
In practice, this does not work out. There is a conflict in the doctor's practice between the time he spends on the private patient and the time he feels he can spend on the dispensary type patient. It is clear that, no matter how many times a doctor sees a dispensary patient, the emoluments he gets do not increase. The amount is a fixed sum. On the other hand, the more private patients he sees, the more money he makes. Quite clearly, doctors, who are no more angels, saints or, indeed, devils than anybody else, tend to neglect the dispensary type patient and concentrate upon the private and fee-earning patient. His case is a simple one. There is something in it. The private patient has as much right to get medical attention, when he falls ill, as the dispensary patient. When he is called out to a private patient, he must go. That is the case he can make.
The dispensary patient must, however, take his place at the end of the queue. The private patient, first of all, is treated in the doctor's private home. The public patient is treated in the dispensary which is very often a draughty, dilapidated, down-at-heel, ramshackle building—quite unlike the conditions which the patient would enjoy if he went up to the doctor's private home. The doctor does not want the patient to go to his private home. When I was Minister for Health, I offered certain financial incentives to doctors to treat the dispensary patients in private. They refused that offer. I believe it is quite a conscious and deliberate decision on the part of dispensary doctors to retain this idea of apartheid amongst our people—one type of service for the poor patient, the non-paying patient and a superior kind of service for the paying patient. They have to go to a separate building and wait a long time for the doctor to turn up and they often have to suffer. Very often doctors tend to try to encourage the patient to go to their private houses where he can be forced to pay a fee. The result is his manner can be brusque, can be short; it can amount to ill manners towards the patient; and he can see that the patient is given to understand that while he will treat him, if he went to the private house, he would treat him rather better. There are exceptions to that general rule but I do not think that anybody here who tries to defend the dispensary services has had any experience of the kind of service given to the average patient in the average dispensary. Until I hear dispensary patients, or a substantial number of them, coming forward and saying that they are quite satisfied with the dispensary service, then I am not prepared to accept the evidence of people who do not try it themselves.
That is a general statement which I suppose could be contested to some extent—it could be asked: "Have you been around to everybody to ask them if they were satisfied or not"—but most people here know that it is broadly true. The idea is based on the Medical Charities Acts of 1850, or somewhere around that period. Most countries, particularly Britain, have long since discarded it and have passed through the panel system of medicine into the present magnificent national health service. They have discarded the dispensary system because they know it is ineffective and inequitable, something which no nation professing to be civilised could continue to have as part of its health service.
On the figures which I have given of 1,500 to 2,200 dispensary patients, it is difficult to believe that doctors could give good service. If there were another 1,500 private patients, which works out at more that 3,000, I do not think that any dispensary doctor could give a good service to both private patients and dispensary patients. One section must suffer and I think most of us know which patients suffer in the contest between the two. There is another consideration, and a most important one, that in the dispensary service there is no free choice of doctor. I do not think any of us honestly believe that that is a good thing, that it is desirable or that it is fair to the patient. There is not one of us here who does not believe that he should have the right to withdraw his custom from no matter whom he is dealing with, whether architects, bakers, grocers, engineers or anybody else. We know that if we have not got that right, the standard of service will inevitably deteriorate. That is true in regard to the dispensary patient. He has no choice, no remedy against ill manners, indifference or bad service. He can ask the Minister to inquire into a case of neglect but it is a very difficult thing to prove and the average patient has tended to find that out. Occasionally we find on the side of the patient but it is relatively rare. There is no doubt at all that there is an unanswerable case for seeing that the poor person gets the same opportunity to choose his doctor as most of us get who can afford to pay a doctor, and to see that in that way he has an absolute freedom of choice.
Another consideration in the dispensary service which militates against efficiency is the money we spend on dispensary services. In 1957-58, there were 150,000 people covered by the service which cost £879,000. It worked at about £1 per head per year. Of that £1 spent on our health services, 16/- went on salaries and 4/- went on medicines. Anybody who knows anything about the cost of drugs today, which has gone up very considerably in recent years, knows quite well that 4/- is a sum on which it would be impossible to treat patients adequately and efficiently. That is an impression one has and which I suggest is supported by the fact that in Great Britain the average per-head expenditure on medicines is not 4/- but 28/-, seven times as much. In the North of Ireland, it is 22/- per head.
