Committee on Finance. - Vote 48—Health (Resumed). – Dáil Éireann (18th Dáil) – Tuesday, 1 Mar 1966

Committee on Finance. - Vote 48—Health (Resumed).

Debate resumed on the following motion:

That a sum not exceeding £17,337,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1967, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Ard-Chlaraitheora), and certain services administered by that Office, including Grants to Local Authorities, miscellaneous Grants and a Grant-in-Aid.

—(Minister for Health.)

Mr. Kyne

I should like to begin by stating on behalf of the Labour Party that we welcome this White Paper as a basis for a discussion of the proposed improvements in the health services. Certainly I found it very amusing today to listen to claims being made by the Fine Gael representative as to the long time over which they have been proposing ideas not as good as those now being proposed by the Minister, but far exceeding them. I thought back to the shades of 1953 when the last Health Bill was going through this House, and I think anyone reading the debates which took place at that time would find it difficult to reconcile the complete conversion from the point of view then expressed to that expressed today. We welcome the fact that the Fine Gael Party have been converted.

No matter which of the two big Parties actually wrote the White Paper, the only regret we have is that whichever of them took it from our 1958 programme did not take the complete programme as we outlined it. I do not think either side can claim to have gone back as far as 1958 and introduced a health programme, other than the scheme produced in 1953 by the Fianna Fáil Government. I have with me a copy of the health programme which was discussed in public in 1958 in Dublin city at the annual conference of the Labour Party and published in the Sunday papers. I should like to quote from page 2, paragraph 6, because this gives a synopsis of the whole health services that we thought were necessary during the period of time we were passing through then. I quote:

Briefly we propose that a new health scheme should be introduced which would cover general practitioner service, hospital treatment, specialist services, dental services, ophthalmic services and pharmaceutical services. There would be no direct charge for the general practitioner service, hospital treatment or specialist services. There would be partial charge to some persons for the remaining services (dental, eye and pharmaceutical) but these services would be without direct charge to certain categories of persons. The dispensary system in its present form would be abolished and all persons covered by the scheme would have a free choice of doctor. The present charges for hospital treatment would be abolished.

I have with me a copy of the Fine Gael policy on health as presented to the Select Committee on Health Services. It includes most of the things we advocated but not all of them. Certainly, Fine Gael and Fianna Fáil have been converted to Labour Party policy in this matter. Of course the Labour Party do not worry about this. So long as the health services we have been advocating are brought in, we do not care who will be using them. It is a matter of indifference to us. I have here a copy of Pulse, an international medical magazine, dated 18th April, 1964. It carries an interview with the Leader of my Party, Deputy Corish, and with me. I shall quote some of it:

Then we got down to the burning questions. Deputy Kyne rattled off the facts and figures: abolish dispensaries; free choice of doctor where possible; capitation system of remuneration—Northern Ireland's 24/- per capita would, he thought, be a fair offer; limitation of lists or panel to 1,500 to 2,000 patients; group practice and rota systems; national health board with local health committees to administer the service; total cost of GP manpower —£3 million.

I do not think some of the people now claiming pride of place in the matter of modern health policy came into the field as early as we did, in 1964. However, we welcome any improvements and their source is a matter of indifference to us.

The Select Committee dissolved after three years during which I had to travel to the meetings, sometimes at great personal inconvenience, a distance of 130 miles in the winter. The Labour Party were forced to the conclusion that it was a waste of time to continue and they withdrew from the Committee. In retrospect, I believe the Committee did some good because it seems to have convinced the other two Parties that there was a public demand for a vastly improved health service, that there was need for a much more comprehensive scheme on a much more liberal basis.

I often sat with the Minister during meetings of the Committee and I gathered that his personal view was that there was need for a much improved service. I do not propose to go into any of the confidential information given to us while the Committee were in session in connection with the various organisations who came before us, but I think it is common knowledge that practically all the organisations and individuals who came before us and gave evidence advocated many of the things the Minister now proposes, the most important being the free choice of doctor. As a Labour representative, I welcome that especially. I gave my reasons during a debate on a health motion before Christmas.

It is not only desirable but absolutely necessary that people in the lower-income groups, if they are to get a first-class service, must have a choice of doctor. At the present time, the doctor-patient relationship could be upset to the disadvantage of not only the patient but the doctor attending him. The patient could be affected by the fact that he was compelled to attend the one doctor with whom, perhaps, he might have strained relations. For that improvement alone, I welcome this step forward. The fact that the dispensary system is to go and that patients will be treated in doctors' surgeries in the same manner as private patients are treated at the moment is another excellent suggestion well worth looking forward to.

Since the Minister published his White Paper in January—I wish to thank him for having sent me a copy personally—I have studied it and have endeavoured, within the limited means at my command, to compare the proposed new position here with the health services in some west European countries. I have here a document dealing with western Europe issued by the Offices of Health Economics in Great Britain in May, 1963. It may not be as up to date as some similar papers published on the subject, but it gives in a condensed, digest form the various health services operated in 16 countries, including Britain. The health services proposed in the White Paper compare very favourably with those of most of the countries listed in the document.

Of course it is difficult to make comparisons because in many countries social welfare and health services are a combined operation, under the one Ministry in many cases. In some, the health services are administered by corporations and insurance societies. Only in Great Britain and one other country are they administered directly by the State. In Finland, health services are non-existent practically except for children and through certain insurance schemes. On the whole, it is fair to say that Ireland will not come out badly except in comparison with Great Britain where they have the highly specialised health services we should like to see operated here.

I was impressed by one point in connection with Ireland. In the various countries of Western Europe, the bed ratio per head of the population varies from one per 100 of the population up to one per 150 of the population, but in Ireland and Sweden, the figure has been estimated at one for each 50 of the population. That a majority of these beds are occupied by people in mental hospitals or those chronically ill should not detract from the figure, because mental illness is not a problem in Ireland alone. All the other countries have to devote a certain number of beds to that type of patient. I expect the finance provided by the Hospitals Trust Fund has helped to create that favourable position. It is nice to find that in some respects at least we are ahead of Great Britain. In general, the western European nations provide hospital coverage for from 75 per cent to 85 per cent of their populations. With the new proposals in the White Paper, it is estimated that we should cover about 90 per cent of our population.

There are certain defects in our health services and it is just as well to admit this. On page 5 of the Health Services in Western Europe report dealing with the schemes in various countries I read:

Hospital care is invariably covered by the schemes and only in France and Ireland must the patient pay a proportion of the hospital costs personally.

