Dáil Éireann debate -
Wednesday, 6 Dec 1961

Vol. 192 No. 8

Health Services: Motion (Resumed).

The following motion was moved by Deputy T.F. O'Higgins on 23rd November, 1961:

That Dáil Éireann is of opinion that existing health services have been proved to be inadequate, and that in their place there should be provided a comprehensive health service based on the principles of insurance which will extend to 85 per cent. of the population, and which will provide without charge an adequate medical service with free choice of doctor, free hospital, specialist and diagnostic services and which will remove the necessity for medical cards for all those within the scheme.

Debate resumed on the following amendments:

1. To delete all words after "That" and substitute: "a select Committee of Dáil Éireann, consisting of nineteen members to be nominated by the Committee of Selection, of whom seven shall be a quorum, be appointed with power to send for persons, papers and records—

(1) to examine to what extent, if any, experience has shown that, having regard to the general structure of our society, the existing system of health services does not meet in a reasonable way and at reasonable cost the essential needs of the various sections of the population for medical care and attention and, if the examination should disclose any significant defects in the system, to what these are due;

(2) to review the income and other limits applicable to the categories eligible for the different health services;

(3) to review the existing arrangements for determining whether a person is or is not within an eligible category;

(4) to consider whether it is practicable to extend the free choice of doctor at present available under the general practitioner maternity and infant care service to

(a) the general medical service, and

(b) the hospital and specialist services,

and if so extended to indicate the consequential arrangements which would require to be made with existing and additional personnel, hospitals and nursing institutions;

(5) to prepare an estimate of the cost of any extension or modification proposed;

(6) to examine the existing arrangements for meeting the cost of the services and alternative arrangements which might be adopted for meeting such costs and the costs of any extended or modified services recommended and in particular to examine the practicability, desirability and economy of meeting these costs by means of a scheme which would be based on the principles of insurance and which would make provision for and have due regard to the position of self-employed persons and persons who would be unable to contribute to an insurance scheme or for any other reason might be outside the normal scope of an insurance scheme; and

(7) to make recommendations on these matters and such other matters related to the health services and their operation as the Committee think fit.—(Minister for Health.)

Amendment to the Amendment:

1. To add at the end of the amendment the following:

"That the Committee report before 30th June, 1962, and that pending the report by the Committee the Minister for Health request County Managers and Health Authorities to liberalise the administration of the Health Act particularly in relation to the issue of medical cards and charges for hospital treatment."— (Deputy Corish.)

Mr. Donegan

This debate is the direct result of Fine Gael stated policy during the last election when Fine Gael produced a policy for health radically changing all the existing health provisions in this country. Having arrived here not in Government but in Opposition, they very properly put down a motion embodying the policy which they had expounded to the people. Certainly they made some impact because while in the ordinary way of politics, the Government would not wish to give the Opposition something they had put before the people—and apparently convinced a great number of the people—they decided to put down an amendment which I suppose is a direct negative but which at the same time does refer the matter to a Select Committee of Dáil Éireann.

I believe if a referendum were conducted on the two policies for health, there is not the slightest doubt that the majority of the people would vote for the Fine Gael policy because it is true that it is really impossible for the ordinary citizen today to bear the cost that may accrue to him in respect of the ill health of himself or a member of his family. The new wonder drugs have meant that illness can often be shortened and that the effects of illness or accident can be lessened or even obviated, but they are very expensive drugs and treatments are expensive. One has only to look at the cost of beds in hospitals which the State builds and maintains, to see that the whole thing has built itself up into very high expenditure.

As I understand it, the present system is that 50 per cent. of the cost of the health services is provided by the ratepayers and 50 per cent. by the Government and the question of whether a person is eligible or ineligible for a health service is decided by the county or city manager in whatever health authority area the person resides. The impossibility of equity in such a system can be very easily explained when one realises that in Louth, to take my own county, there are 69,000 people, a large proportion of whom would fall to be looked after under the health services and that a penny in the £ produces roughly £1,000. In our neighbouring county, Meath, however, there are 67,000 people and a penny in the £ produces £3,000.

Mr. Tully

£3,300.

Mr. Donegan

No; I must correct the Deputy. He is about two years behind the time. The figure is £3,000. Perhaps it is a county-at-large charge as against another charge, but even if Deputy Tully were right, which I contend he is not, the comparison is quite obvious. When a manager comes to decide whether or not a person is in the lower income group, in which he is entitled to get the service free, he must always have in the back of his mind the fact that one penny in the £ will yield either £2,000 or £3,000; but the county manager in Louth with 2,000 more people than in Meath to look after is in the position that he is going to get £1,000. Take only one subsection of the Health Act, 1953, subsection (2) (d) of Section 15, where the county manager rules on hardship cases. Always at the back of his mind must be that if he allows a person enjoy £500 worth of health, and he is going to pay 50 per cent. of it, in one county that figure may be four times what it is in another county. The fact that the present system does not spread the cost is a bad and distressing thing.

Deputy O'Higgins has explained our approach to this problem. It is that ?d. should be charged on the employee and ?d. on the employer, that there should be a cessation of the present dispensary doctor system, that there should be a choice of doctor, whereby a person in possession of a card—not a green card decided on by his county manager because he is in a certain income category, but a card given to him because he is in a certain capacity, because he is an insured worker, because he is a person earning less than £1,100 a year in some circumstances and £800 a year in other circumstances, because he is a farmer with less than £50 valuation—could enjoy certain facilities. It was the intention that if he had five in family, and his card said he had that number, and he brought it to the doctor of his choice, that doctor would, as in Britain, get a payment per member of the family. At the end of the year, if the subscriber was dissatisfied with the service he had received from that doctor, he could take that card, go to another doctor of his choice and the card would be accepted. Then he could stay with that doctor for a year. That would put the ordinary citizen in the position of being the customer. There is an old adage that the customer is always right. As far as health is concerned, we should try to create the situation whereby the person getting the service would be the customer and could, if he wished, remove his custom.

I mean no criticism of doctors in general or particular. I think the dispensary doctors have been particularly good in their approach to this problem, but I feel their situation in relation to it is untenable. As housing areas are built up in the various towns and cities, the position has been that one dispensary doctor may be looking after three times as many patients as another dispensary doctor. Nothing seems to have been done about that. It is obvious, be that doctor as willing and as excellent a doctor as ever there was, that he cannot give the same service to his patients as the man with the lesser number can give, no matter how anxious he may be to give it. The choice of doctor system would mean that you could limit the number of patients a doctor could have the same as in Britain and that, if he had a certain number of patients, he would have to employ an assistant. As well as putting the ordinary citizen into the position of being the customer, that would also see to it that each person would have an equal chance of enjoying the benefits of the scheme.

Our view was that there should be no such thing as a means test, but that the matter should be decided by the category of person, not defined by anybody outside but defined by the person's own position; in other words, that the person who would get the service free would be the old age pensioner, the person on home assistance, the person with a valuation of less than £15, if a farmer, and all people easily defined by reference to their position and not related to a means test, whether they had the pig out in the back or 25 chickens in the shed. That would be a great help. It would get rid of the green card. I cannot say how much I would like to get rid of that, because there is a suggestion of pauperism and the old poorhouse system about it—getting something for nothing as a charity. There is an old saying down the country: may you or yours never know the coldness of charity. I would prefer to see these people in the position of getting something as their right rather than that they should have their means investigated—and their means are usually very small—by the local relieving officer, that they should be questioned by the home assistance officer and eventually have their application for a green card refused when a file is produced before the county manager or someone appointed by him.

