I move:
Dáil Éireann is of opinion that the present health service is inadequate to the needs of the people, and that in particular many injustices arise in the administration of the medical card system, and calls on the Government without further delay to establish a comprehensive no means test health service with a free choice of doctor for all sections of the community.
This motion stands in my name and the names of a number of Labour Party Deputies. In moving it, I want to state that the Labour Party tabled a similar motion about three years ago which received the support of a number of Deputies who had been returned to this House as Independent Deputies. In agreeing with our motion in principle, they submitted an amendment that Dáil Éireann should agree to set up a Select Committee of the House on the health services with a view to reporting back to Dáil Éireann within six months. That was passed by Dáil Éireann without opposition from the then Minister or his Cabinet. The Committee was set up and they found that the volume of evidence was so great—practically every organisation in the country was interested— that they had to report back to Dáil Éireann in an interim report. They reported that they were completely unable to listen to all the evidence, never mind sift and correlate the evidence that was forthcoming, and they asked for an extension of the period in which they were compelled by regulation to report to Dáil Éireann. That was unanimously agreed to.
Unfortunately, it went on and on and the volume of evidence coming in was so great that the Select Committee never made a report. The Labour Party representatives withdrew from the Committee because their suggested time, by which at least amendments to the Health Act, if not a new Health Act, could have been submitted, had been reached. The Labour Party representatives consisted of Dr. Noel Browne, Deputy Mullen and myself. I believe that the Fine Gael representatives on the Committee followed our example, and that finished the Select Health Committee.
I am relating this to the motion because the Committee was set up as a direct result of a similar motion by the Labour Party at that time. We are now putting forward this motion, not with the hope that we will achieve amendments by a simple motion like this but in order to give the Minister an opportunity of making a statement about his intentions as Minister. He has made many statements outside the House. I remember quite well on the day his appointment was announced commenting that I was glad that a fresh view was now coming to the position. I was glad of a new outlook on health services and I said that I believed, as I still believe, that the Minister has a fresh view and is in tune with modern needs in regard to health services.
It is for that reason that this motion has been tabled, to give the Minister an opportunity of stating to this House, and through the House to the whole country, what proposals there are for an improvement in the health services. It goes without saying that the health services, as framed in the 1953 Health Act, are now considered to be totally inadequate for the needs of our people. Not only are they inadequate but the administration of the Health Act is outdated and antiquated. Under it, a relieving officer or a home assistance officer is the beginning and end of the right of a person to secure medical services. As the investigating officer, he has the final decision. No matter what else may be said about the county manager having the final decision, the fact is that the county manager acts on a report of a home assistance officer who makes an investigation, which may be either adequate or inadequate, and who could have, and possibly sometimes had, a biased mind due to an inadequate investigation. Once the county manager signs a refusal notice, there is no right of appeal to anyone but the same man.
I do not intend to break the regulations dealing with evidence given at this Select Committee on the Health Services but anyone who served on that Committee will agree with me that practically 99 per cent of the representatives of the organisations which gave evidence, and they were varied, gave evidence that showed they were conscious of defects of varying degrees in all forms of our health services which were examined by the Committee, whether it was in regard to the lower income group, or the middle income group, or the fringe group which could be brought in and still be in the higher income group. The loudest protestations came from that section of the population who felt they were entitled to medical cards, those who would be classed in the lower income group.
I have tried to summarise briefly the position and I am quite sure that the Minister has examined the evidence given and, from his own personal knowledge, will be able to agree with me that the defects I am enumerating are the most blatant ones, the ones about which the lower income group complain most. They are but a few of the defects which I or anybody else could enumerate but time would not permit it and it would be unfair to use so much time enumerating in full all the defects the lower income group feel exist in our present health services.
One grievance is in regard to how indefinite is the right to a medical card. It is based on a means test of some sort but no definite means test is laid down. It is simply based on an old British dispensary regulation that if you cannot afford medical services for yourself and your family by your lawful earnings, then you are entitled to a medical card. That may not be the actual wording but it is the actual position and that is what it means That is what the 1953 Act meant and that is what the old British Dispensary Act meant the right to a dispensary service and it was accepted on that basis in 1953. But there was no definite, clearcut knowledge as to who is or who is not entitled to a medical card.