That means that only in Ireland and France is there a direct charge on the patient. I do not wish to quote out of context. I know the report goes on to say that there is a limited hospital stay in some of those countries and that in some of them social welfare benefits—which indeed are large in comparison with ours—have to be deducted for the keep of a patient in hospital. But there is no direct charge as such for hospitalisation in any countries other than France and Ireland. This is a defect we should get over. In most of the European countries, social welfare and health contributions are combined and are graded in proportion to the amount of earnings. A person earning £9 a week would pay less than a person earning £11 or £12 per week. Whether or not a contributory system is introduced here—the Labour Party feel it should—the Minister will have to decide whether to have a graduated scale of contributions from workers and employers.

A graduated scale is attractive in some ways, but it has its snags. It introduces a means test which means an investigation into what is being paid and double checking. Very often the cost of administering and collecting such contributions would offset any advantages gained. In Great Britain, Denmark and Ireland, there is a flat payment. I am inclined to believe that, if contributions are to be collected, a flat payment is more economical in the long run. Even though the man with the low wage has to pay as much as the man with the bigger income, there are other ways of getting at the man with the big income through some system of income tax or otherwise.

I should like to go through the White Paper briefly. Let us assume the promises it contains will be honoured in two years' time and let us see what we have. As far as the Labour Party are concerned, the two big things are the choice of doctor and the fact that the patient will now attend at the doctor's surgery rather than some old-fashioned, draughty and ill-equipped dispensary. These two things alone are worth the White Paper and I give it my unstinted praise and support.

In regard to the other matters dealt with, I have a cutting here from the Irish Times of January 21st, the day following the introduction of the White Paper, which examines its highlights under 12 headings. It says, first:

Those who are entitled to take part in the general medical service will be clearly defined, thus ending the present system under which the bases of eligibility vary from one local authority to another.

That is quite true. I made that point when speaking on the Labour Party motion on the health services. In South Tipperary, for instance, you may get a medical card if you have a certain income, while the income limit is different in Waterford and different still in Kilkenny and Cork. It is good that the Minister now proposes to list entitlement so that each person will know as soon as possible to what he is entitled, depending on his occupation. There will be no difficulty so far as income and valuation are concerned but the self-employed person may present some difficulty. However, the charge will be uniform.

The Minister made it clear in page 35 of the White Paper how far he thought the other improvements would go. It says, starting on page 34:

The Government are aware of proposals recently made for the extension of the general practitioner service, with a choice of doctor, to the whole population or to the entire middle income group. In the Government's view, however, satisfactory evidence has not been offered to show that such an extension is necessary. Indeed, the evidence that is available would indicate that hardship is seldom caused in the middle income group through family doctors' bills.

Now comes the portion I would wish to underline:

As a wide extension of State-operated or State-organised general medical services has not been demonstrated to be necessary, the Government would regard it as undersirable and would not, therefore, propose that the limits to be fixed by the regulations mentioned in the preceding paragraph would be such as to include a high proportion of the population.

In other words, what the Minister appears to me to be saying there is that, even though he will make definite, rigid and uniform rules in relation to entitlement to the card, nobody need expect that the position will be any more all-embracing than the 30 per cent who now get medical cards. That, at least, is my interpretation of it. If I am wrong the Minister will correct me.

We have heard the Minister's statements, and we are bearing in mind the suggestion made in the White Paper, that rent and other expenses not normally allowed by county managers in investigating entitlement to a medical card will be considered and that the number of children will likewise be taken into account. Children enter into the consideration at the moment but not, I think, to the extent the Minister is contemplating; the fact that a man is married, with eight children, and has other exceptional commitments which limit his means in relation to payment for GP services will be taken into account. Unfortunately page 35 seems to prohibit me from believing that we should expect any great improvement, if any, in the issuing of medical cards.

Mr. O'Malley

I have done away with the family income concept.

Mr. Kyne

That is so. I should give credit for that. One of my complaints in the past was that the incomes of the sons and daughters were added to that of the father, thereby depriving the parents and the sons and daughters of a medical card. That is a most desirable change. I am sure that it will qualify a far greater number of people than formerly for GP services.

The next point is drugs and medicines. These will be provided through the chemists and not in the dispensaries. We certainly applaud that change. It is an excellent one. Patients will no longer have to queue up in the rain waiting for their prescriptions. Under the proposed new scheme, they will be able to go to the chemist of their choice. There is only one drawback. The private patient will still be able to get anything he likes while the other group will be supplied with a standard prescription from a listed number of medicines and drugs. Is that not so? The Minister shakes his head.

Mr. O'Malley

Not necessarily, There will be a national formulary, but the doctor will use his discretion.

Mr. Kyne

The White Papers says something about being as economical as the health of the patient will permit.

Mr. O'Malley

It is the same as in Great Britain.

Mr. Kyne

I know, but it makes a distinction unfortunately. Perhaps it is a distinction without a difference, but any distinction is, to my mind, undesirable. I agree that there is no other way other than by recklessly allowing any type of prescription the doctor likes. If that were the case, then there would be no way of assessing the cost of the health services in any one year. I just mention that in passing.

People in the middle-income group will be eligible for general medical services and will in certain cases be able to buy drugs and medicines at reduced prices. That, of course, is merely an extension of the circular sent out by the Minister's predecessor in July, 1964. That facility was not availed of to any great extent largely because people were ignorant of its existence. I was unaware of the circular until Deputy Tully drew my attention to it here and, indeed, the attention of the House also. In Waterford, the health authority is a separate entity and the circular was not read at all. After Deputy Tully drew attention to it, the Minister issued a warning and directed attention to this entitlement and advised that it should be brought to the notice of members of local authorities and of the public. After that it was freely availed of in Waterford. I am glad the Minister is now considering extending that further. It is a most desirable advance.

More district nurses will be recruited and home nursing services extended. There will be co-ordination of services for the aged. These are all promises for the future. However, I believe the Minister will endeavour to co-ordinate the various services, including the voluntary bodies, and will also provide home nursing services. All that will cost money and it will all take time but we accept it as a principle and the quicker it is implemented, the better it will be as far as we are concerned.

I should like to pay tribute now to some of the voluntary organisations that give such valuable help to the aged. In my particular town, the Friends of St. Martin, a group of young boys and girls, visit the aged weekly or nightly. They have whitewashed and painted the houses of these people. During their absence in hospital, they have done up the little homes so that the patients, when they return, find their places neat and tidy. They provide social evenings for the lonely and the aged. All this is done out of their own pockets, out of money subscribed by them at their meetings. There is no State aid. It is excellent work and they deserve the thanks of the people for doing it. It will bring a blessing on them. I am glad the Minister proposes to co-ordinate these services. Any help he gives should be extended to this group.

