Dáil Éireann debate -
Wednesday, 17 Nov 1965

Vol. 218 No. 11

Private Members' Business. - Health Services.

Debate resumed on the following motion:

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.

—(Deputy Kyne.)

Mr. T.J. Fitzpatrick

(Cavan): Before I moved the adjournment of this debate. I stated that it seemed to be common case that the health services at the present time are grossly inadequate and give rise to many injustices and hardships. That seems to be accepted by all sides of the House, by the Government as well as by the Opposition Parties. I was dealing in particular with the health card system. This is a system which gives rise to grave injustices and which has created a situation in which the citizens of the State do not know their rights.

I find it very difficult to know who is entitled to a health card. In some counties, the standard seems to be laid down that a person with the income of a roadworker is entitled to a health card and that, above that, he is not. There does not seem to be any definite ceiling for the agricultural community and, by that, I do not mean to convey that everything is free, gratis and for nothing for the agricultural community—far from it. However, neither a person in receipt of an income nor a farmer seems to know when he is entitled to a health card. The most disturbing factor is that health cards seem to be refused all over the place and then, when pressure is applied by a member of the county council or by a member of this or the other House, health cards are granted in some cases. If that pressure is not applied, these people are left without health cards and are deprived of what they are automatically entitled to.

I know a mother of eight or nine children whose husband was in receipt of £11 a week. She told me she was not entitled to a health card and could not get one. The scheme does not seem to make any allowance for children or for dependants. I shall come back later to something the Minister said recently but, in the course of it, he promised he would send out a booklet to each householder explaining what exactly he is entitled to under the health scheme. By that, I wonder if the Minister means under the proposed health scheme or under the existing health scheme?

Mr. O'Malley

The new one.

Mr. T.J. Fitzpatrick

(Cavan): I was going to say I would take off my hat to him and give him credit for unusual ability if he could send out a booklet telling the people what they are entitled to under the existing health scheme because it would be an utter impossibility to do so. It is wrong that people with small incomes, and small farmers, should have to go to members of the county council or members of the Oireachtas asking them, for goodness sake, to get them a health card and that these people, in turn, should have to go cap in hand to the local authority to try to get the health card. Surely that is not a correct procedure? The people say that at the present time you do not get a doctor when you want a doctor but that you get a doctor when you can pay for a doctor. That is an unsatisfactory position. So much for the service available under the health card system.

The next matter concerns the cost of medicines, drugs, dentures and spectacles. Nobody seems to know when he is entitled to these free or when he is entitled to be assisted in procuring any of them. In some counties, persons can have their teeth removed for nothing but cannot get any assistance towards having them replaced. I know people who have been going around without teeth for years because they got them out in the belief that they would be replaced free or that they would get substantial assistance towards having them replaced. Some counties have not got a dental scheme at all. Other counties have a scheme which is limited to expectant mothers and ex-TB patients. However, the vast majority of the lower income group in the country are not entitled to assistance towards having their teeth replaced.

What is the position with insured people? I raised this matter here with the Minister for Social Welfare. An insured person can himself get assistance towards having his teeth attended to but there is no provision in that scheme for dependants of the insured person, and that is undesirable.

Apparently you can get spectacles in a steel frame. They are a desperate looking outfit. One look at unfortunate people wearing them and everybody immediately knows that they got their glasses under a county council scheme. They look to me just as much of a brand as the county home suit and I do not think that is desirable. If people are getting spectacles under a health scheme or under any scheme, they should not bear the brand of poverty or the brand of home assistance or the brand of the lower-paid worker. That is the position at the moment.

When we come to consider people who have to avail of institutional treatment, the position is that if their income is over a certain figure, they are deemed to be able to afford institutional treatment. If their income is over the prescribed amount or, in the case of a farmer, if his poor law valuation is over £50, then, whether or not there has been a lot of illness in the family and no matter how many children he has, they are deemed to be able to afford institutional treatment and can get some relief only if they can establish to the satisfaction of the local authority that their case is one of hardship. In that event I think the local authority have power to accept responsibility for 25 per cent of the hospital account, but even that, in a great number of cases, is not sufficient to remove the hardship.

Since this debate was adjourned, a couple of things have happened. A couple of statements at Government level have been made on the health services. Last evening in a television interview, the Minister stated that he proposes to get out a White Paper on health. He very fairly said that a White Paper is a sounding instrument, a document that will get people talking and bring to him the views of the people. I hope and trust that this is not a means of putting the question of health on the long finger or in cold storage.

I gathered from the Minister's television interview that he proposes to retain a means test. I gathered that he is now prepared to accept what Fine Gael have been urging for a long time in some shape or form, that is, free choice of doctor. If he assures us he will do that, I welcome his conversion to our way of thinking on that point. I want to know is he still going to retain the health card and the present unsatisfactory situation in which no one knows his rights or can ascertain them from the Department, the local authority or the local representative? Is that to continue? Is he going to do anything about the provision of those necessaries—dentures, spectacles, artificial limbs and such items as expensive drugs which, as I mentioned, people cannot afford to provide for themselves at present?

I should like the Minister to tell us if he intends to modify the means test? I urge that he should go the whole way with Fine Gael: abolish it and give a free comprehensive health service——

Mr. O'Malley

Is that Fine Gael policy now?

Mr. T.J. Fitzpatrick

(Cavan): I am making my own speech. This is Fine Gael policy as is well known, and has been stated over and over again.

Mr. O'Malley

A comprehensive free-for-all health service?

Mr. T.J. Fitzpatrick

(Cavan): We fought the 1961 general election on it. The Minister's Party fought the general election on the basis that the health services were all right.

