When speaking on 10th April, I mentioned in my opening remarks that I was an unrepentant supporter of the Health Act. I was speaking as an individual member of a Party and as one who took an active part in endeavouring to secure the passage through this House of the 1953 Health Bill. At that time, I said I felt it was a step forward towards providing the medical services which the people of the country need. Everything I have learned since then satisfies me that it was indeed a step forward, and one in which I am very proud to have taken an active part.
On the last occasion when speaking on this Estimate, I said that much of the criticism which comes both by way of discussion and by way of articles in the newspapers arises from the fact that many, if not almost all, of the critics are ill-informed as to the conditions of the Health Act and the privileges and rights that can be secured under it. The principal offenders are members of the local authorities. One would believe that they had never read through the provisions of the 1953 Health Act because of the confusion in their minds about the groups of people who are served by the various sections of the Act. It is quite common to hear county councillors and members of health authorities in general, and even some Deputies, informing people that they are entitled to medical cards if they have incomes of less than £800 per year. Of course that is completely wrong, just as it is completely wrong to say that unless you have a medical card, you will get no service under the Health Act.
As we know it since 1953, the Health Act covers the total population of this country in a rough percentage of 30 per cent, medical card holders, 55 per cent, middle income group, who are either people with a lesser income than £800 per year or with a valuation of farm land of £50, and then there is the upper group of 15 per cent, roughly who are over those figures of £50 valuation or £800 per year income. We are all pretty clear about the first group, that is, the medical card holders. We are all pretty clear as to what entitlements under the Acts are theirs, and theirs free, with certain exceptions where portions of the Acts have not as yet been brought fully into force.
A number of Parliamentary Questions tabled yesterday by, I think, Deputy O'Higgins and answered by the Minister illustrate the point about such things as hearing aids. It does not necessarily follow that because you hold a medical card, you are entitled to a hearing aid. If you are a holder of a medical card and can prove your need of a hearing aid, it can be supplied by the local authority.
Before I go on to deal with the various defects as I see them in the Act, I should like to deal with just one part of a problem that appears to be arising in the country. I refer to the parades by agricultural ratepayers and farmers that have taken place during the past year, mainly in connection with the demand made by the organisations that the cost of the Health Act should be a national charge rather than a charge on the rates. I should like to be recorded as emphatically rejecting that request. It would be deplorable if the moneys required for the Health Act should be levied through forms of taxation rather than as it done under the present system of party through taxation and partly from rate contributions.
I would instances my own constituency, the city and county of Waterford, where prior to the 1953 Health Act and after its implementation, the standard of the health services given there was as high as it is in any part of Ireland. Unfortunately, there are other areas which, because of their desire to keep down the rates, failed to provide the money necessary for that high standard of service. If a change took place and they became a national charge, we would have the Minister announcing in the House that a certain sum of money would be earmarked for the health services of the country as a whole, and it would result in the Minister being forced to devote to these backward areas, which in the past failed to give these services for economy reasons, the major portion of the money.
The result would be that the counties and areas that had the foresight and the good sense to provide first-class equipment and services for their people would have to do with a lesser amount of money until the backward areas were brought up to the national level. It would also mean that the control of the services given by the local authorities in their own areas would have to pass out of the hands of the local representatives and into the hands of the Minister and his officials.
I am quite sure that if that did happen, the Minister and his officials would enforce a much higher standard than obtains in many places, but I would regret the fact that the local authorities which are in close contact with the people in their constituencies would be deprived of the right to look for services and would have to depend on the sanction or implementation of the services from a higher authority.
I should like to say that the medical card holders who are, as I said, approximately 30 per cent. of our community, taken by and large, receive a first-class service but my complaint about the issue of medical cards is not that medical cards are not given to those who deserve them but that there is no uniformity on the question of deciding what standard of income or circumstances govern the issuing of medical cards. In the case of County Wicklow the County Manager has set a standard which is considerably higher than the standard set in my own county, Waterford. Again you have the system adopted by some groups of managers that where a person is bequeathed or inherits an old brokendown motor car from a friend, and uses that car to take his wife and family to Mass, the mere fact that the car is registered in his name is taken as proof that he is not entitled to a medical card.
For instance, a labourer in a small country area in my constituency earning under the minimum which is accepted by the County Manager as the amount of money that would qualify him for a medical card received an old car from his brother who had returned from America and purchased the car during his holidays. He handed over the car to his brother when he was going away. Because the man realised the value of the car to his wife, to take her to Mass in wintry weather, he gave up drinking and smoking to provide the money required to cover the cost of third party insurance, the tax and petrol. If he had not done that, if he had continued to take a drink as he was entitled to do, or if he had continued to smoke, as he was entitled to do, he would have enjoyed the full benefits of a medical card but because he tried to behave as a reasonable person and endeavoured to help his family the fact that that car was registered in his name was taken as complete proof that he was not entitled to a medical card.