The Minister asked what would this new system give to the people that they had not got before. They would have a choice of doctor. The people who had not a green card would get medicines at 50 per cent. of their cost outside hospital. The middle income group people have got absolutely nothing outside hospital. Hospitalisation would be free to these people as long as they were subscribers to the scheme and were making the statutory contributions. Those are great steps forward and the scheme is not, as was represented by the Minister for Health. simply a change in name.

There is also a great anomaly in the green card system inasmuch as when the county manager or his officer comes to decide who will get a green card and decides on the father or mother of a family, he must have regard to the incomes of sons and daughters residing with that father or mother, but if any one of those sons or daughters applies for a green card, they can get it without any regard being had for the incomes of their brothers and sisters or of their mother and father. That brings about a shocking situation. You can have a father and mother who have worked all their lives and are now at home drawing the old age pension, but because they have sons and daughters living at home with them and drawing good wages, they cannot get a green card. Even though some of these sons may be drinking their heads off, they can get a green card and the only income taken into account is their own.

That situation just will not be tolerated and I would emphasise that, irrespective of what happens in respect of this motion, in ten years' time, you will have a system of health services which will not include this pauper provision. You will not have a position where one family living side by side with another in the same street, in receipt of the same income and having the same outgoings, will have a green card while the other will not.

There is also the strain on the time and effort of the relieving officers and the home assistance officers in trying to make up these green cards. It is impossible for them to do it efficiently and I can assure the House that it is not being done efficiently. There is not the slightest doubt in my mind that the green card system must go in the next ten years. As I have said, politics is the science of what you can get out of it.

I should like to refer to the question of drugs. We must face up to the fact that when the health services began in Britain, drugs were given entirely free and they were being used. People went to their doctors and said they wanted certain drugs and the doctors, knowing that they might lose patients at the end of the period if they refused, issued the drugs. Because of that, the British authorities were forced to put a small charge on drugs. The system we suggest whereby certain persons, such as old age pensioners, farmers with valuations of under £15 and unemployed men or men in receipt of health benefits should pay 50 per cent. of the cost, would mean there would be no abuse of the provision and that quite a considerable contribution would be made towards the cost of the drugs. On the other hand, considerable help would be given to poor people, particularly in the case of such drugs as those of the sulpha group which may cost anything up to £3 for a short course. The 50 per cent. we suggest would be of great assistance to such people.

Then there is the question of the rates. Implementation of the motion would mean that a great portion of the health charge would be taken from the rates. This would result in a considerable reduction in local charges. How could we have a good health service when 50 per cent. of it is being paid by the ratepayers? The 10 per cent. reduction in the rates which we estimate will come from the removal of the 50 per cent. health charge from the rates is something that can be looked forward to eagerly by the ratepayers. Of course it does not mean that the entire health charge would be removed from the rates because ratepayers will still be faced with the task of maintaining county hospitals and similar institutions. It will, however, mean a 10 per cent. reduction in the rates, at a time when they are so high that the ratepayers cannot bear very much more, particularly nowadays when the health services are increasing continuously.

I feel that the insurance contribution system is the only one whereby you will create the situation in which the subscriber is the customer. Such a system could not fail to produce a decent result. A fact which I think is quite extraordinary is that at the moment we are spending only £200,000 on dental care of people unable to pay. From the figures produced, and over which great trouble was taken, it is obvious that we are not prepared to spend anything like £1 million a year on this very necessary service, despite the fact that the 1953 Health Act places a responsibility on the local authorities in this respect.

Many counties provide no such service because they have not been in a position to face up to the cost of it. Consequently, a position has been reached where all that is needed is for somebody to sue a local authority and bring the entire matter through the High Court, and the Supreme Court, if necessary. Of course that would not happen because the type of person affected could not afford to face up to the local authorities who would employ the best legal brains in the country. In my county, we have been unable to provide any dental service whatsoever. However, doctors and even officials of the county council have sent patients into hospital so that when they became patients, they could have a dentist called in and service provided free in a county in which otherwise there is no free dental service. The section of the 1933 Act making provision for such free dental services by local authorities is Section 14 (1).

On these grounds I appeal to the Dáil to accept this motion. Its implementation would remedy obvious defects in our health services. I know the Government have been placed in an invidious position because this work was done by the Opposition and was produced at the time of the election. That was one of the things that increased our representation so considerably.

Mr. Lenihan

One of the stunts.

Mr. Donegan

It is all right for the Minister and the Parliamentary Secretary to laugh, but if the election had been a few weeks later, if the Taoiseach had given us the time he had promised, Harry Wragg might have passed you in the race and you would have been over here and we over there. We got the Government to put down an amendment. If they had not thought the people throughout the country were behind this motion, they would not have bothered with the amendment. It shows at least that this is a matter of great moment and that the implementation of our proposal would provide a decent health service so lacking in the past under the old pauper system.

Mr. Dolan

I have listened with interest to what the previous speaker has said and I wonder what would happen in the case of patients who, he says, would have a choice of doctor, if the doctor refused to take on such patients. Where would they turn then? As regards the charge of 1/6d. for the employer and 1/6d. for the employee, who will collect that? Will there be a staff of people going around to squeeze this 3/- from these people to finance these services? There is another very important question. How will these services cater for those unfortunate people in our community who will be unable to pay this charge? Will they be left to die in the corridors?

Mr. T.F. O'Higgins

They will get the service without charge.

Mr. Dolan

I would like very much to be convinced of that but the previous speaker has not convinced me that this is a scheme which could replace the health scheme already in existence. He mentioned a reduction of 10 per cent. in the rates. Anyone representing a local body and who knows anything about rates will know that if each member of a family has to pay 3/- per week extra perhaps in the long run they might be much better off paying rates rather than carrying this weekly insurance contribution envisaged in this scheme.

Mr. Tully

I have listened with interest to the speeches made on the motion and particularly to Deputy Donegan. He poses the question: if the choice were between the present system and the Fine Gael proposal, which would the people choose? Of course they would be mad if they did not choose the Fine Gael proposal, if it would operate. I cannot agree at all that the Fine Gael proposal could possibly operate. They have enumerated very many things which I agree need to be changed in the existing health services. They have pinpointed very many things which we all know should be done, if we are to have a fairly decent health service. However, the suggestion made by the mover of the motion—he can correct me when he is eplying if I am wrong—that this service can be provided under the scheme which they propose for approximately £8,500,000 and that they would be able to do much more than the Government are doing for £18,500,000 is something which I do not just believe.

We have been working on this question of health services for a number of years and our Party gave their support to the introduction of the Health Act because they believed it could improve the red ticket system which operated up to then. It would be most unfair to say there has not been an improvement, but the red ticket system has been replaced with a blue card or a green card, depending on the county you are in. In one county, they were operating a blue card and when the T.B. scheme for cattle came in, they had to change it because they were also being issued with a blue card. Someone was unkind enough to say the cattle were getting better service than the human beings. I do not know how true that might be but I do know that the present system at dispensary level is not satisfactory and Fine Gael are quite correct to point that out and to ask to have it changed.