Mr. Davern

I think the Deputy is mistaking the position. The 1961 election was fought on the language revival.

Mr. T.J. Fitzpatrick

(Cavan): Immediately after that they set up a committee to investigate the health services. They fought the last general election on the grounds that they would get rid of the then Minister for Health, and they got rid of the then Minister for Health. They promised that they would introduce a new health scheme. We had the Minister for Health within the past few days promising the country a White Paper and, at the same time, we had the Taoiseach going on record as saying that the Minister's blowlamp would have to be applied to the health scheme and to education.

Mr. O'Malley

Capital expenditure.

Mr. T.J. Fitzpatrick

(Cavan): Where do we stand on the question of health? Are we to take it that the Taoiseach's statement does not refer to the Minister's health scheme?

Mr. O'Malley

That is right.

Mr. T.J. Fitzpatrick

(Cavan): Are we to take it that even after these six years, the Minister will get on with his health scheme and let us see it introduced?

When Deputy O'Higgins introduced the voluntary health scheme, he was told it would not work. It was ridiculed and made little of. That scheme has now been accepted by the country and, indeed, by the Minister, as a complete success. The scheme which Fine Gael propose is based on social insurance under which those in the present social welfare classes would be absolutely free. Above that, there would be a contribution of one-third from the State, and a contribution from employers, employees and the self-employed. That is a scheme which will work and under which there will be an absolutely free choice of doctor, which is the only type of medical assistance that can give satisfaction. Human nature being what it is, patients will become dissatisfied with doctors, for one reason or another, just as they will become dissatisfied with solicitors, or architects, or engineers, or any other professional men. It is not right that they should be tied to a doctor if their personalities happen to be incompatible, if they have rows, if they do not see eye to eye, or if the patient loses confidence in the doctor.

It is a pity the Minister's White Paper was not introduced before this motion was discussed. I trust that we will have an early opportunity of discussing it when it is introduced. When the Minister is replying to this debate, I should like him to tell us when he proposes to implement the White Paper, or when he proposes to bring before this House a health scheme which can be discussed as a definite proposal, because White Papers, informative as they may be— and indeed we have had quite a few over the past 12 months—are not effective. A White Paper will do nothing to relieve the distress which the 1953 Health Act has inflicted on the people who are forced to rely on it. While a White Paper may be all right as a talking point and may create considerable discussion in the country and bring the Minister a lot of information, in itself it is useless.

I am not blaming the present Minister because he has been in office for only a few months, but this question of health has been a burning question since 1961. Irrespective of what is said here, the 1961 general election, by and large, was fought on health. It was one of the major controversies in that election. So controversial was it that immediately after the election a motion was put down in this House, and the first critical issue on which the Government were challenged before the end of 1961, having been elected on 4th October, 1961, was the health issue. Indeed it looked as if the Government might have been defeated on that very motion.

In order to play for time, the Government—the present Minister was not in charge then—set up a Committee of this House to deal with, and report back on, health, thereby, in my opinion, accepting as a fact that the Health Act, 1953 was so unsatisfactory that it was beyond amending, that it could not be amended, because, if it could be amended, surely the Minister would have introduced his amendments then and there.

I want to make this complaint, not against the Minister but against the Government, that, having accepted as a fact in 1961 that the position was unsatisfactory and that it was beyond repair, it is not good enough after four years to come along now with a White Paper which the Minister tells us is to give the people an opportunity of expressing their views on the system. During those four years, the Government should have got down to the task and instead of coming along with a White Paper, they should be coming into the House with definite proposals which could be debated, amended, accepted or rejected.

I believe the Government have no health policy and I believe this White Paper is another effort to stall. The Committee has successfully stalled for four years. I sincerely hope the House and the country will not tolerate any attempt by the Government to stall for another four years. I should like the Minister to tell us now, not when he intends to introduce his White Paper, but when he proposes to introduce in this House concrete proposals for a health scheme that will meet the needs of the people of this country.

Minister for Health (Mr. O'Malley)

I listened with great interest to what the proposer of this motion and the other Deputy who spoke on it have said in this debate. Deputy Kyne, as usual on such a motion, spoke a great deal of sound common sense and I would commend Deputy Fitzpatrick to read his remarks in proposing this motion. He might not then make wild and irrelevant statements.

Mr. T.J. Fitzpatrick

(Cavan): Does the Minister accept everything Deputy Kyne said, because I do?

Mr. O'Malley

Deputy Fitzpatrick sat down without telling me, or answering my question, as to what the policy of the Fine Gael Party was. Even at this late stage, when he said they advocated a free-for-all comprehensive service, he seemed to get it into his head that he had committed his Party and then gave it as his own speech.

Mr. T.J. Fitzpatrick

(Cavan): I said no such thing.

Mr. O'Malley

I will sit down and give way to the Deputy if he tells me what the policy of his Party with regard to health is.

Mr. T.J. Fitzpatrick

(Cavan): I admit my speech, but I have to say I spoke on behalf of my Party. I never said anything else.

Mr. O'Malley

The Deputy spoke on behalf of the Party—good. I do not intend to accept the motion for reasons which I shall explain later. The fact that this debate has taken place will be, and has been, of considerable interest and benefit to the Government and to me, as Minister for Health. I have told the House on earlier occasions that since I was appointed Minister for Health about six months ago, I have been reviewing the health services and have been formulating proposals for their further development. When making this review, I have looked back on the history of how the present services developed and, more particularly, on the various proposals put forward, for several years past, for changes in them.