The next point is the abolition of the charges for outpatients, specialist services, X-rays, etc. That is a good move and the Minister is very wise in doing this since I believe it will encourage people to make more use of the outpatient department and put an end to this needless occupation of beds. The cost—2/6 for a specialist—of collection so diminishes that amount that it is hardly worth collecting at all.

Deputy Fitzpatrick referred to the doubling of maternity grants. I would estimate that £6 would be the equivalent of the £4 given in 1953, but it is a good thing that it has been increased to £8, as is also the doubling of the grant for multiple births. The only regret I have is that there may be a long delay before this will be introduced. The present moment may not be the most opportune time but if the Minister could, by some process, bring certain things into operation earlier than others, that is one thing I would like to see brought in as early as possible.

Dental and ophthalmic services and the supply of spectacles are to be extended to the middle-income group. In connection with the dental services, even the lower-income group who, by virtue of their medical cards, are entitled to dentures cannot be supplied. It is said in our county that it is due to the shortage of dentists. I believe that is true. We did get permission from the Department of Health to employ dentists even on a part-time basis. We were not able to get them in sufficient numbers, and if they came, they went very quickly again.

There seems to be no trouble about people getting extractions. The difficulty is in regard to having plates and dentures made. There is an association with headquarters here in Dublin which covers the technicians who make these teeth. This is a recognised body and they are permitted to make dentures and to fit them. In no case do our country dentists do anything other than take the impression and send it off to these technicians and wait until it comes back by post. If the teeth do not fit properly, they may file them if it is a minor fault, but if it is anything serious, they must send them back to these technicians to get them reshaped or re-done in some way. The people who really do the work are not permitted by law to do this thing except through a dentist, and it is certainly a restrictive practice. I would recommend to the Minister to read, if he has not already done so, the Journal of the Irish Dental Association which has an article in the December, 1965, issue on auxiliary dental personnel. It lists three categories: dental technicians, dental mechanics and dental craftsmen. There is another category composed of dental surgery assistants, chairside assistants and dental nurses. They have divided their assistants or helpers into four categories, two of which are not permitted to go anywhere near the patient and two of which are permitted to be in the extraction room and, to a limited extent, to give care of the mouth and, in certain cases, to go and examine school children's teeth and recommend the defects to surgeons or that a further check is necessary by a dentist.

It should be possible to speed up the supply of dentures. It is most unedifying, when a woman gets all her teeth removed at the age of 35 or 40 years, that she has to go through life without dentures, with consequent danger of having stomach trouble because of not being able to masticate her food, all due to the fact that she has not sufficient money to provide dentures.

Dentures as provided to health authorities can be made at a very reasonable price. I happen to know because at one time I was chairman of a health authority and had to sign the contract documents. I was amazed to find the difference, not in quality but in price, between the dentures supplied to one of our patients and those supplied to a private patient. It would make one wonder either how the technicians were able to make them so cheaply or how dentists with private patients were not able to retire from dentistry after a very short period of years having made more than enough to keep them for life.

The proposed ophthalmic and dental facilities are all for the future. We welcome any improvement in these but I suspect there will be a considerable delay before they will be implemented. We regard them more as a principle accepted and as something which will be given, when funds will be available. The immediate thing is to establish a system of priorities and try to give the most needed things as quickly as possible.

In regard to the control of pep pills, I do not know why the Irish Times selected that as one of the highlights of the Minister's White Paper.

Mr. T.F. O'Higgins

It is the only new thing in it.

Mr. Kyne

I would have regarded it as not of the greatest importance. It is certainly a good thing that there should be some limit if there is danger involved for the health of teenagers, dance band leaders or other people who take them. I do not bother about them beyond an odd Aspro. That meets my requirements. I am not an expert on these things, but if there is need for control, it is desirable to introduce it without delay. It certainly will not cost a great deal.

The screening of certain diseases such as cancer and various other things is also dealt with. That is an extension of the infectious diseases section. Anything that will help early diagnosis so that treatment can be effective must be welcomed by everybody.

I should like to deal with the cost of the extension of general medical services to all classes of the people, that is, the right, say, for all the people to have a free GP. I know it will be said we just cannot afford that, that it is impossible to give all the people a free service. We are giving a hospital service to 90 per cent of the people. It is true there is a limited charge which, as the Minister pointed out, is not a very serious one but which brings in a certain amount of money. When anyone proposes that a GP service should be given to all the people, we must realise that there is a percentage of higher grade people who will never accept health services. They just will not go in with the common herd. If they feel like that and have enough money to pay up, I have no grievance on their account. It is their privilege if they want to pay for exclusive attention.

The suggestion is to give free medical service so that people can call the doctor when they need him without thought of how much must be paid or whether it is possible to pay him at all. This is quite a big factor with ordinary middle-class people. I do not know what doctors in Dublin charge per visit but I think it varies according to the doctor, from as low as 7/6d to 12/6 per visit. I know that in the country, certainly in my area, and I can say this without fear of contradiction, the charge is £1 per visit to the house, irrespective of how many times the house is visited in a week. If a doctor is necessary for a middle-income group person, if his wife or child is ill, and if it requires 10 or 14 visits by the doctor to the house, it is £1 per visit, and very often it is £1 if you attend at the surgery and 30/- if the doctor comes to the house, depending on which doctor you get.

I do not think it is proper to say, as the Minister said in the White Paper, that this is not a factor in the lives of the middle-income group. I know of cases were people have deliberately gone without medical service because of that very fear. They could not pay for it and thus were deprived of it. I should like to read from a Tuairim pamphlet which deals with this point as I think it is worth quoting. "Wealth Producing as well as Health Producing" is the heading and it says:

It certainly shows a superficial grasp of the functions of the social services to regard them as a dead weight on the productive members of the community by which the unproductive—those no longer able to work—are supported or helped. For the social services, and especially health and education, pay partly if not wholly for themselves; they can be, in other words, an economic investment for a community.

Health services are wealth as well as health producing; they add to the national product in many indirect ways; they reduce the death rate, make for a larger and more efficient labour force and greater output per head by workers; they reduce the number of work-days lost to the economy by absenteeism due to illness, many times more serious than the loss caused by the industrial disputes so often deplored in the press.

Many people, who say the country cannot afford it, forget that if this service is paid through the rates and if it is costly in taxes and contributions the national economy so benefits that we can get back practically all we lose. The article goes on to say that indirectly even the payment of benefits to people incapable of work may have favourable reactions on the health and well-being of the next generation of workers. Not only does it pay dividends in the present generation but it can be reflected in a stronger and healthier race of children.