There are a number of dispensary doctors throughout the country and they supply a domiciliary service to the ordinary people. Most of them are very decent and devoted to their job but some of them unfortunately seem to forget that if there were not poor people needing free medical assistance, there would be no necessity for dispensaries or dispensary doctors. Every effort should be made to wipe out the system whereby those who have money to pay get precedence over those who have not, even though those who have not got the money are often very much more sick than those who have the money. Any effort in that direction must be welcome. I agree Fine Gael have that idea in the motion but even if we can agree that they are genuine about it, I do not think it can be done as easily as they seem to suggest it can.

The question of drugs for the sick poor is one which from time to time has engaged the attention of anybody who is interested in social services and medical services. Recently, I was intrigued to find the Department of Health had issued to local authorities some statement to the effect that they did not need to make everybody who had not got a medical card pay for their drugs, particularly if they were expensive drugs, and in fact they were entitled to take the normal circumstances into consideration at the time of the illness and to see to it that the drugs were supplied free. The unfortunate thing about it is that it does not seem to have gone any further than the files of the local authorities because the local authority members have not had it brought to their notice. It is likely that unless the Minister makes a statement about it which will be taken up by the national Press, this concession—it is a very big concession—will not be known to the people who will be affected.

One of the shocking things about this system is that some people who have been working all their lives may find that because they have a reasonable income—and in country districts, that may be as low as £6 per week— when they fall ill, the doctor who attends them may say that as they have not got a medical card, they must pay him before he attends them and they must pay for any drugs they may need. There is a flaw in the existing Act that the insured person who has not got a medical card, even though he goes from full wages down to social welfare benefits, is still considered ineligible for the treatment to which he would be entitled if he were in possession of a medical card.

We think, as we have suggested in our amendment, that the Committee which the Minister for Health proposes to set up should report back not later than 30th June next, which is over six months' away and that the county managers and county health authorities should liberalise the administration of the Health Act in the interim period. Another unfortunate feature about the whole matter is that somebody in the local authority is officially responsible for deciding that a person is or is not entitled to a medical card. Deputy Donegan was quite correct when he said that you will find instances of two families living side by side, next door neighbours, one of whom may have a fairly hefty income and be in possession of a medical card while the next door neighbour with a very moderate income is without a medical card. It has been suggested that there are various causes for this. One of the most common suggestions is that there has been a certain amount of political pull. I hate to think that that should be so. It occasionally appears as if it is so. But, no matter what the reason, it does seem to be the case that people who public representatives know are not very well off, and who are entitled to free health treatment at local level, are refused it while those who might possibly be able to pay, and in some cases are definitely able to pay, can get free treatment. The answer may be that the doctor has the right to report such cases to the county manager and to ask that the medical cards in such cases be withdrawn but doctors are human beings and many of them do not want to report those cases.

As I mentioned earlier, there are doctors who would have no hesitation in telling people that they must pay for these services. A few days ago, I heard of a man who was earning almost £10 a week with a considerable amount of overtime. In order to go to his job, he was paying for a car which cost him £2 10s. per week. He had a wife and four children and the wife's mother, an old age pensioner, was living with them. The local authority decided that none of those people, including the old lady, was entitled to free medical treatment. That is what can happen and what is happening under the scheme as it is at present. It is quite right to ask that a change should be made in that system.

As far as dental treatment is concerned, the biggest trouble seems to be that in any county where a dental service is in operation there is a waiting list in many cases of a year, a year and a half or two years. It is just too bad for some people who, on a doctor's recommendation, had their teeth extracted by the local authority representatives or local authority dentists and who have then to wait that period for dentures. As a matter of fact, in some cases they have to wait that period before they get their teeth extracted at all. The same thing happens with people awaiting spectacles. Many of them have to wait that very long period before they are supplied. Naturally, the eyes must suffer over the period they are carrying on without the spectacles.

A third matter which I think is far more serious is that I understand the Department of Health have recommended to local authorities that the accent should be on the children, particularly where dental extractions are concerned, rather than on older people. We find that the local authority are prepared to look after the teeth of youngsters while the older people are running into bad health because the Department of Health says the accent should not be on them but on their children. That is something which must be taken into consideration by the Department if any effort is being made to improve the present health services.

As far as the hospital service is concerned, one matter causes a considerable amount of uneasiness. In some areas, people are required to attend at the hospital daily or twice weekly or weekly for treatment. If they are really poor people the only way they can attend the hospital is for the local authority to supply transport. This may mean that the local authority will send either the ambulance or a car to take them to the hospital or clinic for the treatment and home again, at considerable expense. In many cases, a hospital beside their place of residence, three, four or five miles away, cannot be used because of nothing other than red tape, or, should I say, green tape. A particular instance of that is both sides of the town of Drogheda. On the Meath side, people have to travel to Navan for treatment although they could receive it in either of the two Drogheda hospitals at very much less cost to the local authorities. In fact, they would probably be able to cycle or take the bus or train to Drogheda and get the treatment there without having to go to Navan by car or ambulance.

In Louth, in Deputy Donegan's constituency, people have to go to Dundalk in many cases when in fact they could receive treatment in Drogheda. As far as those entitled to free treatment inside the hospital are concerned, the position is something better. However, one extraordinary feature came to light recently during an inspection of the accounts of one of the local authorities. It was discovered that the amount of money recovered from people who had received treatment in local authority hospitals amounted to between ½d. and 1d. in the rates. In other words, if everybody who went to that local authority's hospitals had received free treatment it would have made the difference between a halfpenny and a penny in that local authority's rates. When we talk about how difficult it is to give free treatment to everybody who needs it in hospital, those facts seem to show that it is not so difficult at all if we had the will to do so.

Specialist services also are sometimes easily obtainable. Most local authorities co-operate very fully in seeing that the patients get treatment quickly and, as far as possible, cheaply. But again the question of green tape arises. If the proper form is not filled up, if the local authority have not been notified in time, a patient may receive a bill after leaving the specialist which, if the patient had not heart trouble before he went to see him, he would be inclined to have after reading it. Again, this is something which should very easily be looked after if the various local authorities went to the trouble of trying to arrange to have specialist services made available at the nearest possible place.

It should be possible, after a person has received treatment, to have the necessary forms filled up because, if somebody very ill is going away for consultation or for treatment, the question of who is to pay the bill afterwards does not seem to worry him, and I am not surprised. But it is a bit of a shock to find that the bill is sent along and in many cases is ultimately paid by the local authority after confusion and annoyance have been caused to everybody concerned.

A number of local authorities are very co-operative about the question of where a patient may go for general hospital treatment. We know some local authority areas where patients find that the full quota of beds is taken up with the result that they have to be sent to a hospital further away. Again, we find some local authorities insisting that the patient, who is going to get what is called free treatment, must go to the local authority hospital no matter where it is situated rather than to the nearest available hospital. That is something that must be taken care of as quickly as possible. It is rather unfortunate that if somebody is ill he or she should be asked to go to a hospital in a town where very often there is neither a bus nor a train service, a town perhaps 30 or 40 miles away from the patient's home while suitable hospitals are within easy reach, or at least situated where there is a decent bus or train service. This causes a lot of annoyance particularly to older patients who, when they go to those hospitals, find they cannot have visitors because their friends are too poor to hire a car and have no other way of coming to visit them.