I have studied the Labour Party policy on the health services issued earlier this year, and on which I presume the present motion is based, and the proposals in relation to the health services circulated by the Fine Gael Party. In addition, I have had informal discussions, without commitment on either side, with some bodies especially concerned with the health services, such as the Irish Medical Association. Some of the matters covered by my examination and dealt with in these discussions were, I may say, the possibility of introducing a choice of doctor in the general medical service for what is called the lower income group. A further matter considered was the hardship which may be caused in the middle income group in some cases arising from the necessity to purchase expensive drugs and medicines.

I should have stated at the outset that the White Paper, as such, will not alone be an invitation to comment or criticise but will set out in detail the Government's proposals for the health services. Deputy Corish said to me, on another occasion, in a very good description— I hope I am not misquoting him—that we should have a progressive policy as far as the health services are concerned and that everything cannot be done overnight. I think everyone in this House will subscribe to that but there are certain things crying out for rectification. With regard to medical cards, I know the position well. I was a member of a health authority myself and a member of the Health Services Committee of this House and I want to say that I consider that certain aspects of the present system are practically a joke.

Mr. Mullen

Good man.

Mr. O'Malley

The original concept was perhaps sound. Anyone can come into this House with a White Paper and Bills; but it is one thing to bring them in and another to make them work. There are some counties of which I am well aware, where the county managers, for reasons best known to themselves, decided on a very inequitable and unjust scale in determining eligibility for medical cards. Each case should have been dealt with on its merits.

Further I firmly consider that social welfare beneficiaries, the unemployed, the widows and the old age pensioners should automatically, and with no question, be given medical cards. They should not even have to ask for them but should receive them by virtue of their social welfare status. If they have not got them now I will see they will receive them in the future.

Some managers have been operating this so-called scale referred to the week before last by Deputy Kyne. I think he spoke of the year 1961 and said that wage limits were set at £5 or £6 per week. Of course that was completely unjust.

Mr. T.J. Fitzpatrick

(Cavan): That is still the position.

Mr. O'Malley

I agree, and this is what we will have to spell out in the future. I am, as Deputies will appreciate, in a predicament about this because I have not yet got my final clearance from the Government in relation to my proposed White Paper.

Mr. Corish

It looks as if the Minister is going to put up a good fight for what he wants.

Mr. O'Malley

I think everybody agrees—

Mr. T.J. Fitzpatrick

(Cavan): I do not envy the Minister.

Mr. O'Malley

——that injustices exist. What I hope to achieve is the spelling out in no uncertain manner of a realistic eligibility rate for a single person, for a married man with a child, which will be uniform and binding, and if that is not sufficient, then I will have to do a bit more about it. To get back to the White Paper——

Mr. T.J. Fitzpatrick

(Cavan): Might I ask the Minister a question? Does he intend to do something about the means test before he introduces the new scheme? Did I understand him to say that?

Mr. O'Malley

Before what?

Mr. T.J. Fitzpatrick

(Cavan): I understood the Minister to say that he would do something immediately to right the injustices of the means test.

Mr. O'Malley

I am sorry if I misled the Deputy. I said that I consider that anyone in receipt of social welfare benefit at present should, in my opinion, automaticaly get a medical card without any question. I know that there are county managers who say: "You have two sons and a daughter" and so on. If I am to be logical, then the Mental Health Treatment Bill which will be coming before the Dáil——

Mr. T.J. Fitzpatrick

(Cavan): I do not want to interrupt the Minister but——

An Ceann Comhairle

I think the Minister should be allowed to make his statement without interruption.

Mr. O'Malley

The big change in the Mental Treatment Bill will be that whereas hitherto the incomes of children were taken into account when assessing the means of the husband and wife in future it will only be the income of the husband and wife. The incomes of the children in the house, who might be saving up to get married, will be ignored or dealt with on their merits. That is the kind of thing I hope to achieve as far as uniformity is concerned. As regards medical cards I hope to wipe out of future health discussions the expression "medical card". How I am to achieve that I do not know.

To get back to the White Paper, I should like to say that from time to time criticism has been expressed about Ministers making speeches at chambers of commerce or in other places and not in this House. That as everybody knows is not a realistic approach. The moment a Minister has certain proposals, he cannot jump up here out of the blue and start talking about them.

Mr. T.J. Fitzpatrick

(Cavan): Or he should not.

Mr. O'Malley

We have to be sensible about these things and anybody indulging in that kind of criticism is being mischievous and is deceiving the people. I am going to set out the Government's intentions and proposals and I have no objection to another motion or an opportunity for further discussion. I would be quite prepared to have a certain amount of elasticity, in certain respects, in regard to proposals. As I said before, I do not consider that all the brains of Ireland are on the Fianna Fáil benches, nor do I think that the only people who get sick are supporters of Fianna Fáil. I will be quite willing to listen to further constructive contributions.

I have referred to the question of drugs. This, as far as I am concerned, is one of the grave hardships on what is now known as the middle income group, the limit for whom will be raised to £1,200. Ill-health and sickness can be a great leveller—a person could have a very good income and have a very severe burden placed on him through sickness. It is in those instances that I want to try to have some kind of let-out clause where people with a charitable and just disposition will adjudicate on the interpretation of what is hardship. I hope also to have—whether I will succeed is another matter—some form of appeal, because we have had in the past, in local authorities, the little Caesars I spoke of, striking a blue pencil through a man's name without taking the whole case into consideration, without considering for how many months he has been unemployed, and so on.