For instance, an old age pensioner who at that time received 37/6, or who earlier received a lesser amount, did not necessarily come within the scope of being able to provide for himself and his dependants, even though he qualified under the very strict means test that relates to social welfare. It may seem amazing but it is really true because under a ministerial regulation —and unfortunately, in the 1953 Act the Minister got power to make regulations—those investigating the means were permitted to correlate the earnings of all those residing in the house or under the roof of the applicant, and should it turn out that sons or daughters or other people residing there coming within a certain relationship, had means that could be so added together as to reach a certain figure, not only did it disqualify them for medical cards in their own right but in many cases it disqualified old age pensioners for such a card. If that be doubted, it will be my privilege to submit proof not only in respect of my own county but, I am convinced, in respect of every constituency in the country.
Another great defect that was and is being felt is the variation in decisions as between one health authority and another. You might qualify in the Tipperary health authority for a card because the county manager there or his advisers—more probably the latter—took a distinct and separate view from that taken in Waterford, or vice versa. One of the most liberal health authorities, in fact, was the Waterford Health Authority. I do not know the actual percentage of people covered by medical cards in Waterford county and city at the moment —it is one of the few combined health authorities—but at one time it was one of the leading health authorities and more liberal than a great many others. Yet, even there, I, as a representative, have been continually pressed by letters and personal requests, and on my submissions to the county manager, a good number of cases that had been ruled out for medical services have been redressed, very often without any explanation of the change.
I suggest it is wrong that because somebody does not get a Deputy or member of the health authority to plead his case and to put forward facts that perhaps he without a knowledge of procedure and how to state a case properly would omit, should be deprived of a service that is free by right under the 1953 Health Act. Variation in decisions is one of the defects that are causing the canker to grow in the minds of the lower income group throughout the country. Much of the value of the 1953 Act has been lost because the Minister was permitted to make regulations by order—in other words, to do things without reference to the Dáil—that could and did amend the Health Act or take away the value of it that was apparent in 1953. One of those regulations in which I was particularly interested is that permitting an investigating officer to lump together the total income of the family residing in one house.
In 1953 when the Health Act came before the Dail, I was keenly interested in this Act which was brought in by a Fianna Fáil Government and, with the support of the Labour Party, passed through the House. I was interested in the fact that a worker who was 16 years or over was not a dependant of the applicant father, even though he resided with him. For a number of years after 1953 that son had, and exercised, the right to claim a medical card on his own, provided he, as an individual, was eligible within a means test of an indefinite amount never yet clearly stated but in respect of which each county apparently got some instruction from someone as to the limit to be fixed. In my county it was estimated at that time that a single man was entitled to a medical card if his earnings were less than £5 a week. If he had a wife, you would add £1 and for each child under 16 and not working, you added a further 10/-. If, then, his earnings came under the limit, he was entitled to a card.
Then there was a complete change. Fathers of households and single sons and daughters living with them were all refused medical cards, even though for a number of years they had enjoyed the privilege of being classified in the lower income group. Because of a ministerial regulation which never came before the House—which could have been examined but no opportunity was given to discuss it— the combined earnings of the family not only succeeded in putting the sons and daughters out of benefit for medical services, that is, free dispensary services, but the fathers, the breadwinners and in some cases old age pensioners were disqualified also. I think there is a proposal in connection with the middle income group to be made in the new Bill which indicates that the Minister has seen the injustice of this. Lest I seem prejudiced, I should say that later an allowance was made by which the first £100 of earnings of sons and daughters could be ignored. Very often the regulations still deprive breadwinners or heads of households of the right to claim medical services.
One of the main injustices, in my opinion—and this point has been and will continue to be made by various people and organisations—is the failure to have a right of appeal. Should a person apply for a medical card and be turned down, he gets a curt note from the secretary of the health authority acting on behalf of that authority—which is really the manager because the elected members of the health authority have no power in regard to giving a medical card. It will be and is the duty of the manager. If the manager turns you down, he does so on the advice of officials and I suggest that the only officials who make these investigations are the relieving officers or the home assistance officers, men who are unqualified on any ground other than that they are paid officials of the authority, men without any qualifications and with all the bias of small closed communities. A person can be deprived of something which this House has given to him on the advice of one of these men and he has no right of appeal to anybody other than the person who refuses him. He cannot go to the courts or to the Minister.
The granting of an appeal to the Minister would put an end to hasty decisions on eligibility. I have found, in dealing with all Ministers of all Governments, that when a complaint comes to ministerial level and an investigation is ordered, the people at the lower level working for a local authority are most careful that such investigations will not show that their own investigation of any particular case had been negligent or biased. A right of appeal to the Minister would be an invaluable safeguard of the rights of the people. The evidence given before the Select Committee on Health Services by various organisations throughout the country went to prove that fact.