Another thing that causes considerable trouble is the tendency in some local authority hospitals to send older patients who do not seem to be making a rapid recovery to what were known until very recently as county homes. These have now got more respectable names, such as the name of some saint. Perhaps that is all to the good, but I do not think it right that decent people, who go for treatment to a local authority hospital, should be sent to the county home without their consent if they are not recovering as quickly perhaps as those who are looking after them would like, or else sent to their own homes where they get no treatment. I often wonder if those people had sufficient money to pay for themselves in hospitals, would they be sent away. We know what the answer is.

Another aspect, on which I should like to touch lightly, and which I think the Department should note, is the system whereby people, old age pensioners for instance, who go into a county home, not for shelter but for treatment for illness, have deductions made from the old age pension and in some cases have the entire pension stopped, although there is no authority whatever for such procedure. The Department should notify local authorities that it is unfair and unchristian to deprive those old people of their pensions or whatever small incomes they have when they go for treatment rather than for shelter. If they go for shelter, it is an entirely different matter.

There is also the question of cost. It has been the practice over years— goodness knows why; I do not—that people who go into hospital and are willing to pay for treatment find, when they get their bill, that it runs to something like £10 7s. 11d. or £9 18s. 9d. whereas if they went to a private hospital the bill would probably be about five or six guineas. The reason given by the local authorities for the difference in cost and for the pennies in the account is that repairs are being carried out to the hospital and that the cost is being added over a period of years to the per capita charge so that there will be no loss either to the Department or the local authority. I think that system is entirely incorrect. A charge should be laid down for the local authorities and the extra charge imposed because of repairs should not be put on.

As far as the health service generally is concerned we believe it must be changed. We believe, following the discussions that will take place as a result of the Committee being set up here, that the change will be made and we feel the Government will be big enough to admit that the present system is wrong. We should love to see a system introduced that would save £10,000,000 with improved health services. We do not think it possible, but we think it can be done if the health services which we have at present can be brought up to the required level if we continue the existing system of collecting from the local authorities and the Government and, in addition, make a charge on an insurance basis. A very small charge will pay what is required and farmers and other self-employed persons can get the same service by paying a small charge.

We also believe, as do Fine Gael, that those who are unable to pay should not be debarred from the treatment they need but we would like to point out that people who are unemployed or ill—insured persons—should be entitled to benefit because of their insurance. In conclusion, I should like to reiterate what Deputy Donegan said, that the really important thing when improving the health service is to provide a service which the insured worker and the insured person generally can demand by right and not seek because it is a charity to which somebody thinks he is entitled.

Mr. Hogan

(South Tipperary): The present health system is financed on a fifty-fifty basis between the central and local authorities and when the Minister for Health intervened the other day he seemed to think that system of financing was quite satisfactory. He mentioned that he was quite satisfied with the Revenue Commissioners and the rate collectors. The system suggested by Fine Gael is intended to replace that by insurance stamps. Deputy Tully, I think, wants a mixture of both.

The present health system gives a varying degree of coverage to about 85 per cent. of the population on a completely free or partly-free basis. In other words, 15 per cent. are outside the scheme and are expected to look after themselves although they appear to be individually, in the majority of cases, the larger contributors. I am endeavouring to portray an aspect of it for the House which has not been already adverted to. If we go back far enough, at one time in this country probably 85 per cent. of the people were providing free or partly free service for about 15 per cent. of the population. There was no outcry. It was no burden. But, as the years passed, an increasing number of people came under public services. We have now the position I mentioned earlier in which about 15 per cent. are left to contribute to a great extent to 85 per cent. In other words, fewer and fewer are paying for more and more. All these costs have gone up considerably, due largely to the increased cost of living but particularly to the increased cost of modern drugs.

An expenditure of £30,000,000 is in contemplation on rural water supplies. Again, to give approximate comparative figures, a few years ago, 85 per cent. of the people were supplying free piped water to 15 per cent., namely to non-urban towns and villages. With the progress of a rural water supply scheme, with our ratepayers paying a 25 per cent. contribution, ultimately the position will arise that 85 per cent. of the rural community may have a piped water supply and 15 per cent. will be permanently excluded. Consider the position of a man who happens to be geographically so situated that he can never get a piped water supply, and also so situated by virtue of his valuation which may happen to be £50, or by virtue of his income, which, because of his efforts, may be over £800. Will he be expected to pay 10/- for water he cannot get or 12/- or 15/- for a health service in which he cannot participate? Clearly there is a social injustice here. I believe the financing of our health services, when we take into consideration further imposts like water supplies upon our county councils, is clearly becoming unjust. In fact, I think the Government recognised that before the election, unless it was for propaganda purposes they established a commission to inquire into the distribution of local rates.

It is all very well to say "To each according to his needs and from each according to his means". These are relative terms. That could easily become: "To each beyond his needs and from each beyond his means". Many of us on this side of the House think—others may think with us— that it is the function of the State to supplement rather than supplant. As a result of our Hospitals Sweepstakes money and the prodigal extension in the number of hospital beds under State auspices, we have now more beds per thousand of our population than any other country in the world.Is this "To each according to his needs?"Is this "From each according to his means?"I know I will be told we have a shortage of beds and that there is a long waiting list in every institution. One could build a hospital extending from here to Finglas and fill it with patients so long as it was comfortably centrally heated, the patients were well fed, and charged very little. I have never seen a hospital yet that could not be kept filled. The criterion of a hospital well run is a waiting list and a demand for beds. Our mounting rates are largely due to the increased number of hospital beds and increased hospital expenses rather than any rise on the domiciliary side of the service. Our complaint in the Fine Gael Party is that there has been an over-emphasis on hospital treatment and not sufficient emphasis on domiciliary treatment. Deputy O'Higgins has given the facts and figures——

Mr. Leneghan

A bad Health Act.

An Leas-Cheann Comhairle

Order.

Mr. Hogan

(South Tipperary): Deputy O'Higgins has given the facts and figures as to what the contributory insurance may cost. I recognise the difficulty there is in making these estimates. Such calculations must be extremely difficult. I think I am right in saying that when the 1953 Act was introduced, the Minister for Health at the time, Deputy Dr. Ryan, estimated it would mean 2/6d. in the rates.

Sir Anthony Esmonde

Two shillings.

Mr. Hogan

(South Tipperary): At the moment it is costing 15/- in the rates in County Waterford so these estimates seem to have an extraordinary——

Mr. Lenihan

But not extra.

Mr. Leneghan

There must be awfully silly people in Waterford when they elected you anyhow, if that is your attitude.

Mr. Hogan

(South Tipperary): There is an amendment here suggesting we should give the people a free service. That is Deputy Dr. Browne's amendment. Unfortunately he is not here. You had him thrown out. Now, I have not read Das Kapital but I have read the Life of Washington.He once said that a Government should not do for people those things which they are well able to do by their own efforts. Under the contributory insurance scheme we put forward, 85 per cent. of the people will be given coverage; 15 per cent. will have to fend for themselves either directly or by taking out some type of insurance.

(Interruptions.)

An Leas-Cheann Comhairle

Deputy Leneghan should allow the Deputy in possession to make his speech without these interruptions.

Mr. Hogan

(South Tipperary): Nobody will deny, I think, that it is not unreasonable to expect, unless we are all paupers, that 15 per cent. of the better off people should be able, in ordinary circumstances, to provide for themselves. To a great extent, they are doing so at the moment. That will be the position under the scheme as we envisage it. I think it cannot be denied that a scheme embracing 85 per cent. of the population should be largely self—financed. It is not suggested in our proposition that it is completely self-financed—I said “largely”—because 15 per cent. will as employers and as ordinary revenue payers be making their contribution either into revenue or in paying for the stamps of their employees.