As a matter of fact, I said at the Health Services Committee that one of the defects in the General Medical Services Scheme was that there was no space on the application form to supply details of any unusual circumstances. You just filled it up, got the employer to state whether the man was working, his wages and then the decision was arrived at, but there was no provision made for saying: "This man was idle for two years and has had one child very seriously ill." What happened? The case came to the unfortunate local representative, he listened to his story, and then he went back and either wrote or put his case to the local official. This should not have been necessary.

My examination of the present pattern of services, and of the various ideas for changes or developments, has been made and naturally it took some time because the issues are complex and the suggested solutions to the problems were many. The Government are satisfied that some changes should be made in the services, and the proposals for such changes should be published before Christmas. I should be in a position to circulate them for general discussion and consideration.

It has, accordingly, been decided, as announced last week by the Taoiseach, to publish this White Paper and explain our proposals in relation to the future development of the health services. It will deal with each service in some detail: the questions of the choice of doctor, drugs for the middle income group in cases of hardship, the so-called lower income groups eligibility for the general medical service and particularly, I hope, the general financing and administration of the services. In my opinion, the administration leaves a lot to be desired. The White Paper, having set out our intentions, will arouse discussion. I do not intend to anticipate its contents by giving a detailed statement of what the Government may propose in the way of changes. I am more free to say what the Government will not propose to do. I might as well be straight about it—the Government will not adopt any pattern of free-for-all services on the lines advocated in this motion. I do not think the Labour Party are really genuine, and I do not say that in any rude or hurtful way. I believe that individually they are a body of very courteous Deputies but collectively they can be appallingly stupid. Because they are the Labour Party, they think this cliché of "free-for-all" must be adopted.

Mr. Corish

You have the republicanism; we have the socialism.

(Interruptions.)

Mr. O'Malley

I am quite serious in saying that I believe the Labour Party in their hearts are not wedded to this free-for-all idea. It is completely impracticable, apart from the cost, which would be an additional £15 million. When people make mistakes they should learn from them. One of the most radical members of the British House of Commons was the Labour Member, Miss Jenny Lee, widow of the late Aneurin Bevan, and I note that in Hansard, volume 677——

Mr. Donegan

God forgive you for quoting that.

Mr. O'Malley

Deputy Donegan has just come in and he has not a clue. His clientele, in the main, would not worry about the hazards and exigencies of medical cards holders.

Mr. Donegan

My voting strength in Louth would be largely composed of those people and the Minister should know that.

An Ceann Comhairle

The Minister is speaking within a time limit and should be allowed to speak without interruption.

Mr. O'Malley

I should say that in Britain where insurance contributions are in their nature, and in the proportion of health expenditure which they meet, closer to suggestions about the proposed contribution than continental examples, the position seems to be that the former Conservative Government in England accepted contributions as a feature of their health services financing, but without any enthusiasm. The former Conservative Minister for Health when speaking on the proposal to increase the rate of weekly contribution by 1/- said:

It is said, and broadly, it is rightly said, that this contribution, like the flat rate National Insurance contribution, is of the nature of a poll tax: it falls irrespective of the earnings of the person by whom it is paid.

This proposal was strongly resisted in Parliament at the time and during the debate numerous references were made to the disadvantages of this form of tax from the workers' point of view.

An Ceann Comhairle

I dislike interrupting the Minister but he has just five minutes left.

Mr. O'Malley

It appears the present Government in Britain would favour the abolition of the health services contribution. I just wanted to get on record what Miss Lee said.

Mr. Cluskey

Did she think it was like the turnover tax?

Mr. O'Malley

She conceded in the light of experience that there was no justification whatever for imposing a poll tax on every man and woman who happened to be an insured worker. She said: "We want it to be widely known that a future Labour Government will end this totally unfair practice". That is in volume 634 and I commend these debates to the Labour Party.

A free-for-all service is neither necessary nor desirable and unless advocated purely on doctrinaire grounds such a service could not be justified so long as the people of this country can, through a combination of public and private arrangements, receive the medical care they need. So far as hospital services are concerned, I do not think it can be contended this is not the position. I have already mentioned the Health and Medical Treatment Act. I am not complacent about the services and I recognise the need for changes, but to admit this is not the same as admitting that the services are inadequate and to remedy any deficiencies that exist will not call for such a drastic solution as is contained in this motion. Indeed, to do what the motion proposes would not remedy the deficiencies which may exist at present but could well accentuate some of them.

Replying to a Parliamentary Question last March, my predecessor indicated that the additional cost, over and above that of the present health services, of a free-for-all service would be £15 million a year excluding any capital expenditure that might be involved. There is no indication in the motion as to how this extra cost would be met but Deputy Kyne, in introducing the motion, referred to financing improvements in the services. He said that Labour Deputies would wish to vote the necessary money for improving the health services provided they were satisfied that the burden would be placed on the shoulders best able to bear it. He also said it would be better to scrap the Health Act and introduce a scheme similar to the British health services on a contributory basis.

The British health services are not financed by an insurance scheme; less than one-sixth of their cost is met by insurance contributions and the rest is a charge on ordinary taxation. Secondly, insurance contributions as a means of financing even this proportion of the cost of the services, are not very popular in Britain nowadays, particularly in Labour circles. I think it would be a useful study for all of us and for Deputy Kyne and the other Labour Deputies in particular to read the reports of the debates in the British House of Commons in February, 1961 on the Bill to increase the rates of contribution. I do not think such a scheme would satisfy Deputy Kyne's requirements that the burden of the increasing cost of the health services should be placed on the shoulders of those best able to bear it.

An Ceann Comhairle

I am afraid I must intervene. Deputy O'Connell.