I also know of a fish merchant who was struggling to make a living on £3 or £4 a week and whose net income was proved to be less than £5 10s. a week. He had to use an old, dilapidated van to earn his living but the fact that that van was registered in his name deprived him and his family of the most valuable thing he could have, that is a medical card. I feel that the administration is faulty because of the fact that all power is vested in the County Manager. It is quite obvious that in a big county, say, Cork, or Tipperary, or Waterford and Kilkenny, which is governed by one County Manager, it would be a physical impossibility for the Manager to examine the various cases. He must from necessity rely on the report of his home assistance officers. When these officers have come to a decision you have the right of appeal to the County Manager but in practice you have no appeal at all because you can appeal to the County Manager who will send back the papers to be reinvestigated to the very same people against whose decisions you are appealing. Is it at all likely that they will condemn themselves and admit they were wrong in the first instance?
I know of cases where people entitled to medical services free, who could not by their lawful means provide the services for themselves or their families, were deprived purely on a personal basis in small country areas because of the fact that they had a disagreement with the local home assistance officer. The Minister should consider some right of appeal to the Department which would give him the right to send an investigating officer to examine such cases if he was satisfied that a case had been made by the person putting forward the claim. I am satisfied that there is a blatant misuse of the power vested in some relieving officers. I am satisfied that there are people holding medical cards who are not entitled to them and that people are being refused cards who are not entitled to them. When I endeavoured, as a local representative, to see the register of names of those entitled to medical cards in the local authority of which I was a member, I was told that it was a privileged document and that even a member of the local authority was not permitted to see it. I feel that is carrying the secrecy of medical services to an extreme and is an action which tends to cover up corruption, or maladministration at the least, in an area. Local authority representatives are entitled to know who is getting medical services and who is not so that with their intimate knowledge of the circumstances of people in their area they can decide whether there is, in fact, as I suggest, maladministration.
I have recently discovered, in connection with the issue of medical cards, a new system which has apparently been used in some local authorities and that is the grouping of families together on the one medical card. I am well aware that the father holds the card which covers his wife and all members of his family under 16 years of age but a new system has developed where individual members of a family who are over 16, who are persons of responsibility in their own right but who are still living in the same house, are being grouped. That to my mind is depriving numbers of individuals in families over the 16 years age limit of rights that they formerly held.
I should like the Minister to investigate the reason for the alteration in the issue of medical cards and the effect it has on people who formerly qualified and who are now being deprived of medical cards by the adding of the various incomes together and showing an average income that would justify the withdrawal of the medical card.
There are circumstances—and the Minister will tell me that the Act specifies what these circumstances can be—where two people are receiving the same income. One man might be paying a rent of £1 or 25/- a week, whereas the other might be occupying a council house or cottage at 5/-. Both receive the same income. It would appear that they are issued with medical cards on their income alone without any question of what rent they pay or their particular circumstances. I know of a case where a man paying up to 30/- a week rent was refused a card because a man living next door, or quite close to him, who only paid 5/- rent, was refused. The basis for that was that their income was over the level the county manager had decided would qualify them for a card.
I suggest county managers are not operating the Health Act in the spirit in which it was framed. It was said that county managers could ignore income and take the particular circumstances of a family into account. My experience has been, however, that the county manager fixes a level of income and that, except for extreme cases of hardship, no other circumstances are taken into account. Representations made in connection with dependants, for instance, who strictly speaking are not in the same category as children, are practically always ignored. I am saying to the Minister that there should be a right of appeal to him so that officers of his Department could investigate alleged cases of hardship.
I should like now to make some comment on this outcry in regard to the cost of the health services to the rates. One would think from all the shouting about the increased cost since the Health Act came into force that the health services were confined to the medical treatement of people who are ill. Apparently it is forgotten that we, as a Christian country, have an obligation to provide for the disabled, the blind and so on. We have an obligation to provide through disability benefit, home assistance and blind pension, for those who from their own means are unable to secure a livelihood for themselves. We have to maintain our county homes for those who have no place else to seek shelter. These things account for a good proportion of the Health Estimate. Surely nobody will suggest we should neglect those people? Surely nobody will suggest we should go back to the days of Oliver Twist and simply provide them with a Poor House?
The cost to the rates of the health services provides the cheapest form of health insurance possible. For the amount each individual must pay in rates in respect of health services, no insurance company or group scheme could provide anything like the benefits available. I have before me the cost to my own local authority of maintaining patients in their institutions. The average cost is at least 50 per cent. higher than the sum charged to persons in the middle income group. The maximum charge for such a person is 10/- per day. If that person had to maintain himself in his own home, an estimate of 2/6d. per day for breakfast, 4/6d. for dinner and 2/6d. for tea would practically account for the 10/-. But, in addition, he receives in hospital medical services from a doctor, and from a specialist if necessary, he gets extras, he gets the best nursing attention, plus food and shelter—and all for 10/- a day. That is the maximum charge. Therefore, any middle income group person who has the misfortune to fall sick is well served for the amount of money he has to pay through his rates.