The Labour Party programme for the extension of general medical services to all the people is something that will come. We may delay it, but every country in Western Europe is heading in that direction and the programme, as outlined by the Labour Party as far back as 1958, will in time become the policy of some Government here and certainly the policy of a Labour Government, if and when we assume power. The question of whether we can afford it has been mentioned. As I understand it, at present we pay some £30 million for health services. That may not be the exact figure but it is in that neighbourhood. Now we shall pay another £4 million or £5 million for these improved services, making £35 million. In Northern Ireland with approximately half our population it costs, I think, £25 million to give all the health services they ahve which include all we are seeking, free GP service, hospital service, dental and optical treatment and so on. Assuming that with double the population here the expenditure would be twice as much, that would be roughly £50 million. That is a pretty big figure but we are already spending or proposing to spend £35 million. It would mean increased taxation in some cases but I think it could be met to a limited extent, to the extent of £5 million or perhaps £10 million by the payment of contributions by employers and workers and by State grants.

There will be certain areas in rural Ireland where the dispensary system will be retained and the doctor will compound medicine and make up prescriptions. In other cases, in rural towns and villages, and so on——

Mr. Kyne

They would be so near civilisation that they would be able to go to the nearest pharmacist. I think that will cover it. I do not want to cross-examine the Minister and perhaps when he is replying, he could answer this question. How soon does he think he will be able to cover the question of eligibility for medical cards? This is really a burning question and every day we have people saying to us: "Look, my next-door neighbour has a card and her husband is earning just as much as mine is, and in fact we have more children than she has, and they have a car——"

Mr. S. Collins

If they eliminated some of the inquisitions, it would be far better.

Mr. Kyne

It would be a good thing if a directive could be issued to county managers to indicate some limits on eligibility so that people would know where they stand. There are, of course, always the hard cases and you must leave the manager a right——

Mr. P.J. Burke

A discretionary clause.

Mr. Kyne

Yes, he must be left that. Some kind of a flare-up may be necessary to avoid all the annoyance that members of health authorities, Dáil Deputies and, I am sure, anyone in any position dealing with local authorities go through. It would be a great help, indeed, if the Minister could speed up a decision on this.

I am keenly interested in the conditions obtaining in the nursing profession. I always have been and more so now because I have a daughter who is a nurse. I felt that nurses were the Cinderellas of the medical profession, notwithstanding the fact that were it not for their zeal and attention much of the medical skill which goes into bringing patients back on the road to recovery would be wasted.

I am afraid that in many of our hospitals nurses with four or five years' service and who have to have a high standard of education, at least the leaving certificate, are asked to do very menial tasks. It is very wrong that a nurse should have to do such things. It is a waste of a nurse's time because many of those duties could be performed very well by hospital orderlies or girls who have no medical skill. Indeed, in some of our smaller voluntary hospitals some of our student nurses are expected to do very degrading work. In the best interests of the profession they should not be asked to do such work. This drives people from the profession who would otherwise stay on and be very useful to society.

The pay which nurses receive is completely inadequate. The nursing profession, unfortunately, suffers from the defect that they believe that theirs is a vocation as the secretary of their organisation reminded me one time when I suggested that nurses had only themselves to blame because they did not go on strike. She said: "Mr. Kyne, ours is a vocation". I said: "If it is, why are you worried about getting paid for it? If your organisation said to the health authorities that on and after a certain date, unless certain conditions and improvements came into operation, the officials would have to do the nursing themselves, I think you would have done much softening up." I still believe that. We would all deplore a situation in which attention was withdrawn from any patient in hospital. Because people are devoted enough not to take advantage of what they could do and go on strike, there should be some system of arbitration whereby their case would be dealt with fairly and honestly.

Some of the hours nurses work are incredible. I know Dr. Browne did an excellent job for a start when he reduced the hours from 48 to, I think, 45 at present. The 45 hours are very broken up. In the case I am thinking about nurses start at 8 and finish at 2 or maybe 2.30, depending on whether a doctor comes in to see a patient. They get a break from then until 5 but when they take their dinner break out of that they have but two hours. You cannot go to sleep and have recreation in two hours. The nurses go back from 5 o'clock to 8 o'clock. Then there is night duty which is from 8 o'clock at night until 8 or 9 o'clock in the morning. If an ambulance calls you may be out two or three hours longer. It is true that they get this time made up but that does not compensate for the irregular hours.

The pay given by local authorities— it is better than that given in the voluntary hospitals—is very poor. The Minister should endeavour to see that the scale of pay, the time and conditions of service are improved so that they will be a credit to the health authorities. Indeed, I regret very much, when the Minister visited our county home at Dungarvan, that I had not an opportunity of meeting him there. I am afraid that because his visit was short he did not have time to see things. There are things I could have told him about. Indeed, I intended to do so but I missed him. I was there before he came and after he was gone but not when he was there.

The nurses live in the town and they have to cycle to work, a distance of probably a mile, in windy weather or in rain. They have not even a place to change their clothes. They have to change in the kitchen. There is no place else to change. If they eat a meal they have to eat in the kitchen. There is no place to put their bicycles, no rest-room and no special wash-up in the hospital. The hospital attendants and the nurses have to use the one toilet. When they made a protest to the local authority all the satisfaction they got was a reply to say that the letter was noted. Indeed, I intended to draw the Minister's attention to this by way of a Parliamentary question or by a letter asking him to investigate the conditions under which those qualified girls have to carry out their duties.

I do not know whether the Minister was in office when I raised this matter last year. I refer to the International Health Conference held in Germany. A number of nurses in the Dublin Health Authority applied for leave of absence to attend it. They were travelling there at their own expense. They were not asking for anything other than permission to attend the conference. I think it was in Berlin. At least three of them applied from St. Mary's and various other hospitals. They were refused permission to go. They went but they had that stopped out of their holidays, notwithstanding the fact that some of the officials of the Dublin Health Authority, who were not nurses, or connected with the medical profession, were there. Not only had they not to take it out of their holidays but they went at the health authority's expense. Nurses who are willing to pay their way to a health conference so that they may learn something and keep up to date with progress in the medical and nursing professions should, indeed, be encouraged rather than hindered, as they were in this case.

I put down a Parliamentary question in regard to this matter and I think the answer from the Dublin Health Authority was that the applications were not received in time. The applications were in long before there was any need to have any decision at all. In fact, they were in for months before the conference took place. The officials made no application at all. They were simply appointed and sent out.

I appreciate the Minister's consideration for the aged. I want to pay a tribute again to the Friends of St. Martin as well as to the voluntary organisations. In areas where it is not possible to get volunteers to visit aged people, maybe to wash and tidy up a patient, partially trained girls would be quite suitable for this work. They do not need full nursing qualifications to help old people. Indeed, the district nurse's duties very often consist of work which could quite easily be done by untrained assistants. The local authorities should be encouraged to employ that type of help for old people Those people could visit the homes, tidy them up, prepare meals and do ordinary tasks which are necessary and they could leave the nursing to be carried out by the district nurse on her visits.