Dr. O'Connell

In supporting this motion, I want to say that I think the present health services are grossly inadequate and a disgrace to this country. The dispensary service places a stigma on the lower income group. We have a part-time medical service. People getting ill in the evening must wait until the following morning to attend a dispensary for medical attention. Workers must lose a day's pay to attend at these dispensaries. A part-time medical service is not good enough for the lower income group. It is degrading.

People have no choice of doctor. We all like our own doctor. We do not like being forced to attend one particular doctor if we have not faith in him or he has not got a manner which suits us. These poor people are forced to accept a doctor they may not like. As a result, many people with medical cards try, at great expense, to seek the services of a private doctor and obtain the medicines and drugs at the dispensary on his prescription. The dispensaries do not provide the drugs ordered by the private doctor for these patients. Too often they are told the drugs are not there. They must go to the central depot and they are returned again to the dispensary. They may have to wait two or three days for the drug which is ordered for them. Any person can become dangerously ill while awaiting the proper drugs for his or her condition. This commonly happens in the dispensaries in Dublin city. The proper drug ordered by the doctor is not available.

We also have borderline cases, those who are not qualified to receive a medical card but who cannot afford the drugs prescribed for them. Many a doctor has undue worry with patients about the cost of prescriptions and the number of tablets which would be within the means of a patient. I remember one patient I saw. She did not qualify for a medical card. She had two children ill with bronchitis and pneumonia. I could not prescribe an adequate quantity of the drug required because the woman could not afford it. As a result, each child received only half the quantity of the drug necessary.

We have two cases of people who have been deprived of cards. I had a case of a woman who was deprived for five years, despite the fact that I made repeated representations on her behalf as a doctor. I applied on no fewer than 20 occasions but was refused. When I became a Deputy, I applied again and the card was granted. For five years I had been trying on behalf of this woman who was suffering from bronchitis and asthma and was bedridden but whose means did not permit the provision of the drugs necessary. Due to my representations as a Deputy and not as a doctor, she has now got a card. As a result, she is up and about now because she has got the proper drugs. But she was deprived for five years.

Then we have the burden imposed on people outside the medical card range. By Wednesday they find the money is completely gone and they have to forgo medical treatment. Many a man has had to return to work prematurely because he could not afford to be out, with the cost of drugs. The Minister has made an investigation of the cost of drugs. In a normal illness, it costs £2 or £2 10s. to cure a patient. For a man with a normal weekly wage, this is prohibitive and exorbitant. Many a patient has had to tell a doctor not to call again because he could not afford the cost. Many a doctor has had to make second and third visits social visits because he knew the patient could not afford the cost. Many people prematurely leave hospital because they cannot face the tremendous expense of hospital treatment. In fact, they are sued by the health authority for an amount they cannot afford. I have seen many patients who have had four or five bills from a hospital over two or three years, who could not pay and said they could not go back to hospital because they were faced with these tremendous bills which meant they would have been in debt for the rest of their lives. These were people with chronic illnesses who would not qualify for a medical card.

Mr. O'Malley

What is the tremendous bill? Up to 10/- a day?

Dr. O'Connell

When this extends to three, four or five months, it is no joke for these people who cannot afford to pay it. I remember writing to the health authority recently. They said they would not waive this bill but the matter went to court and the judge waived it because he found out the circumstances of these people. I have seen four or five bills in a house—two civil bills from the Dublin Health Authority. These are chronic cases with recurring illnesses who are forced to go back again because there is no proper system in the hospitals to investigate early and act quickly.

We have an ophthalmic service which, under the Health Act, is not considered a specialist service. People are burdened with the expense of this for their children. One case came to me recently of a woman with a five year old child. Her husband was earning £14 a week. She brought the child to the Royal Victoria Eye and Ear Hospital. As the child was about to be examined by the specialist, the almoner told her the child did not qualify. She was told to attend the ophthalmologist at his private rooms. The cost to date is £25.

We have cases of children of school-leaving age or those attending secondary school, whose parents earn £12, £13 or £14 a week, who do not qualify for this service under the present Health Act. The biggest drawback of the present health services is that the ophthalmic service is not adequate to meet the demands of the people. We have not a proper ophthalmic service in this country. We have a large waiting list of people in need of major eye operations who are being deferred under the present system.

The dental service is totally inadequate. The number of dentists in this country is not sufficient to meet the needs of the school service alone.

Take old age pensioners in hospital for treatment. Who is to decide the dividing line between medical attention and institutional care? These people have the blue card or medical card. They are suddenly told they do not qualify for medical attention, that they are now in the institution. Despite the fact that these people are ill, a deduction is made from their pensions. Who is to decide the dividing line? These old age pensioners who may be convalescing are charged for this service in St. Kevin's under the guise of institutional care. An old age pensioner would prefer to have his own doctor and pay the cost out of his meagre pension rather than have no choice of doctor under the dispensary system.

When people apply for a medical card, who does the investigating? Unqualified people who do not know the circumstances. Income is assessed on the total amount earned by the whole family. Now, sons and daughters pay only for their keep at home. They do not pay over their entire earnings. The result is that parents are sacrificed. They do not qualify because the income earned by the children is taken into consideration. That is wrong.

We have then the Voluntary Health Insurance Scheme for those who do not come under national health insurance. This Voluntary Health Insurance Scheme is no answer to the problem. It does not cater as a proper insurance scheme would. Two of the disqualification clauses are, first, that you be ill and, secondly, that, having been ill, you are debarred from having attention for a similar illness in the future. Old age is yet another barrier. Those over 65 years of age cannot join. The scheme is far from adequate. Only a comprehensive health insurance scheme will serve all sections of the community. That is the only answer. We want a service similar to that introduced originally by the Labour Government in England. Only a similar scheme will be satisfactory here.