It seems to me that our dispensary patients are not being adequately treated and not being effectively treated in the dispensary service. This may not be due to any fault of the Department of Health which gives great scope to the dispensary doctors in the choice of drugs. The fact is we are not spending on these services a sum of money which would give us any reason to believe seriously that we are giving the patient the best chance of survival, if he is very sick, or early relief of the symptoms of any illness from which he may be suffering.
This suggestion that our dispensary services are grossly inadequate seems to me to be supported by the decision of the Minister for Health, Deputy MacEntee, in 1947, to bring in his free, no means test health service in respect of tuberculosis, fevers and also in relation to maternity and child welfare. It was a magnificent Health Act. I have often praised it and it is the finest piece of health legislation we have ever had. It was brought in, I believe, because the Minister at that time fully understood that there was a great need for a revolutionary change in our health services. He also knew, as well as I know, that the obliteration of the means test, the obliteration of the poor law legislation from our Statute Book, was imperative, if we were to get the standard of health services which we would all like to see.
I suspect he was also assisted to some extent in his conclusions, with which I agree completely, by the finding in 1946 of one survey in the city of Dublin which has always rather shocked me. That was the death rate in a number of groups divided up between farmers, the professional group, salaried group, manual workers, skilled and unskilled workers, retired, and not gainfully employed. The two groups I shall refer to are the farmers and the professional classes, the death rate for which was 29 per 1,000. In manual, skilled and unskilled workers it was 133 per 1,000. I suspect that those figures—I am sure Deputy MacEntee was aware of them —shocked him just as much as they shocked me.
I do not want to draw anything more from those figures. They are very limited figures with very limited application—one year—and cannot be the basis on which to make a case for expansion, improvement or removal of the means test or anything else. I am giving them merely as they are, with all the weaknesses that there are there. I do think that most of us would be impressed by this great discrepancy between the chance of living which an infant has born into the relatively wealthy class, the farming and professional class, on the one hand—29 per 1,000—and an infant born to a manual worker, skilled worker, or unskilled worker—133 per 1,000—on the other.
The Minister at that time was very proud, and rightly proud, of his free mother and child service and he said, in September, 1950, the free mother and child maternity service for every family without reference to means was provided in the new Health Act, 1947, passed by the Government, and so on, and then he went on to say "Under this Act there is no compulsion and there is no means test."
I do not at all wish to raise any of the old controversies. I am quoting that merely to show that at that time the Minister did believe that the elimination of the means test was a very important prerequisite to the establishment of an equitable and efficient health service.
Deputy T.F. O'Higgins also agrees with the Minister for Health and myself on this question of the dispensary service. At column 689, Volume 183 of the Official Report, Deputy O'Higgins said: "...our general medical service are obviously inadequate". At column 683 of the same volume, he said in relation to our medical dispensary service, that it was carried over when this State was formed, that it was not changed in the slightest, that it was not altered in any part. Further, he said:
When the Health Act of 1953 came before this House it is notable that into it went the dispensary system unchanged, without alteration.
He said:
The dispensary system has long outlived its usefulness. It is absurd that in 1960 we should operate general medical services for our poor in the same way as was thought proper over 100 years ago.
He went on:
The dispensary system is bad.
Then we had:
Our general medical services are obviously inadequate.
It seems to me there is unanimity in the House on this question. The thing I cannot understand is why we cannot set about getting the radical change which is needed.
There are other services which I should like to refer to briefly of which our people can avail. There is the Voluntary Health Insurance Scheme brought in by Deputy T.F. O'Higgins. Of course, it has its advantages as far as it goes. It has certain attractions, in so far as there is no other service better for the middle-income group patient. I notice that the percentage increase in persons joining the service over the three years since it was established is only 1.2. All right; I am glad it is expanding. It has a total of 105,000 members. The number of persons without a general practitioner service is something in the region of 2,000,000. The Voluntary Health Insurance Scheme merely covers 100,000. It is a good thing that they are covered but it is only a limited cover. There is no maternity service, no general practitioner service, only a limited cover for a limited time. You cannot get cover for the person who needs a health service most. A sick person with a bad health record cannot get into this scheme. You have to pass a health test.