There is one thing in connection with the voluntary health which the Minister spoke about and I want to say it will be very hard for him to look for help from voluntary organisations in so far as the Civil Defence groups, who have ambulances and various other medical equipment are concerned. They have refused completely to co-operate with anyone dealing with the aged or, indeed, the lonely people. I know of an organisation that went to the trouble of taking some old people on an outing. They gave them a picnic at a seaside place in County Waterford and they sought a loan of some equipment—I think it was a field kitchen—from the Civil Defence authorities but under some Army regulation it was refused.

I wonder would the Minister endeavour to see the Minister for Defence and get a loosening up of whatever conditions there are which prevent the Civil Defence unit from lending either ambulances, field equipment or other equipment? One would think that using their ambulances for that type of work, either on the field or to transport old people, would form a part of their training in that respect.

It will be very hard to get voluntary organisations to co-operate and help out our local health authorities, unless our State-sponsored organisations, which again are not voluntary but are uniformed and financed by the State, do so. Unless they do it, you cannot expect the voluntary organisations to give the one hundred per cent co-operation they wish to give.

The question of the charge of 10/-per day was pretty well dealt with by Deputy Fitzpatrick (Cavan). I shall not prolong the House by dwelling on that. Indeed, I know he was quite correct in saying that, of the £500,000 collected, 50 per cent goes in administration, in collection. That is so in certain areas because I have had the figures examined. Certain health authorities anyhow estimate that 50 per cent goes between solicitors' fees, postage, investigation, medical officers, health inspectors and all the people who have to travel around. Indeed, in most cases the repayments are completely forced on the health authority because of the inability of the people to pay. I have seen people getting a bill from a health authority running up to £40 or £50 when those people had not 40/- or 50/- to their name. There was more expense involved in investigating it than would pay the bill itself. I know of one case where a man was asked what was his income, would he get a certificate from his employer to show his income for the year and then, would he get a certificate from his employer to show his income plus his overtime. The employer said: “I would rather pay the bill myself than have all the trouble you are giving me”. That is all added expense.

Even if the Minister feels that some money must be obtained, would he not consider the simple expedient of adding something to the social welfare scheme and so cover all people in hospital? He could collect it that way quite easily. People would pay it, as they worked, and they would not have the worry. I get continuous letters from women saying: "I hope my husband will not be in hospital long because we have not got the money to pay the bill."

Mr. Corish

It stops them from going for operations.

Mr. Kyne

It makes them anxious to get out of hospital and gives many a woman indigestion. You know how scarce money is when a man is out sick. He is on social welfare; he has not enough to keep his children, never mind himself and his wife. At the end of that, he has to face up to a bill——

Mr. O'Malley

If he is on social welfare, he should be charged nothing.

Mr. Kyne

He is, unfortunately.

Dr. O'Connell

Obviously, he is on social welfare if he is sick.

Mr. Corish

Deputy Kyne's point is that pounds are wasted investigating it.

Mr. Kyne

I wonder if the Minister got the circular from the Medical Union in connection with remuneration?

Mr. O'Malley

Yes.

Mr. Kyne

I was particularly interested in it. I intend to deal only with the first part of it. It commences by saying:

In view of the proposals in the White Paper, it is pertinent to consider the various ways in a scheme of socialised medicine in which doctors might be required to carry out their duties. In doing so one must consider the experience of other countries and bear in mind the doctor's position, having regard to the system of remuneration adopted and how such system affects ...

and then they list four points. These points are so interrelated, they cannot be taken separately. Point (1) is: The doctor's professional work standards. That is one of the considerations which must be taken into account. Surely a doctor is expected to live up to his profession, to give as good a service as he is capable of giving? I cannot see what other way he would give service. Surely it is not suggesting that if he does not get a special type of pay, he will give a substandard medicine? I would hope that very few doctors would accept a contract if they were not satisfied with it, and if they did accept a contract with which they were not satisfied, surely they should not take it out on the patient by giving him substandard medicine?

Point (2) is: his work load, including administrative duties. Surely the capitation system would take care of that, and there would be a limit on the number of patients he would be permitted to take? If he exceeded that, he always has the power to take in a partner and have a rota system of some sort. Point (3) is: the doctor-patient relationship. I would imagine that a choice of doctor and, perhaps, the doctor having a choice of patient, should take care of that.

I suspect that point (4), his net income, is really the big point. Surely that is a matter between the doctors and the Department? I am sure the Medical Union and the IMA are very well able to put their case. Just like nurses, they should not be deprived of the right to get a proper income. They should be paid for their services. They do a wonderful service, a service we all value when we need it, and all of us hope that we shall never need it. Just the same, it is desirable that there should be goodwill in the medical profession because, if we are to have a socialised State-sponsored health service at all, we can have it only with the goodwill and co-operation of the medical profession. I am sure it is the wish of everybody in this House that good relations should continue to exist between the Department and the medical profession. I am sure the Minister will endeavour to establish these good relations.

I should like to conclude by complimenting the Minister on his personal views on the needs of the people of the country as regards medical services. I believe the Department is in good hands in his care and I can assure him he will get the fullest co-operation from the Labour Party. But, while we are satisfied with everything the Minister proposes to do, we are not satisfied that he is doing everything we would like him to do.

Parliamentary Secretary to the Taoiseach (Mr. Carty)

First of all, I must congratulate Deputy Kyne on his forth-right and down-to-earth approach to this problem of the health services. I was particularly gratified that, even at this late hour, a tribute was paid to the work of the Select Committee on the Health Services, of which I was Chairman. Deputy Kyne said—and I think it holds for all of us—that we got a lot of useful information about the operation of the health services during the couple of years the Committee met. He stated—and indeed it could be said of many others of the Members—that he travelled many miles, at great inconvenience, to meetings of that Committee. We met in rather difficult conditions, oftentimes outside Leinster House, and we had to leave these other establishements to come back to the House in the event of the bells ringing. We had many other difficulties to contend with, but, by and large, we did learn a lot about the health services and from that pool of information the Minister has admitted that he drew a lot in formulating his proposals for the White Paper.