The Minister states that the Government are satisfied that changes are necessary. From my recollection, the Government were satisfied that our existing health services were adequate. Now they say they are satisfied changes are necessary. I gather from the Minister that he will not substitute for the present pattern, but there will need to be radical changes before it will meet the needs of our people. The health service in Britain is the ideal. Dare any Government try to change that service or to abolish it, it would bring about the downfall of the Government immediately. The people are satisfied with the service. The initial abuses have been overcome. The people have proper attention and care. I do not know what the Minister meant when he said the Labour Party collectively are appallingly stupid over the health services.

Mr. O'Malley

And individually charming.

Dr. O'Connell

Collectively stupid.

Mr. O'Malley

On occasion they can be.

Mr. Corish

Then Deputy MacEntee was very stupid. The present Minister's attitude is different, but, mark you, the present Minister supported Deputy MacEntee for years and years, and he was a stupid conservative.

Dr. O'Connell

The Minister has a way of coming in on his own and making pious promises. He says he will do everything. Yet, when he attends the Irish Medical Association dinner, he has the audacity to stand up and say the doctors want a free choice of patient.

Mr. O'Malley

The Deputy should be the last to use the word "audacity."

Dr. O'Connell

I heard the Minister speak those words. He said the doctors wanted a free choice of patient. Perhaps the Minister is not so genuine after all. Perhaps these are only pious promises. I shall judge the Minister by results and by what is achieved. I shall not judge him by these promises. I do not think £15 million, as suggested by the former Minister, is a proper figure. Of course, everyone who is against health services always tries to make the cost look prohibitive. The Labour Party stand for a comprehensive service for all sections of the community. No slight extension of the medical card system will do. We want a comprehensive service similar to that in existence in Britain. Nothing less will satisfy the Labour Party.

Mr. Donegan

The wording of the motion is quite explicit and quite satisfactory. We are extremely disappointed with the present situation and we believe it is necessary now to institute a comprehensive, no means test health service. The only question is how to do that. If the aim is towards a certain target, then the question is how to hit that target.

Mr. O'Malley

A comprehensive, no means test health service?

Mr. Donegan

A comprehensive, no means test service.

Mr. O'Malley

A free-for-all.

Mr. Donegan

I shall use my own phrases and the Minister, at his pleasure, can use his. I shall try to explain what we mean by a comprehensive, no means test health service. At the moment there is a contribution from the workers' stamps towards the cost. There is the division, as to 50 per cent, between the local authority, which is the rates, and the Exchequer subvention. That means that, if the lady about whom Deputy O'Connell spoke, needs a rather expensive drug, a drug costing 50/- per week, 25/- of that will come from the rates. I am aware that in the case of an insured person, which this lady was not, there is a contribution from the Exchequer.

Mr. O'Malley

A what?

Mr. Donegan

I am sorry; there is a contribution from the stamp of the insured contributor. The Minister may say "No" but some funds find their way in that direction.

Mr. O'Malley

From the stamp for the drug?

Mr. Donegan

At the moment the cost of the drug prescribed would be met as to 50 per cent from the rates and 50 per cent from the Exchequer. If the Minister wants to pick me up as I go along, he can do so. The position is as I have stated. The limiting factor is the rates contribution. The person who accepted the estimate from the local authority is the same person as will decide whether or not a patient should get certain medical treatment. His aim is not to exceed the estimate already sent in and, therefore, his mind is conditioned by cost. We cannot, of course, decide that every drug that comes on the market, irrespective of cost, must be provided for everybody. There are, however, instances in which the use of drugs would save hospitalisation and, therefore, save money. But all the time there is the limiting factor of the rates contribution. That has been a deterrent in the provision of a decent health service under the 1953 Act for those who cannot afford one for themselves.

Let me give a simple example to illustrate what I mean. I am a member of the Louth County Council, which is the health authority for my constituency. We do not provide proper dental services because we cannot afford them. Yet, if the Minister chooses to look up the 1953 Health Act, he will find that we are obliged to do so. As I said in the debate on the economic situation last week, there are cases where dispensary doctors in Louth have sent people into hospital to get their teeth looked after, because, when they went into hospital, they were hospital cases and it could be done there under a different heading, whereas otherwise there was no service available in that local authority area for a person who was in extremely bad health because of the condition of his teeth. That is a practical example of where we have fallen down. It is a practical example that I know of as a member of the health authority and which the Minister can verify if he cares to do so.

The Fine Gael policy on this matter is that anything that has to be provided has to be paid for. Fianna Fáil have been constantly assuring us of this fact. Our idea of paying for this is that there should be for medicine outside hospital a contribution from the stamp. I do not want to go into this in detail with the Minister because he will pick me up on one detail or another and we will probably end up at cross-purposes. The stamp should be increased by something of the order of 2/9 a week. We did not object to going out at the last election or the previous election and saying that in order to get a comprehensive health service for approximately 85 per cent of the population you would have to have payment for it through the insurance stamp.

We believe that an extension of the Voluntary Health Insurance Board idea is the only way in which the Minister or his successor will find himself able to provide the sort of service required. The Minister may shake his head. These things are matters of opinion and he has had short opportunity to look these things up. Sitting on the Select Committee on the Health Services was a rather long opportunity, especially when Deputy MacEntee, then Minister for Health, was sitting on the same Committee.

Mr. O'Malley

The Deputy will have to make allowance for a "banana republic"; we do not get on as quickly as developed countries.

Mr. Donegan

I do not know what the Minister is talking about. It is true that I did say that the 6¾ per cent given last week was the highest rate of interest given outside a banana republic but the following sentence was, "I hope the loan will fill". I prophesied that it would fill.