The health card system and the means test have been mentioned. It does not need emphasising that much of the difficulty and a good deal of the outcry against the Health Act at the moment is in relation to the means test. I think that people are particularly worried by the fact that, if they have not got a health card, they will have to pay something when they go into hospital. The Minister said they should not be charged this 10/- per day. At the same time, a little brochure was issued to every county councillor and to members of the public who applied showing this charge. By our proposition, we are, in fact, abolishing the means test. We are abolishing a means test which applies at the moment to the base of the social pyramid, if you like, to the people at subsistence level, and raising it to a higher level, a subapical level, to embrace a few pople.

It is not exactly a means test. It is merely a test to find out whether they should come in under the compulsory insurance scheme or whether they should be free to opt out of it. This test, carried out on a small number of people of £50 valuation or people with £800 a year income, will not and could not cause the same distress, the same hardship or the same objections as a test applied to a large number of people in very poor circumstances—a test, which has, I believe, under the regulations, to be applied annually. We know that it is not being applied annually. It is impracticable to do so but where it is being applied it is causing considerable distress. It would be simpler to abolish it completely and merely have to deal with people of £50 valuation and people with £800 a year income and tell them they must come into the scheme or stay outside. To these people it would not make very much difference whether they join the voluntary health insurance or the compulsory insurance scheme. I am sure they would not bother very much either way.

There is another aspect of the matter which has been mentioned already—the question of the free choice of doctor. The Minister for Health made great play on that phrase calling it restricted choice and so many other things that he had me all tied up. Free choice of doctor is a recognised term all over the world. The Irish Medical Association, the British Medical Association, and the World Health Organisation have always advocated what they term free choice of doctor. It is a relative term. What one means by the term "free choice of doctor" is that a man in the town of Clonmel may, irrespective of his income, pick any doctor in Clonmel and if he wants to go three miles outside Clonmel he is free to do so but he is not going to travel to Dublin. We must be rational about these things. There is no point then in raising a hare about restricted choice or using any other verbiage of that kind. Free choice of doctor is accepted all over the world. It is accepted practice and has been in operation in England for the past 30 or 40 years. We believe that the free choice is good for the doctor.

Mr. Leneghan

That is exactly what the Deputy believes all right but what about the patient?

Mr. Hogan

(South Tipperary): We also believe it is good for the patient because we believe that the doctor should not own the patient nor should the patient own the doctor. We believe it would be good for the patient because it would introduce an element of competition. We believe it would be good for the doctor because it would keep him up to scratch. I think that the best type of payment is the insurance contributory scheme which is based on a contractual basis by which the patient may take his card from one doctor to another. I think it would remove much of the element of difficulty which arises at the moment where we have in some cases large dispensaries with doctors overworked trying to deal with thousands of patients while doctors in rural areas attend to a small number of patients only. Free choice of doctor is the system adopted in most civilised countries at the moment.

The free choice of hospital and specialists constitutes a more difficult proposition. Before national health was introduced in England the specialist was largely obtainable even by the poor patients. In the rural areas of this country there is very little choice left as regards hospital or specialist treatment. Even where that is possible the regulations do not permit it. In my own practice, a purely private practice, I could make my living on 15 per cent. of what somebody might call top-drawer people but it is largely on 85 per cent. of the people who are already provided for through Government services. They prefer to elect to come to me. That shows that at least people are prepared to pay for this free choice and that is a thing very much desired by the people of this country. We should endeavour to give our people free choice.

There is a final aspect of this matter which has not been mentioned here before. I think it is important for the success of any health scheme. We hear a lot nowadays about staff-management relationship in regard to the industrial worker but we hear very little about Minister-doctor relationship. One would have thought that the more liberal lines of thought permeating the industrial world would have now permeated through the hidebound atmosphere of the Custom House. I need hardly stress that good relationships between the Minister and the Medical Association are a necessary prerequisite, a sine qua non, of any satisfactory health service.

Our Minister's estrangement appears to derive from the medical practice of inserting certain State appointments in an advertisement column of its journal under the title of important notice. He has variously described this important notice as a ban, a boycott and a proscription. As a consequence, he has refused to meet the Irish Medical Association. He gave us a dissertation on these important notices here to-day.

What are these important notices to which the Minister has been objecting for so many years and which caused this estrangement? The important notice is merely a request attached to certain advertised posts advising potential candidates to communicate with the Medical Association if they are applying for such posts. The medical man may or not seek this advisory service and, having sought it, may ignore it and is not in any manner precluded from accepting such positions. It is purely an advisory service which the Medical Association is constitutionally entitled to offer to its members. As the Irish Medical Association is not a trade union, it may not, therefore, impose formal restraint on any member. This type of notice was first inserted, I think, in the year 1904 in the British Medical Journal.

It has been found to be a very useful and essential weapon down through the years in the interests of medical care. It is particularly used in the British Medical Journal to protect doctors travelling to overseas appointments, badly equipped posts like rubber plantations or to colonial services. No British Minister has ever objected to these important notices. I do not know whether any Irish Minister has objected to them except the Minister for Health. I may be wrong there but in over 35 years of often embittered controversy, no British Minister has ever refused to meet a representative of the British Medical Association. The Minister for Health has consistently refused to meet them. The Road Traffic Bill, 1960, the Poisons Bill, 1960, the Mental Treatment Bill, 1960, and the Nurses Bill, 1960, were all introduced without consultation with the I.M.A. who might have had important contributions to make. The National Health Council and the Opticians' Board are statutory bodies on which the Medical Association have a legal right to representation but the Minister has withdrawn the Association's right to nominate its own representatives. He has further reduced the number of medical members of various boards. He elects the members of such bodies and their removal is now the sole prerogative of the Minister for Health. Terms of office of members, the procedure governing the calling of meetings, the numbers requisite for a quorum are all determined by the Minister and so in fact these bodies cannot reasonably be expected to offer to the Minister objective guidance or critical observations.

We must all daily compromise to live. Even heads of State, much less Ministers, find it expedient to do so. The Minister for Justice found himself in an uncomfortable position last week and he compromised, and, in my opinion, gained in stature by doing so. May I express the hope that even at this eleventh hour, the Minister for Health may in some fashion rearrange his mind, set aside his silly obsessions, and take a headline from his junior colleague.

Mr. Leneghan

The difference between Fianna Fáil and Fine Gael with regard to the Health Act is that Fine Gael are the doctors' Party and Fianna Fáil the patients' Party. I am on the side of the patients' Party. I should like to point out to the geniuses who have thought up this scheme that they were six years in office during the past 13 years and they had none of these brainwaves. When the election came, they were fired out of office, as fired out they should be. It is rather strange that they did not have any of these brainwaves during their six years in office. The Deputy who has just concluded his statement is leaving the House now because he knows he has met his match.

Why did they not put this famous scheme which they now put forward into operation during the periods they were in office? The number of people insured in this country is relatively small and, in my opinion, if we had a health scheme based on insurance, it would mean that most of the people would have no health service at all. I see nothing wrong with the present health services so far as my county is concerned except for a few trivialities which could be easily remedied if we had discussions with the Minister.

These geniuses have come here tonight as they came a few nights ago with this famous scheme. What would be its outcome? It would mean that no one where I live could get free treatment for anything. I am sure that no one in this House would seriously suggest that I for one should stand idly by and allow such a position to be reached. I will not. I have no trust in anyone over there.