Even the relatively conservative Mr. Kennedy, President of the United States of America has accepted that the time that you need a health service most is when you are old. In the face of his hostile critics, he is determined to push through, apparently, a health service which will give people some sort of protection in their old age. This is the one group into which we all know we shall fall. From 65 and onwards, we are all going to need medical care; we are all going to have doctors' bills, hospital bills, chemists' bills and other bills to pay; but the Voluntary Health Insurance Scheme does not offer you any protection—you are not wanted. That is not the fault of the people operating the scheme; it is the fault of the legislation, in so far as they were told they had to pay their way and, of course, you cannot pay your way in this organisation of health services. There is only a nominal subsidy. The result is that the small number of people cannot bring in an actuarially sound and at the same time medically sound health scheme, so that I do not think that is any kind of real answer to the needs of the middle-income group patient.
The dispensary patient at least has this rudimentary scheme; the Voluntary Health Insurance Scheme has some sort of scheme; but for a middle-income family, where there are four to six children, there is virtually no protection at all, certainly no general practitioner service and many fathers and mothers must go through a really worrying, terrifying time during a period, say, like the recent 'flu period, when they were worried as to whether the 'flu was a winter cold or was turning into bronchial pneumonia. They had this terrible worry as to whether they should get in the doctor for three or four children. They worry about the doctor's bill and the hospital bill and the chemist's bill. It tends to delay them in going to the doctor. When they go to the doctor, they are further advanced than they should be in their illness and it takes longer to get better and costs more to get better. They have this unpredictable expenditure.
None of us knows who is going to become ill next. There is this unpredictable expenditure which could be so much more easily borne by the community. Spread over the whole community, we could have a service which would be a real service, a full service in every sense, an equitable and efficient service in every sense, if the community would accept its responsibility to individual members in the community and share the burden of this unpredictable disaster in any family of any kind of serious ill health.
The interesting facts, indeed, are that the British national health service —the cost of which I shall talk about later—for about £7 or £8 per head of the population gives the most magnificent health service in the world. I do not think there is anybody who questions that. In spite of the Tories' activities in trying to undermine its fundamental principles, it still is a very fine health service for about £7 or £8, and £7 is the price you pay for the very truncated, the grossly inadequate— they are doing their best, admittedly— Voluntary Health Insurance Scheme. There is no midwifery, no maternity, no old people carried, no cover for people who have a record of bad health, relatively bad appliances, an inadequate, limited period in hospital, little drug treatment. That costs £7 per person insured. The British national health service costs virtually the same —£7 to £8 per head.
It seems, then, that the unfortunate middle-income patient here is probably worse off, if it is possible to be worse off, than the dispensary patient, because at least the dispensary patient can call on something. With the finely balanced budget of the average middle-income family, with school fees, with the hope of getting a child to the university, the cost of clothes, food, holidays and one thing and another, the fear of hospital, medical and chemists' bills is a very real one. We should try to remove the impediment to the normal or natural doctor-patient relationship, that is, the fee. A lot of play was made with this doctor-patient relationship when the then Minister for Health, Dr. Ryan, and the Medical Association were fighting me. The only real impediment to proper doctor-patient relationship is the fee the unfortunate patient is trying to find when he is in bed, sick, out of work, with the prospect of the bills to pay at the end of his recuperation period and it is time to go back. This fee for service system leaves the patient at the mercy of his fears and in receipt of an inferior service, except for those who can afford to pay for it, a service inferior even to that which the dispensary patient gets.
Even the doctor suffers under the health service; not the specialist—he is doing very well—but the general practitioner. He has a very hard time. He provides a 24-hour, seven day a week service. He has no security. He has no insurance, no superannuation and no guarantee of income. He has the most bitter competition from all his colleagues and has to work in complete isolation. That is another bad aspect of our health services. Instead of working in collaboration with his colleagues, he works in competition with them. The general practitioner, in my view, works under conditions which no trade union would tolerate one moment for its members, in this rat race of medical practice in Ireland.