Mr. O'Malley

What sabotage that was in the middle of the loan.

An Ceann Comhairle

There is a motion before the House.

Mr. Donegan

I advised everybody in the country who had money to take the loan because they were getting the best side of the bargain.

Mr. O'Malley

If you stick the knife in my back and then send for the doctor, what good is that?

Mr. Donegan

From whence did the "banana republic" come? There is no use in trying to get me off this: that the only way you can get this service outside hospital is by introducing this element in respect of the working man's stamp. Anybody can produce a computation to say what that will amount to and anybody who wants to ask a Parliamentary Question can be told what is the cost of the provision of medicine outside hospital, and how much it will represent on the stamp. We were prepared to say how much and we are prepared now to ask the same Parliamentary Questions. The Minister may not like it. We are prepared to ask the same questions and get the same information and find out whether or not there is an increase and state how much it will cost the people. That will remove the means test——

Mr. O'Malley

Completely unjust.

Mr. Donegan

——and that will remove the situation where people in my constituency and in the Minister's constituency and every constituency have to come to their unfortunate TD to get them to plead a case. Deputy O'Connell has instanced a case where as a doctor he could not do something for a woman for five years but as a Deputy, a person with influence, in his association with highly experienced members of the Labour Party, he could find out what the woman was entitled to. As a Deputy he was able to do what he could not for years do as a doctor.

Mr. O'Malley

Choice of Deputy.

Mr. Donegan

Choice of Deputy and choice of doctor and choice of patient.

Mr. Corish

And, what is important, choice of Minister.

Mr. Donegan

The Minister is a man with a very fluid mind. I will deal with his choice of patient and doctor. The Minister instanced a figure of £15 million. If he wants to look up the debates, he will find the extra figure quoted by his predecessor for a comprehensive health service was £30 million. His predecessor was facile with figures and was adept at making black red. In fact, in his conservatism, nobody knows better than the Minister that he would quote just as readily £30 million or £130 million. Our idea was that, outside hospital, there would be this extra contribution from the stamp. Inside hospital, there would have to be a contribution from the rates. That was a practical approach inasmuch as we all know that local authority institutions have in charge of hospitals persons who are also executives of the local authority. The County Manager in Louth and the managers in the various counties and cities are also the executives who look after the local authority hospitals.

Mr. O'Malley

That is the trouble.

Mr. Donegan

If the Minister would like the Fine Gael policy on health and documented detailed evidence of what I am saying, I will deliver it to him within 48 hours. If he finds that my memory has failed or that I have digressed, the opportunity will arise for him to contradict me. Has he got the document? Does he know what it means?

Mr. O'Malley

I do not know what it means. At least, the Labour Party are straight about it. They say what is their policy. The Deputies of the Fine Gael Party do not know what their policy on health is.

Mr. Donegan

I thought they were "appallingly stupid".

Mr. L'Estrange

I thought the Minister had it stolen after last night's speech.

Mr. O'Malley

The Deputy was not here for my remarks.

Mr. Donegan

People must have their tea. The Minister does not like me to say this, but we believe that, practically speaking, you cannot divorce local authority hospitals from the rates. You can subvent them in any way you like but unless you want to set up another chain of control which would be highly expensive, as it would be a new chain, you cannot divorce them from the rates but you can divorce health outside hospital from the rates and can introduce an Exchequer subvention and at the same time get every man working in this country to provide something extra in his stamp and become a paying patient and no longer a person who has to come as a suppliant to Deputy O'Connell, to me or to any other Deputy. The Minister facetiously says: "Choice of Deputy". That is not a proper Ministerial remark. It is just being funny.

I want to talk now about the thing that is the real political effort on health of the Fianna Fáil Party over the past four years. I do not want to go into detail as to what were the relations between the Minister's predecessor, Deputy MacEntee, and the IMA but to say they stank to high Heaven would be no exaggeration. Then over a period there was the anxiety, because the Fine Gael Party and the Labour Party had both produced the view that there should be choice of doctor, that this might disrupt things. I found among my friends and the doctors in my constituency and in the country that there was this uneasiness. Experienced practitioners—and I do not mean medical practitioners; I mean political practitioners—like Deputy MacEntee, thrive on that sort of thing. The outcome was the marriage which was consummated on a night in Iveagh House when the entire Select Committee on the Health Services and all the IMA turned up. There were Deputy MacEntee, the blushing bride, and the IMA and we all made it up, and then there was the situation as we approached the election where the IMA were happy that there was going to be no choice of doctor and therefore no upturning of the dispensary system, no such thing as a new look or a health policy. They went to the election in that situation.

Like the publicans, the doctors are highly influential people who wield considerable political influence. I have many friends among them, great friends, people who vote for me, people for whom I have the greatest respect. My considered opinion is that the majority of doctors in Ireland voted for Fianna Fáil in the last election on the basis of the marriage consummated on that night in Iveagh House. I do not care whether I lose votes or not for saying that I believe that to be true.

Having said that, I want to say what was the truth. What was the truth? The truth was of course that the Labour Party were not hogtied to do anything and I am certain that Fine Gael were not either. In fact, there are quite often two systems. There has been the panel system which exists in England and the fee for consultation system in the Antipodes. The scheme is on the basis that if you went to a doctor, you paid him a fee or signed a document and then the State repaid this. This is what dispensary doctors would have had to compensate them had they lost money.