I listened to Deputy Fitzpatrick of Fine Gael stating that the Fine Gael policy will be based on socialised insurance or, perhaps, he used the words "social insurance." I have followed as best I could the information that emanated from time to time from Fine Gael on their insurance policy and I must say that I am at a loss to understand what exactly Fine Gael have in mind. I have here a copy of part of the speech made by Deputy Declan Costello on 1st June, 1965, as reported in Dáil Debates, Vol. 216, Columns 58 and 59. He says:

There is only one way we can extend the health services to give the people what they need, that is, through health insurance. They have done it in other countries. There is no way in which we can bring about the necessary reforms unless we use health insurance and I give the Minister a guarantee not only on my own behalf but, I feel certain, on behalf of all my colleagues, that we shall forget what the Taoiseach and the former Minister for Health said about the insurance principle and shall not refer to it again if in fact he accepts this principle and brings it in because there is no other way of doing it, taking into account the standard of health of the country, our system of payment to the health authorities and general level of taxation.

Then he goes on:

If we had a system of health insurance, it would mean there could be a free choice of doctor for all. It would mean there would be free treatment in hospital for all insured persons. It would mean giving a free general medical practitioner service.

He goes on to say:

When I say "free", of course, I know Deputies will understand exactly what I mean. We have never said the services can be provided otherwise than by health insurance and have suggested that the people would willingly accept the need for a weekly contribution in respect of the services they would be given in return.

Later on, also on 1st June, 1965, in columns 97 and 99 Deputy T. F. O'Higgins said:

We can, of course, do it without difficulty provided people are rational and do not close their minds. We can do it by insurance. I do not believe we can do it otherwise. It was unnecessary, and I think politically unsound for the Minister's predecessor to endeavour to intimidate and frighten people by picking figures from the sky and saying: "This is going to cost £34 million or £35 million".

That is exactly what it is going to cost now. He goes on:

The need and the object of these proposals is to provide a cover in relation to personal health services, that is the services of the individual outside hospital when he is sick— nothing more than that.

How can these two statements made by two responsible spokesmen of Fine Gael, one the former Minister for Health and the other the spokesman for Health and Social Welfare of the Fine Gael Party be reconciled? He goes on to say:

Our proposals related to personal health services and we can cover these and extend them and improve them on the lines of insurance.

What exactly do Fine Gael mean?

Mr. T.J. Fitzpatrick

(Cavan): That is it: cover them and extend them and improve them.

Mr. Carty

There we have it. I will read these two again for you. On the one hand, we had Deputy Costello saying:

On the other hand, we have Deputy T.F. O'Higgins saying:

Nobody contemplated or suggested that the hospital service should be run on insurance lines.

What is one to draw from these two statements? Deputy O'Higgins went on:

but it was not part of, or in any way concerned with, the proposals we made.

Fine Gael do not know what they are talking about and then how are the people to understand or know what they are talking about? Deputy Costello says: "A free hospital service" and Deputy O'Higgins says: "No hospital insurance service". Where are we to find out what they mean? Deputy O'Higgins says that it is nonsense to talk of expenditure of the nature of £34 million or £35 million but expenditure this year is running at the level of £30 million and with the improvements envisaged in the White Paper, expenditure will run to £35 million or £36 million.

I propose to deal briefly with the proposals outlined in the White Paper on the Health Services and their Future Development. Part I of the White Paper deals with the development of the present services which is of academic interest to us. We know that they developed, as Deputy Fitzpatrick has said, from the poor law system. We carried out great improvements in the Health Acts of 1947 and 1953 and we know that there will be further improvements and developments with the growth of preventive medicine.

I would like to concern myself with the things of which I have some knowledge, having served on a health authority for some 21 years. The first question is in relation to the eligibility of persons for the health services, Valid complaints have been made that there is no uniform method to determine who is entitled to have his name placed on the general medical register. I remember that in 1952 and 1953 when Deputy T.F. O'Higgins was Minister for Health, he paid a visit to us in Galway and addressed the health authority there. He asked the county councillors to indicate to him what they thought would be a proper basis for the determination of who should get health cards, what the income should be in the case of a single person, what the family income should be, what the poor law valuation should be.

It was impossible, and I think it still is more or less impossible, in relation to farmers, to say in terms of poor law valuation who should be entitled to a medical card. It might be possible to do something in relation to personal income or salaries. That, of course, would vary from area to area. I assume it would be harder to live on £x income in Dublin than down the country. I accept that, but in relation to farming, we are immediately presented with a difficulty because the poor law land valuation varies so much from district to district. In one place land might be valued at only 5/- an acre, and in other places, depending on the former landlord, it might be valued at £2 per acre, and oftentimes it is, in various parts of Ireland, I understand.

The Minister has stated that he proposes to specify certain limits or certain standards in relation to incomes and to farming. I hope he will be successful. If he is, I feel sure he will go a long way towards solving the problem, but if that could be done, it would immediately let many people know whether or not they are entitled to medical cards. As the previous speaker said, oftentimes people come to us and say: "My neighbour has a medical card and my circumstances are more or less the same. I have a more or less similar job. I am earning more or less the same weekly income. I have the same number of family dependants. How is it that he has a medical card and I have none?" By laying down certain standards—if they could be laid down—the Minister will go a long way towards solving the problem of convincing people that they are not losing something to which they feel they are entitled, and in respect of which they feel they are being deprived of their entitlement by a decision made by the health authority, which means the county manager. If the Minister succeeds in doing this, he will achieve a great deal.

Deputy Kyne expressed the opinion that while this might facilitate matters and grant an easement to certain people, he could not see the total overall figure rising much above the 30 per cent at which it is at present. I doubt that. I think it might rise to a higher figure of the population. There is one thing that amazes me in relation to these medical cards. It is something I noticed this evening when I was having a second look at the figures given in the White Paper. I see that in a county like Leitrim, it is——

Mr. T.J. Fitzpatrick

(Cavan): 24 per cent.

Mr. Carty

In the county of Leitrim, 8,193 people are covered by medical cards. That represents 24.4 per cent of the population, that is, one out of avery four people in Leitrim, which is one of the poorest counties in Ireland, is covered by a medical card. The figure is somewhat bigger in Sligo which is an adjacent county. It is 28.2 per cent.

Mr. T.J. Fitzpatrick

(Cavan): In Kilkenny, it is 43.9 per cent.

Mr. Carty

I do not know much about Carlow but I should imagine that the people there enjoy a higher standard of living, and are certainly more prosperous than the people in Leitrim, and in Carlow, 47.1 per cent of the population are covered by medical cards. The ratio between Carlow and Leitrim is two to one. That cannot be justified. There cannot be a different standard in Leitrim for determining entitlement to medical cards.

The figure for Cork county, excluding the county borough, is 25.1 per cent. For Dublin county borough, it is 16.2 per cent. In many counties the figure ranges between 30 per cent and 40 per cent, and the highest proportion of all, I think, is in County Carlow where 47.1 per cent of the population are covered by medical cards. In his proposal the Minister seeks to establish a more or less uniform system for determining entitlement to these cards. Whatever efforts he can make, and whatever he can do to bring that about, should be commended, and I wish him luck.