Mr. Donnellan

On which side?

Mr. Leneghan

I am not including Deputy Donnellan. These people have been there for years. I have seen them on other nights and after making silly statements they disappeared and left Deputy MacEoin and some other primitive persons——

An Leas-Cheann Comhairle

The Deputy should not refer to members of the House in that fashion.

Mr. Leneghan

If those people are genuine about the scheme, they should be here to defend it but they are not here. They talk about what they would do if they won on a vote but they cannot win and if they did, they would be fired out tomorrow. I do not believe in hypocrisy.

Mr. Donnellan

Where is Deputy Dr. Browne?

Mr. Leneghan

I do not care where Deputy Browne is, where the Deputy is or about anyone else. The point is that bad as is the Fianna Fáil scheme —I do not say it was the best possible —it is the only scheme which was ever brought in which gave anyone any type of decent health service. I know there are flaws in it and I ask the Minister to go to the trouble of correcting those flaws. When the Minister has discussed some of the outstanding flaws with Deputies, and with anyone else with whom he may wish to consult, I believe he will correct them. When he does, we will not have a bad health service at all.

Parliamentary Secretary to the Minister for Lands (Mr. Lenihan)

I find myself in sympathy with many of the sentiments expressed by the previous speaker. I also think the approach of the Labour Party has been a practical one, and one which has been of value in the debate generally. The main Labour Party criticism has been directed at the administration of the health services under the Health Act rather than an attack on the principles of the Health Act itself. That form of criticism is at least valid and should certainly merit attention at the meetings of the Select Committee.

There are undoubtedly some anomalies in the administration of the Health Act in the various local authority areas and certainly the Select Committee should seek ways and means of finding some more uniform standard in regard to the administration of the services and a more equitable system of administration. Anomalies exist particularly in regard to the different standards adopted by the various local authorities and these anomalies are very clearly defined in border areas, in towns such as those mentioned by Deputy Tully, like Drogheda, between Louth and Meath, where people in one county area may have medical cards and people on the same income but in a neighbouring local authority area may not.

That line of criticism is, I think, valid enough. It is certainly a line of criticism that should be followed up at the meetings of the Select Committee. In principle, I think the Health Act, 1953—and I agree with Deputy Corish in this—is quite adequate. That Act, following on the Act of 1947, sought to introduce here the most comprehensive scheme of health services for our people yet devised. I believe the principle of that Act is largely adequate and that if any improvement is to be effected, it is an improvement of the administration under that Act.

Mr. Leneghan

Yes.

Mr. Lenihan

That, by and large, is the spirit of the Labour Party amendment and of the Labour Party contributions in this debate. I regard the Fine Gael motion as largely a fraudulent one.

Mr. Donnellan

What?

Mr. Lenihan

A fraudulent one. I regard the Fine Gael motion we are discussing here as a fraudulent motion which was born as an election stunt. Obviously, there was not much thought given to it at that stage. A certain amount of hurried thought has been given to it since the election and we now have it produced here as a comprehensive scheme for medicine in Ireland.

First of all, it is designed to cover 85 per cent. of the population. That is exactly the percentage covered by the existing Health Act. The existing Health Act, taking medical card holders and members of the middle income group, covers approximately 85 per cent. of the population. Therefore, in essence, the motion does not seek to cover any wider percentage of the population than is covered by the existing Health Act.

The claim has been made by Fine Gael speakers that their scheme abolishes the means test. There is not a scintilla of basis for that. There is a means test. There is implicit in the motion a means test, several means tests, but particularly a means test when 15 per cent. of the people are excluded from it. In essence, how do you segregate 15 per cent. of the people from the operation of the Health Act, unless you apply a means test to them? There are a number of other means tests throughout the scheme proposed in the Fine Gael motion. There is a means test involved in deciding what people should pay a contribution and what people should not pay a contribution. That, in essence, is again a means test decision. One must take a means test between the contributors and the non-contributors under the Fine Gael scheme.

Mr. T.F. O'Higgins

No, there is no means test whatever involved. The Parliamentary Secretary might have taken some trouble, at least, to read my speech. I know he did not listen to it.

Mr. Lenihan

In essence, somebody must decide who is to contribute. The whole basis of the fraudulent scheme which is advanced here in this motion is that some people contribute and some people do not contribute.

Mr. T.F. O'Higgins

No; it will be decided——

Mr. Lenihan

The making of a decision on who should contribute, is in itself the application of a means test.

Mr. T.F. O'Higgins

Is the Parliamentary Secretary interested in knowing, or not?

Mr. Lenihan

The making of the decision involves a means test.

Mr. T.F. O'Higgins

Is the Parliamentary Secretary seeking information or not?

Mr. Lenihan

The making of the decision is the application of a means test.

Mr. T.F. O'Higgins

No.

Mr. Lenihan

There is no point in engaging in any double talk. There is a means test, first of all, in deciding to exclude 15 per cent. of the people. Secondly, there is a means test in deciding the number of people who should get free treatment without any contribution; and there is a means test involved in deciding the people in the in-between group who shall pay a contribution and what they shall pay. However, under the guise of being an advance in health provisions in this country, the scheme proposed by the Fine Gael Party is an obscurantist retrograde scheme, a scheme which is seeking to take from people who are entitled to free services under the 1953 Health Act and to add to their cost in meeting health expenses. Under the existing Health Act, for practical purposes—it varies from county to county —every farmer up to £20 valuation, with a family, has a medical card.

Mr. T.F. O'Higgins

Rubbish.

Mr. Donnellan

That is nonsense.

Mr. Lenihan

In practice, as it works out in the case of local authorities with which I am acquainted, every farmer up to £20 valuation, married, with a family, has a medical card.

Mr. T.F. O'Higgins

Not at all.

Mr. Donnellan

That is nonsense.

Mr. T.F. O'Higgins

The Parliamentary Secretary will get to know the country after a bit.

Mr. Lenihan

I have a guide here which is used by a local authority.

Mr. T.F. O'Higgins

A guide which is used by a local authority? Did the Parliamentary Secretary show it to the Minister for Health? The Minister sitting beside the Parliamentary Secretary issued such a guide once and there was a clear direction by the Minister for Health that they may not have a guide.

Mr. Lenihan

Every local authority must have a guide or rule of thumb.

Mr. T.F. O'Higgins

There was a clear direction by the Minister for Health that they may not have a guide.

Dr. Ryan

They may have their own guide.

Mr. Donnellan

On a point of order, the Parliamentary Secretary has made a statement that every farmer under £20 valuation is entitled to a medical card.

Mr. Lenihan

Married, with a family.

Sir Anthony Esmonde

How many children?

Mr. Donnellan

Is that correct?

Dr. Ryan

Is that a point of order?

An Leas-Cheann Comhairle

That is not a point of order.

Mr. Donnellan

It is not correct, of course.

Mr. Lenihan

By and large, in most local authority areas and certainly in the one with which I am intimately acquainted——

Mr. Donnellan

Roscommon.

Mr. Lenihan

Yes—farmers, married, with a family, under £20 valuation, get a medical card.

Sir Anthony Esmonde

With how many in family?

Mr. Lenihan

Farmers, married, with one in family, under £20 valuation, can get a medical card.

Mr. T.F. O'Higgins

That is not true.