Remember Deputy Hogan of South Tipperary asked questions here and proved that there are dispensary doctors in this country looking after as many as 2,500 patients and yet in Waterford there is one looking after 250. The whole dispensary system, as I see it, is tied up not only with the salary paid, which is £1,300 a year, plus a certain allowance for a car, but with the numbers of patients existing within the dispensary district for further practice. When a local authority wants to change a dispensary district—when houses have grown up here and there and there is a denudation in population in another place—they cannot do it without the wish of the dispensary doctor who is the incumbent. The health authority looking after matters in Louth found they could change the area of a dispensary district only when a dispensary doctor died or retired. That is the reason why there is a doctor in Waterford looking after 250 people and others in various parts of the country looking after as many as 2,500.

Mr. O'Malley

Of course the Deputy is wrong again.

Mr. Donegan

I would be extremely pleased if the Minister would tell me where I am wrong or where I am caught out——

Mr. O'Malley

It is not a question of being caught out. The Minister for Health can by direction, define boundaries of dispensary districts.

Mr. Donegan

How many times has he done it, say, in County Louth over the past 30 years.

Mr. O'Malley

I was not asked to do it.

Mr. Donegan

I am merely telling the Minister my experience of this. Maybe I am lax in that I should have gone to the library and read up the legislation. I think, if you asked 100 Deputies out of 143 most of them would agree with you that as far as our opportunity in local authorities is concerned, we can only change dispensary doctors at a time of resignation or death.

Mr. Geoghegan

That is not so.

Mr. Donegan

It seems there is one Deputy present who does not agree but I do not notice anybody else standing up and denying this.

Mr. T.J. Fitzpatrick

(Cavan): Is the Minister saying that a council can change the terms of appointment of a doctor without his consent?

Mr. O'Malley

No, but if it came to such things as defining the boundaries or areas, the Minister for Health, I believe, has such powers.

Mr. Donegan

If this debate did nothing else, it has produced a good result in that we know it now. It was well hidden under the bushel by previous Ministers for Health.

I should like to deal with this matter of the charge of 10/- per day. If you look across the broad spectrum of the population you will find that some of us are in hospital only when we get shot or run down by a car while others find themselves in hospital quite often from perhaps some chronic ailment. The only way to approach this is on the basis of insurance because Deputy O'Connell is quite right when he says that a man with three or four children who has not a medical card will not get it if he is earning something of the order of £14 per week. It is a very great imposition to find he has to pay 10/- a day for a child of his who might be in hospital for anything from six to 12 months. A farmer in my constituency has a child who is a haemophiliac and that child has been in hospital for at least three months of the year for the entire period of its life, which is about seven years. Now the decision as to whether or not the parent has to pay for the child or gets away with less than 10/-a day, rests absolutely with the county manager or whoever the chief executive might be. I submit to you that whatever you do about it——

Mr. O'Malley

Are the parents of that child being charged?

Mr. Donegan

Yes.

Mr. O'Malley

If the Deputy will give me the details, I will be delighted——

Mr. Donegan

I will certainly give the Minister the details. It may be ruled upon all right but this man has been paying this charge for years. I would like to take the Minister up on this. The Minister I know is sincere in his effort to help and I think the Minister will accept that I am sincere in my efforts to help my constituents too. The Minister received three letters from me in the course of the past few months. I had forgotten that we had not the right to appeal to the Minister under the 1953 Health Act. The Minister wrote me personal letters and told me that, in fact, the decisions were wrong. The Minister is in exactly the same position in this case, as he was in the other three, in that he can express the opinion that the local authority is wrong and then——

Mr. O'Malley

I can do more.

Mr. Donegan

Well, if the Minister can do more, I urge him to do it.

Mr. O'Malley

The Deputy said there was a child suffering from haemophilia?

Mr. Donegan

Yes. The child is seven years old and has been frequently in hospital during its lifetime. When the child gets a cut, it must go to hospital. The Minister says he can do more. I admit I made an error and that there was not a right to appeal to the Minister but the Minister can do no more than recommend, and the Minister has done no more than recommend to my local authority in the last three months.

Mr. O'Malley

I could look into the position and if I was satisfied there was a succession of unjust decisions, I could very clearly have steps taken to remove somebody in the administration of the health services.

Mr. Donegan

Has the Minister the right to remove somebody? Have we got him in a cleft stick? Do not think that because I may be friendly with the Minister for Health and friendly with all the officers of the Louth County Council, I would not have the pluck to go and say there are cases for investigation and enable the Minister to remove one of my friends. I will certainly take it up if the Minister wants to do that, but I should like to know under what legislation the Minister can remove somebody in the county council. The Minister has posed a question of what he can do and I want to know under what legislation he can do it. Happily, I think I shall be asked to move the adjournment of the debate in a few moments and that will give the Minister time to look up his files and legislation. It will also give me time to assemble my information.

Mr. T.F. O'Higgins

The Minister says he can do it.

Mr. Donegan

Let us then approach this matter, not on the basis of a contest between the Minister and myself——

Mr. Corish

Has the Minister power to suspend any local authority official?

Mr. Donegan

——not on the basis of unpleasantness, not on the basis of power, but on the basis of doing good.

Mr. James Tully

As a matter of interest, could the Leas-Cheann Comhairle say is there a time limit on Deputies?

An Leas-Cheann Comhairle

Deputies are entitled to 30 minutes and the Deputy who has just concluded has spoken for 25 minutes.

Mr. T.F. O'Higgins

How much time is left for the debate?

An Leas-Cheann Comhairle

When the debate was resumed, there were two hours and twenty minutes remaining. There are now 50 minutes left.

Mr. Corish

What is left for the reply?

An Leas-Cheann Comhairle

A quarter of an hour.

Debate adjourned.