In my opinion, many people look for medical cards when they are faced with a period in hospital. When the father of a family is told he has to go to hospital, and that he may have to spend a lengthy period there, or when he is told that his wife or one of the children has to go to hospital, he then, and not till then, looks for a medical card. He regards it as a form of insurance—if I may use the word not in the Fine Gael sense—against hospital maintenance charges. He looks for the medical card and he gets it, and that entitles him and his dependants to free hospitalisation. In many cases the father has no objection to paying his local doctor whose charges are oftentimes very modest, but he certainly is a bit diffident about facing the hospital charges, particularly if his period in hospital is to be of long duration. The Minister is to set up standards for determining entitlement to medical cards and I welcome that so far as it will be practicable.

Dr. O'Connell

What the Parliamentary Secretary has said justifies what we have asked for: that hospital charges should be abolished.

Mr. Carty

I will come to that when I reach it in the White Paper.

Dr. O'Connell

The Parliamentary Secretary has reached it. He has said that hospital charges are the biggest worry.

Mr. Carty

Mr. Corry

Let the Deputy read all about the Verolme Dockyard.

Mr. S. Collins

I was not referring to the Parliamentary Secretary.

Mr. Carty

I was referring to drugs, medicines and appliances, not to the Verolme Dockyard. Many people look for a medical card for the reasons I gave. Many people feel that the cost of a supply of drugs, medicines and appliances will be a cause of great hardship to them. In the White Paper, the hardship clause referred to by Deputy Kyne and issued in a circular in June, 1964, is to be continued on a much broader basis. That will be welcomed by most people. Many of the antibiotics, the wonder drugs of today, are very costly and on a tight income or a modest budget, 30/- a week for drugs and medicines could be regarded as severe hardship on a young family. The Minister is to be congratulated for continuing the hardship clause and making it apply to people of that kind.

The White Paper also mentions the practicability of providing a choice of doctor. During the sessions of the Select Committee on the Health Services we heard evidence from many responsible bodies, and others sent us written submissions. Quite a number of those bodies stated they were in favour of a choice of doctor, particularly the trade unions, the Congress of Trade Unions, the Irish Transport and General Workers' Union, the IMA —we did not have evidence from the Irish Medical Union—the Dublin Health Authority—they came out very strongly in favour of it—the Dublin Council of Trade Unions, the Limerick Health Authority and the Association of Medical Officers of Health. Most of them recommended a choice for the lower-income group within the proposed scheme and some of them recommended an extension to the middle-income group.

I think the Minister was right in confining it to the lower-income group because the middle-income group are in a better position to avail of choice of doctor. They are not as confined to a dispensary medical officer as are those in the lower-income group and the cost of an extension of the choice of doctor to the middle-income group would be out of all proportion to the anticipated benefit. Although most people in the lower-income group have received excellent care and attention from the district medical officers, for many reasons some of them did not feel they were getting the best service. There might have been some little nark, something that made it awkward for them to attend the doctor locally, some little row. They should be given a free choice and they are now to be given that choice at a cost of something in the region of £1 million a year.

The Parliamentary Secretary has been a long time a member of a health authority and the Deputy would be surprised at what he understands. I am pleased to know the Minister proposes to abolish outpatient specialist charges. There used to be a charge of 2/6 to 7/6. There is mention in the White Paper of choice of hospital. That is something that has concerned me over the years. I know doctors in my area would like to send patients to a particular hospital rather than a local hospital but they are more or less hamstrung. They would, perhaps, like to send the patient to a voluntary hospital in Dublin where there was a specialist with a particular reputation. I say that without casting any reflection on the local surgeons and physicians. But the doctors who wish to do that were frowned upon by the administrators of the local authorities. If a local doctor is part of the service, he should have a right to send a patient to the hospital with the surgeon or physician of his choice. I now read in the White Paper that this is contemplated and I welcome it.

Mr. P. Hogan (South Tipperary)

Could the Parliamentary Secretary give me the reference in the White Paper?

Mr. Carty

Mr. James Tully

We will revalue the whole lot if you do that.

Mr. Carty

That assurance will be appreciated very much in the western countries, the counties which have worked so hard to promote better health services.

Reference was made to the need for a change in the administration of the services and the setting up of regions throughout the country as single entities for the administration of the services. Any step in that direction which will effect economies is to be welcomed, but I should like to be informed as to how it will operate. I should like to know how the proposed new bodies will be constituted. If the State is paying a bigger proportion of the cost of running the services, it would certainly be entitled to increased representation. However, I hope the Minister will give the local bodies a majority because local bodies generally—this has been my experience— are very careful about expenditure. When the rates come to be struck, estimates are prepared and there is a detailed examination of all the items making up the expenditure. That will be done on these new bodies if you have on them a majority of solidheaded country councillors.

Mr. S. Dunne

"Solid-headed" is right.

Mr. Carty

The country councillors, whether Fine Gael or Fianna Fáil, are used to that kind of examination and they will prune all unnecessary expenditure. I welcome this White Paper. I believe a great deal of good will come from it. Hospital and other services will be improved. In particular, I welcome the references to the Select Committee by Deputy Kyne. He was the only speaker so far who had a good word to say about that much maligned body.

Mr. P. Hogan

(South Tipperary): This White Paper is a classic example of Government by Opposition since, as Deputy Fitzpatrick put it, it represents the first instalment of Fine Gael health policy. I was a member of the Select Committee. The former Minister for Health was also a member. It was chaired by the good-natured Parliamentary Secretary, Deputy Carty, in so far as the less good-natured Deputy MacEntee would allow him to be chairman. We took a great deal of evidence and, towards the end of our deliberations, it certainly looked as if Deputy MacEntee was inclined to drag his feet; first Labour left the Select Health Committee and finally Fine Gael.

At the penultimate stage, no meeting was held for about ten months. When Deputy MacEntee was questioned by Deputy T.F. O'Higgins here in the House, he replied that the reason was obvious: the Dáil was being repaired and there was no place to meet. That was a rather weak reply and it was apparent to me that, at that stage. Deputy MacEntee had virtually lost interest in the Select Committee. In fact, at no stage was he prepared to agree to the ideas now adumbrated in this White Paper. He may have been acting as devil's advocate but he certainly gave the impression that he was against the proposals adumbrated in this White Paper. His attitude consistently was that there was not any great public demand for any change, the dispensary system was very cheap and it had the added advantage that you could easily sack the doctor.