An Leas-Cheann Comhairle

The Parliamentary Secretary should be allowed to make his speech. Other Deputies will get an opportunity to make their own speeches.

Mr. P. O'Donnell

Provided he tells the truth.

Mr. Lenihan

Certainly, the total figures in the country refute the allegation of Deputy O'Higgins that the present medical card system is merely a pauper system. Thirty per cent. of our people, in some cases up to 40 per cent. in certain local authority areas, but 30 per cent. on a national average of our people, have medical cards at the moment. However, how do we find the proposed Fine Gael scheme in regard to people who at the moment have medical cards and are entitled to free medical services? According to Deputy O'Higgins' motion and his remarks, he seeks to impose a levy, a penal levy, on every farmer over £15 valuation. Every farmer over £15 valuation would pay what Deputy O'Higgins seeks to call an insurance charge but which, in fact, is disguised penal taxation. In fact, he goes so far as to suggest that this insurance charge should be collected every six months along with the rate demand. Will the farmer whose valuation is in excess of £15 and up to £20, who at the moment has his medical card entitling him to free hospital and medical expenses, regard the £1 6s. he will have to pay every six months along with his rates as an insurance charge or as additional taxation? We are only dealing in double talk here in seeking to call it an insurance charge when, in fact, as Deputy O'Higgins suggests, it should be collected every six months from the farmer.

Mr. P. O'Donnell

Why do you want to set up a commission at all, if you are so satisfied?

Mr. Lenihan

We want to set up a Select Committee to clarify this.

Mr. P. O'Donnell

Why have a commission at all, if you have made up your mind that everything is in order?

Mr. Lenihan

We are very anxious to set up a Select Committee. The suggestion in the Fine Gael motion is that this scheme would provide a comprehensive health service based on the principle of insurance which would extend to 85 per cent. of the population and would provide without charge an adequate medical service, etc. Will the farmer of £15 to £20 valuation, who has at the moment a medical card, regard the £1 6s. he will pay every six months along with his rates as anything other than taxation?

Mr. T.F. O'Higgins

His rates will be down by £1 10s. a year.

Mr. Donegan

That is right, exactly.

Dr. Ryan

By £1 10s.?

Mr. Donegan

He will have 4s. to go to the pub.

Mr. T.F. O'Higgins

For the benefit of the Minister for Finance, 2/- in the £.

Dr. Ryan

I will deal with that all right.

Mr. Lenihan

So much for that category of people, the 33,000 farmers between £15 and £20 valuation who at the moment are entitled to a medical card, and who under Deputy O'Higgins' scheme would be asked to pay £1 6s. every half year along with their existing rates. So much for them. On top of that, it is proposed that the farmers between £20 and £50 valuation, who at the moment are entitled to all the benefits under the middle income group provisions of the Health Act, 1953, should pay a penal tax along with their rate demand every six months, representing 2/- every week.

Mr. T.F. O'Higgins

What benefits do they get at the moment?

Mr. Lenihan

Those applicable to the middle income group.

Mr. T.F. O'Higgins

And the benefits under that are hospital services, for which they are charged £2 10s. a week.

Dr. Ryan

Try to contain yourself.

Mr. Lenihan

The farmer between £20 and £50 valuation, if Deputy O'Higgins' fantastic scheme were put into operation, would get a bill for £2 12s. every six months on top of his existing rate demand.

Mr. Donnellan

God knows, he is getting enough demands without that.

Mr. Lenihan

I agree with Deputy Donnellan. The farmer who at the moment is entitled to benefits on a middle income basis will, under this proposed scheme, get this penal levy imposed on him by the rate collector every six months. Bringing it down to a practical level, the man paying it will not see any distinction between an insurance charge and a rate charge if he has to pay £2 12s. out of his pocket along with his rate demand every six months.

Mr. T.F. O'Higgins

Why are you afraid of it? Why do you not withdraw your amendment?

Mr. Lenihan

A fraudulent claim has been made, and I think it was Deputy Tully who referred to it, that by some wave of a miraculous wand everything is going to be provided for £8½ millions which at present is costing £18½ millions. The most glaring omission in the scheme is that it practically ignores the cost of hospital and specialist services. Institutional services administered through the local authorities would cost, under this scheme, about £583,000. There is no indication how the balance of administering institutional services is to be met.

Mr. T.F. O'Higgins

That is not so. The Parliamentary Secretary should not misstate what I said. I suggest he is deliberately misstating what I said in this House. I did not say that the hospital and specialist services would cost half a million pounds. They will cost that, plus their existing cost.

An Leas-Cheann Comhairle

May I point out to the Deputy that the use of the words "deliberately misstating" is not in order?

Mr. T.F. O'Higgins

I withdraw the words; I am sorry.

Mr. Lenihan

I am concerned to point out that £12½ millions at the moment is expended on institutional services. Deputy O'Higgins makes no mention that the balance will have to be met as at present, under taxation and under the rates. Twelve and a half million pounds must still be met out of general taxation and the rates. That very definitely highlights the fact that under his scheme, ill-thought out as it is, there is no prospect whatever of any substantial rate reduction. In fact this scheme is merely providing, or seeking to provide, what is in fact provided under the existing scheme. Under the existing Act, 85 per cent. of our people are covered. He seeks to indicate that a more comprehensive scheme without a means test, providing for an insurance charge, will be provided, when in fact the same number of people are going to be covered —that is 85 per cent. He seeks to introduce this insurance charge which is in fact a thinly-disguised method of taxation or rate exaction, as far as the farmer is concerned.

Apart from the farming community between £15 and £50 valuation, and they comprise about 103,000 whom Deputy O'Higgins seeks to burden with this penal levy disguised as an insurance charge, there is the question of insured workers, all of whom are going to be obliged to pay ?d. a week contribution towards this scheme. At the moment a large proportion of insured workers have medical cards. In fact, depending on the numbers in the family, men with from £6 to £9 a week in most local authority areas have medical cards. In most local authority areas, a man with £6 a week automatically gets a medical card and as his family increases he can get a medical card with an income of £9 per week. These people, already in insurable employment, paying contributions to social welfare, are now going to be given a further burden of ?d. a week, as a further penal levy in respect of health services.

That again is sufficient indication that this proposed measure is a step backwards and not a step forward as it is claimed to be. Indeed, it certainly is not surprising that it should be a step backwards because it was only by the combined efforts of the Fianna Fail Party and the Labour Party that, despite the reactionary opposition of Fine Gael, the present progressive Health Act was passed in Dáil Éireann. The attitude incorporated in this measure is again a reactionary attitude, seeking to impose additional levies disguised as insurance charges on farmers between £15 and £50 valuation and on a large proportion of insured workers who at the moment have got medical cards.

The further point was made by Deputy O'Higgins in his opening remarks that the present dispensary service is inadequate and not suited to our needs. While his argument may have some validity in regard to urban centres, it falls to the ground completely when you seek to apply it to remote rural areas. I think Deputy Leneghan from North Mayo referred to the dilemma that would occur in his area, and certainly Deputy Donnellan and myself are aware of areas in the West of Ireland where you would have no medical services in the event of the dispensary service being abolished.

Mr. Donnellan

Correct.

Mr. Lenihan

Were it not for the fact that you have adequately paid dispensary doctors who must live in the area, dispensing medicine to the people, many areas, particularly in the West of Ireland, would be left without any medical service whatsoever.

Mr. T.F. O'Higgins

Is that not perfectly obvious?