Most middle income group people do not realise that, if they were not covered by health services, a single illness might cost them £100 or £200. It would take years to pay a sum like that through the amounts paid in rates for the health services. I have found that some middle income group people do not avail of the services of the dispensary doctor, although some of them do. I do so myself. As a private patient, I prefer to go to the dispensary doctor.
Outside doctors are usually connected with some private hospital or nursing home. If a person goes to them, he very often finds that in an emergency he is sent to one of these hospitals or homes which have no contract with the board. In some cases, the doctor sends the person to hospital at once and he is put into either a semi-private or private ward without his knowledge or the knowledge of his relatives and without their knowing what that means. Very often, that middle income group person finds on discharge that he has to face a bill of £30, £40 or £50. He would not have that bill had he the knowledge to insist that he should get public ward treatment, which would be just as effective and just as good in every way, except that he would not have the privacy of a private or semi-private ward. There should be a responsibility on people in charge of hospitals that, when a person is entering, either he or, if he is not capable, somebody on his behalf should be told clearly that if he enters a private or semi-private ward, he is doing so at his own request and will be responsible for the special charges that can arise.
In regard to the people in the upper income group—the 15 per cent. of our people over £800 or with a valuation over £50—they, too, are entitled to health services. Should they have long and expensive courses of treatment, it is within the law that the county manager may exercise his right as agent of the local authority and give considerable help to the families of such people. However, I feel it would be well if the income of that balance of 15 per cent. were completely ignored.
It should be possible to include all the people in the country willing to accept medical services and treat them equally. It is true it would mean an increase in costs. It is unfair that the white collar workers in the city, a typical civil servant or bank clerk with a family and with heavy commitments in respect of housing, education and so on, with an income of £800 a year, are now forced to enter the Voluntary Health Insurance Scheme and at the same time have to contribute through rates to give benefits to all the middle income group and lower income group people in their area. Voluntary health insurance is an excellent idea, but if your family history is bad, if your medical record prior to joining is such that the Voluntary Health Insurance people feel you are not a good risk, you can be turned down. Even though you were accepted last year, if you had a recurring attack of some illness, just when you wanted medical insurance cover would be the very time you would be told your policy in regard to that particular coverage would not be renewed.
There is a failure in that part of voluntary health insurance. I would prefer to see a system whereby all the people in the country would contribute a fixed amount each according to his means by some method, plus a contribution from central funds raised by taxation. That would meet everybody's medical requirements without this souldestroying problem of a means test. It has worked effectively in Great Britain, in France and other countries. It is quite true we are a small country, that we shall never be able to reach the high standard of other big industrial countries, but in so far as this country can provide, money spent on the preservation of the health of the people, in giving to the people the best medical services we can afford, is money well spent.
I am aware that there is a Select Committee of the House sitting to consider this problem and to make suggestions to the Minister. I am a member nominated by my own Party. I believe much more will be done at that Select Committee than in discussion here in the Dáil, but I am simply putting forward a view of the problems as I have met them as a layman deeply interested in health problems for over 20 years in public life. More good work will come from the findings of that Committee, if implemented by the Minister, than from discussion on Estimates such as this which can be useful only to the extent of giving the Minister the feeling of how the Act is being administered throughout the country.
It would be wrong for me to neglect appealing to the Minister in connection with the salary scales and the conditions of those I describe as the Cinderellas of the medical profession, the nurses. I am aware that the Minister is sympathetic, but I would again appeal to him, in view of the fact that nurses in general have refused to avail of their rights as a trade union organised body to enforce their demands by methods which have been successful in other walks of life. Nurses look upon their work, not as a job but as a vocation. Because of their idealism, they have neglected to secure advantages for themselves to which they are justly entitled. Because of their honesty, they should receive the sympathetic consideration of the Minister.
Practically all organised labour are now on a 45-hour week. If anyone is entitled to a 45-hour week surely it is those who labour amongst the ill, those who labour in contagious circumstances? I would suggest to the Minister that he should use his good offices with the local authority and voluntary hospitals to see that the nursing staffs are given adequate compensation for the wonderful services they give.
I should like to pay tribute to the dispensary doctors in my area. They are excellent people. Though often run down and abused, they give an amazing service when you consider the terms of their appointment mean that they must be available to all of the lower income group, both night and day.
Finally, I wish to thank the Minister personally for the way he has received any complaints I have forwarded to him. At all times, I have received a courteous acknowledgment and later a full explanation in regard to the various matters on which I made representations.