If the general practitioner is a conscientious doctor he tries to see as many patients as he can. He works too long; as a result he is tired; the patients suffer and get an indifferent health service. If he is a sympathetic and understanding doctor he will say to himself in respect of his patients: "Can they afford acromycin, teramycin chloromycin or some of these other costly antibiotics? Should I take a chance? Shall I call in a consultant? Should I send the patient for X-ray?" He has all these worries which are hard lines on him but it is worse for the patient because it is the patient who suffers. If he is too soft-hearted and tries to save the patient expense, the patient may lose his life or may suffer unnecessarily long.
Under the British health service doctors are perfectly happy. One of the great tests of the health service there is that the British Medical Association is one of its best defenders. They tried to sabotage it there as they did here but now they are the most ardent defenders of the national health service. In relation to prescription charges they thought that these were a barrier to the doctor-patient relationship. It is a wonderful thing to see their conversion. It is again a great proof of the value of the health service to the profession. The doctors do not suffer any hardship; in fact they have greatly benefited by the national health service. The basic salary is in the region of £2,700.
I have a quotation here from Dr. Doolin whom I am sure the Minister for Finance, Deputy Dr. Ryan, well remembers, in which he says the national health service now in operation in Great Britain and Northern Ireland is the best paid medical service in the world. Therefore it seems to me the doctors are completely satisfied. They are very well paid. An effort was made to get them to go on strike recently but it was found that they had nothing to complain about and there was no question of their going on strike.
There is the question of the cost of these services, the cost that can be afforded. The only answer I can give to that is in respect of the British national health service, that the Guillebaud Report shows that the cost of the national health service in Great Britain in proportion to the national income is reduced by comparison with what it was when the service was started. These are the figures: 1948-49, 3.5 per cent.; 1953-54, 3.4 per cent. of the national income. That is in spite of the fact that they have increased the various services, the number of doctors, the number of nurses, the administrative staffs, the services in respect of industrial accidents and extended the amount of research carried out and completed. In spite of all these things, in spite of what people say, the national health service not only has been a wonderful achievement from the social point of view but has also remained at a relatively low level of expenditure for the British.
In relation to our own costs, all I can say is that, with regard to the mother and child service, I would settle for that if the Minister would be prepared to say he would make a start with that service on the 1947 lines. We considered it at that time and as everybody knows a most conservative Minister, Deputy McGilligan, accepted that we could afford that free no-means test mother and child service. It was accepted also by the then Taoiseach, Deputy Costello, and by the then leader of the Labour Party, Deputy Norton. It was also accepted by the present Minister for Health, Deputy MacEntee, when he said that the mother and child welfare scheme provided in the 1947 Health Act would have been brought into operation in 1948: "The scheme would have been a costly one because they realised the strength and hope of the nation lay in its children."
He is quite right. It would have been a costly scheme but all of us on all sides of the House—the Labour Party, Fine Gael, Fianna Fáil—are agreed it is not only ethically and medically desirable but also financially possible, that it would be possible for us to bear the cost of a free no-means-test health service. I mention the word "ethical" only in passing. I do not think anybody seriously believes there can be any ethical objections to the bringing in of a free no-means-test service. We already have it in children's allowances; we also have free primary education, a free tuberculosis service, a free maternity and infant service, free fever hospital services and, looking at it from the point of view of the farmers, there is a free bovine tuberculosis eradication scheme. In many other aspects of our life we believe in a free no-means-test service. There is a free no-means-test health service in the Six Counties, so I do not think anybody seriously can suggest there is any objection on any score.
There is, first of all, a great need for a free no-means-test service and there can be no objection on any score to the introduction of such a service by the Minister. We have the hospitals; we have the doctors and nurses; we have the money. All we need now is the legislation and I sincerely hope the Minister will give serious consideration to the plea I have made that he should introduce the legislation as soon as possible.