Mr. Lenihan

It did not appear to be——

Mr. T.F. O'Higgins

I expressly excluded the sparsely populated areas.

Mr. Lenihan

I do not see it in the motion.

Mr. T.F. O'Higgins

It is in my speech.

Mr. Lenihan

I do not see it in the motion and certainly it is again an example of the ill-conceived, ill-thought-out way in which this proposal has been worked out. As I say, it bears all the marks of an election stunt which is getting some post factum justification in the form of a hastily drawn up scheme after the event in order to justify the fact that it was pushed to the forefront as a plank in the middle of an election campaign. When examined on a practical basis, it falls to the ground.

The present Health Act, as I have said, may have defects in regard to its administration. These can be examined by a Select Committee. As Deputy Corish said, there is no body better equipped, particularly members of the House who are also members of local authorities, to deal with what defects there may be than such a Select Committee. Now is the practical time to do it. We have had the Health Act of 1953 in operation for seven or eight years and most of us are aware of its virtues and its defects. A practical investigation can go into these virtues and defects. It is a far more practical proposition to have a Select Committee now than when one was suggested by Fine Gael during the passage of the Bill in 1953. At that stage, before the Act got under way, they suggested a Select Committee. Now that the Act is under way and has been administered, surely this is the time to have the investigation suggested in the Government amendment, an investigation by a Select Committee composed of members who have had practical experience of the working of the Act?

Mr. T.F. O'Higgins

A coroner's inquest.

Mr. Lenihan

I should like to repudiate entirely the suggestion that the Health Act, the present system, should be rooted out, lock, stock and barrel. I fully agree with Deputy Corish in his reaction to that suggestion. It is entirely a destructive line of reasoning. As I sought to point out here, it is a line of reasoning which is in fact retrograde, which seeks to impose additional penal levies on people who are at the moment entitled to free, medical services.

In conclusion, I should like to emphasise that the 1953 Health Act brought in two services which at the moment apply to 85 per cent. of our people—free specialist treatment and free mother and child treatment, subject only to the maintenance charge. Those two key points in the 1953 Act have been of tremendous benefit to 85 per cent. of our people. The outstanding burden prior to 1953 was the burden of heavy specialist expenses. These specialist expenses, which often had to be suddenly met, sometimes amounted to hundreds of pounds. They can now be met by 85 per cent. of our people under the 1953 Act, people in the low and middle income groups. There is a similar position in regard to the mother and child service under the 1953 Act. It applies also to those groups and is subject only to a maintenance charge payable by the middle income group people.

In regard to the maintenance charge, Deputy O'Higgins was ill-informed in stating that the figure of 10/- per day applied to all middle income group patients in hospital. In fact, that statement is incorrect. For the year ended 31st March, 1961, the position was that, of all the patients charged for hospital services, only 50 per cent. were charged 10/- per day, approximately 20 per cent. were charged between 5/- and 10/- and approximately 30 per cent. were charged 5/- per day.

Mr. T.F. O'Higgins

What the Parliamentary Secretary means is that the bills were settled for those amounts. They were charged 10/- and they had to go around to Deputies and Senators to get them reduced.

Mr. Lenihan

Only half were charged 10/-. The Act quite clearly states that this charge of 10/- is only a maximum charge. The Health authority cannot charge any more than that, and in 50 per cent. of the cases, the charge is much less. That is the only burden to be borne by 85 per cent. of our people.

Mr. T.F. O'Higgins

The Parliamentary Secretary should not misstate the facts. They have to pay X-ray and specialist fees. They must be charged by the local authority.

Mr. Lenihan

In regard to specialist fees, there is clear provision in the Act that everybody with a medical card or in the middle income group is entitled to free specialist treatment, subject to the maintenance charge in the case of the person in the middle income group.

Mr. T.F. O'Higgins

Hear, hear! Unfortunately, the Minister for Health, who succeeded me, brought in an amendment providing that specialist services and X-ray services must be charged.

Dr. Ryan

"May be".

Mr. T.F. O'Higgins

No, "shall be". I can assure the Minister for Finance that the words "shall be" appear in the Health Act of 1957. I moved an amendment to substitute the word "may" but it was defeated by the Fianna Fáil Party. It is an obligatory charge that cannot be waived.

Dr. Ryan

Why did the Deputy not make it right when he was there?

Mr. T.F. O'Higgins

When I was there, there was no charge, but when my successor came, he imposed the charge. The Minister does not even know what is going on in the Fianna Fáil Government.

Dr. Ryan

There was no charge because the Deputy suspended the Act.

Mr. T.F. O'Higgins

When I left office, I had the Act in operation, something my immediate predecessor never contemplated.

Dr. Ryan

When you were going out, you did it.

Mr. T.F. O'Higgins

I knew what my predecessor was up to.

An Leas-Cheann Comhairle

Let us hear the Parliamentary Secretary.

Dr. Ryan

I had no idea you would be there.

Mr. T.F. O'Higgins

No, you had not and you got a shock.

Dr. Ryan

I did, when I saw what you did.

Mr. T.F. O'Higgins

I called the Minister's bluff this time.

Mr. Lenihan

Under the Health Act, a person with a medical card in the middle income group can get free specialist treatment and the only charge is the maintenance charge by the institution in which he is given such treatment.

Mr. T.F. O'Higgins

That is not so.

Mr. Lenihan

That charge of 10/- is the only statutory charge. It is a maximum charge, and in 50 per cent. of the cases, much less than 10/- has in fact been charged. This proposal of Deputy O'Higgins seeks to impose on a large number of people, to be accurate, on, first, 103,000 farmers, additional penal taxation in the form of what he calls an insurance charge but which I would call an exaction of £1 6s. every six months for 33,000 of them and, for the balance of 70,000, a charge of £2 12s. every six months, and they do not have to pay these charges at the moment. As well as that, it seeks to impose on a large proportion of insured employees the further additional burden of paying on a different coloured stamp an additional ?d. a week, apart from the equivalent burdens on the employers. I feel the sensible thing is to agree, and I feel the House will agree, to a Select Committee being set up and to a thorough investigation into the administration of the Health Act, the principles of which are admirable.

Mr. Mullen

Having regard to how the Health Act affects working-class people, it has been heartening to listen to what the main Opposition speakers and the Parliamentary Secretary have said. The Labour Party have made a sensible approach to the problem. Our speakers have indicated that there are certain features of the Health Act that are by no means objectionable, but there are other features that need to be remedied. Naturally, we must welcome this wind of change because it is an indication that people who felt happy and contented about the Health Act since its inauguration in 1953 have suddenly come to realise it has certain defects.

I submit that one of the main defects in the Health Act is the manner in which medical cards are issued. I was intrigued when the Parliamentary Secretary said that every local authority had a guide or rule of thumb in regard to the issuing of medical cards. I think that is a pious wish. That is not the situation in Dublin, where the lack of a guide for the issuing of medical cards is causing a tremendous amount of trouble among the people. You have people in exactly the same circumstances, living alongside each other, and one person gets a medical card while the other does not. While the Act says that people who cannot provide for their own needs should be given the necessary services, the unfortunate situation is that that is left in the hands of an individual burdened with the responsibility of keeping down the rates. That individual must realise that we cannot spend too much money by way of extending medical services to the people in the area for which he is a representative. The problem in relation to medical cards has also created difficulties among assistance officers.

Debate adjourned.