The last point I wish to make is that it was the unanimous suggestion of all who made representation before that Select Committee that there should be a choice of doctor, where such choice was available. We heard much from both Fine Gael and Fianna Fáil when the 1953 Health Act was going through the House about doctor-patient relationship, of the importance of people having confidence in the medical doctor who attended them. The phrase "doctor-patient relationship" is a high-sounding one. Many of the people in the lower income group will not understand the significance of it but all of them will be able to tell you that they would prefer Dr. A. to Dr. B. or that they have no confidence in Dr. C. If you enjoy a medical card, you will find that you will have to accept a doctor whose appointment you had nothing to do with and it does not matter whether you like him or not. It does not matter what his manner is like or whether you consider him capable of treating you or diagnosing your illness.
The limit to which you are entitled under the 1953 Health Act, if you have a medical card, is the choice of one dispensary doctor. In many parts of the country, particularly in the west of Ireland and in the more remote rural areas, that will mean that there is only one doctor within reasonable distance. In most of the rural towns, however, there would be a choice between three or four doctors or, at the least, two or three doctors. I suggest to the Minister that he should consider amending the Health Act so that a choice of doctor will be given, where possible. It can be so arranged that ultimately that choice can be extended to the wildest and most remote areas.
That exhausts the main difficulties as seen through the eyes of those in the lower income groups who have the medical card but there are also those in the middle income groups, representing about 55 per cent of the population. The lower income group represents about 30 per cent of the population and the higher income group about 15 per cent, which leaves 55 per cent for the middle income group. That is more than half the population, whether their income be calculated on income or valuation level. They also have a grievance. Again they object to the indiscriminate method by which their means are investigated. They object to disclosure of their private lives, to the disclosure of what their sons and daughters give them in the privacy of their home. Not only that, but they object to their sons and daughters being assessed to give them certain things, to an assessment, not of what they get, but what should be given to them by their sons and daughters.
Evidence has been given that in certain counties if a parent has a ne'er-do-well son or daughter, the assessing officer will ignore the fact that such a child earns an income of £10 or £12 a week but does not give up anything. That is not a general practice but views were expressed to the Select Committee by representatives of the relieving officers, who carry the main burden of the administration of the Act, that some of them took a different view of this matter from others in this question of decision and the decision in these cases is as vital to people in the middle income group as it is to those in the lower income group.
Then there is the question of hospital expenses, leaving aside altogether the question of medical expenses. I know of a case where a charge of £2.19.6d per day is being made in respect of a person whose income is assessed at over £800 a year. The £2.19.6d. per day is for maintenance and medical attention as given by the hospital, completely exclusive of what the doctor will charge and the specialists' fees. There is no one in the middle income group as I know it who can afford to be sick and to pay £2.19.6d per day. A person in the middle income group might be earning £15 a week and could not afford to pay for a dependant who might be sick at the rate of £2.19.6d per day. The figure is not real or of practical application.
I congratulate the Minister on raising the income limit from £800 to £1,200. That reform was urgently needed. It must come into force as quickly as possible. The Labour Party will support the Minister in the amendment proposed but we feel that it is a stop-gap and that it is inadequate. If the Minister tells us that it is an interim measure and that he is tackling the essential things first, we will be happy to have his assurance that in the near future he will introduce a comprehensive amendment of the Health Act of 1953 or, alternatively, a new Health Bill. If it is an improvement, we will support that improvement. Not only will we vote for that necessary health service in the House but we will vote the necessary money for it, provided we are satisfied that the burden will be placed on the shoulders best able to bear it.
It may be suggested that persons in an income group above £1,200 can afford to pay insurance contributions to cover health services. I would like to point out that if in the first year or second year of a voluntary health insurance contract the insured person suffers an illness, it is quite possible that the Voluntary Health Insurance may decide that that person is a bad risk and cannot be insured or, alternatively, must pay a higher premium. I submitted such a case to the Minister's predecessor. The reply I got was that it was a matter for the directors of the Voluntary Health Insurance. Only today I saw proposals from the Voluntary Health Insurance that will practically double the contributions. They have indicated in a circular to members that payment by them in respect of patients in public wards—mark, public wards—will in future be at the rate of £15 per week. I suggest that it would be better to scrap the Health Act and to introduce a scheme similar to the British Health Service, on a contributory basis. There are only 15 per cent of the population in the higher income group. If you include them, although I would make them pay for it, they will not avail of it. It should be made a fully comprehensive service based on contributions by the people.