There was a general election and the Taoiseach announced that Deputy

MacEntee was no longer seeking ministerial portfolio. At the same time, it was announced that Fianna Fáil would introduce a health system with a free choice of doctor for those who did not have that choice up to then. It is not clear from this White Paper what percentage of people will ultimately be covered. I do not suppose the Minister or anybody else could say at this stage what the figure may be. The lower-income group represents some 30 per cent of the population but, when one comes to examine the percentage in the different counties, and realises that there is such a small percentage on the western seaboard with health cards, it must suggest that, with a universal system of assessment, free of the restraints which must have operated in the minds of county managers on the western seaboard, the percentage will probably rise from 30 to 40. It is believed it will end up around 40.

The Fine Gael Party policy document advocated an 85 per cent coverage. I have never been able to decide why exactly they picked 85 per cent. I rather imagine it may have been to harmonise with the percentage of people in the lower and middle-income groups who are already entitled to a free hospital or near-free hospital service; it may have been expedient to have the same percentage of people entitled to free medical treatment outside hospitals.

Whatever may be the reason, I have no fixed mathematical notion about what that percentage should be, but I would not go so far as Deputy Kyne and say that there should be 100 per cent coverage. I certainly do not see any purpose in providing free domiciliary service for some man with two motor cars outside his door or some man who has got a status increase of £900 in the past couple of years. We are not such a poor nation as not to have ten to 20 per cent of upper income people able to pay and easily able to pay for their general medical services. I see no reason for providing 100 per cent coverage in respect of general medical services, unless one is a doctrinaire socialist, and if one is a doctrinaire socialist, one must socialise everything to the limit.

There are three cardinal points in this White Paper about which the Minister has not been particularly clear, although I admit he has difficulties. First, there is finance; secondly, remuneration; and, thirdly, coverage. I have not got the gift of prophecy but I believe that whatever coverage we provide now will gradually extend. It may start off at 35 per cent, go on to 40 per cent and 50 per cent. That has been the pattern in most countries over the years and this country will probably prove no exception.

In the long term, therefore, the Minister has not given us a method of financing the service that one could feel was completely satisfactory. All he has said is that he will freeze the health charge moiety on the local rates and that any further increase in health charges will be borne by central funds. He has not said how long that freeze will last or whether it will be removed in different circumstances in the future. Probably no Minister in his position could give us any reassurance over any considerable period ahead.

The Minister has not, as I have said, given us a percentage and is in no position to give us a percentage of the coverage which the scheme envisages. Furthermore, he has not given us any adequate indication of the method of remuneration of the doctors under the new scheme. He has mentioned as a possibility the capitation system, but he has also made it clear that at this stage his mind is open and that he is not tied to any particular method of remuneration.

The question of how any general medical service should be provided, how it should be remunerated and what coverage should be provided under it, are three important points which we are not facing now. We shall have to face them at some future date, and certainly if there is to be an agreement made with the medical profession on the question of remuneration, it will have to be faced immediately.

There are basically four methods of medical remuneration in operation in the world, extending from the Russian system to the American system, extending from the salaried system obtaining in Russia, where the profit motive is anathema, to the private enterprise system of the United States where everybody pays for everything. Within that broad spectrum of remuneration, there are all sorts of variations from the red of Russia to the violet or ultraviolet of the United States.

The system of financing medical services has, by and large, been a system of insurance, voluntary or compulsory, and the system of remuneration outside the two extremes, Russia and the United States, has been either on a capitation basis or a fee per service basis. In this country I think people in general are more familiar with the notion of a capitation system and that largely derives from the fact that the system is capitation in the United Kingdom. There was and has been for a long time in Great Britain a system of club practice. It was a poor system in which in industrial firms and at pitheads a few pence were collected to remunerate doctors and general practitioner services for the members. In 1913 an English Prime Minister whose name should be well remembered in this House, Mr. Lloyd George, introduced his national health insurance. It was called by the ordinary patient coming into the surgery "the Lloyd George." Every patient coming in immediately said" I am on the Lloyd George." That system covered insured persons but not their dependants and it continued for a number of years.

Doctors were still allowed to do private practice mostly upon relatives of insured persons and they could buy and sell their practices, but in 1948 Aneurin Bevan introduced the present national health service operated in Britain. The full national health insurance service was a compulsory insurance system and the new system introduced by Aneurin Bevan therefore was a compulsory insurance system covering 100 per cent of the population. It gave complete general practitioner and hospital coverage, with free drugs or sometimes a token payment for drugs. The question of drug payments has varied since the system was introduced. Various Governments have come and gone without altering the system except to alter at different times the drugs payment in order to prevent, as they maintained, abuse of the drug system. Specialists were paid on a sessional or sometimes salary basis. The doctors were paid out of a central pool.

Under the present system doctors are not free to enter the present insurance scheme: they must enter through a medical practitioner committee which is mostly composed of local medical practitioners. There is now no more selling or buying of practices. It is important that we should realise the implications of the British system because doctors are free to go to Britain from this country and vice versa. We must always secure that, whatever system we adopt, the livelihood given to doctors will be in some fashion comparable with the livelihood they can obtain in Britain if we are to hold the better members of the medical profession here. So far, I believe we have been happy in that regard. Many Irish doctors for one reason or another like to return here, but if medical services became unduly depressed here, that trend might not continue.

The capitation system in Britain has been reviewed by commissions and there are very mixed feelings about it. Personally, I think the income doctors enjoy there is quite good but I am also satisfied that the working conditions are not satisfactory. The capitation system, as such, leads to overcrowded surgeries, large visiting lists and to general abuse of the system by the public. Much of the dissatisfaction arising from the capitation system arises on the score, not of income but because the doctors feel they are not doing a worthwhile job. In some places it has become so bad, with overcrowded surgeries, that doctors find it very difficult to give satisfactory individual attention and they become, in effect, nothing more than signposts to hospitals. Before we talk about the capitation system here, we should weigh up these inherent defects. It is not because such a system operates in Britain that it would necessarily be the system for this country.

I have examined some of the systems operating on the Continent. Whether our proposed entry into the Common Market has any bearing on the medical systems obtaining there I do not know. Deputy Kyne already briefly dealt with the type of practices and the methods of medical control in some European countries. When you pass from Britain, the next country you meet which has a capitation system is Holland where they have compulsory insurance of employed persons up to a given wage limit and there is provision for voluntary insurance for others, providing coverage for 70 per cent of the population. Payment is on a capitation basis, with special fees for maternity work.

Holland is a country of about 11 million people, with a substantial agricultural community, not as big as ours, 20 per cent. There is an industrial population of 40 per cent. The medical system there follows largely the British pattern in that they have general practice, public health system and hospital system, a tripartite arrangement which is characteristic of British medicine and characteristic of our own medical services. They have 93,000 hospital beds or 8.2 per 1,000 of the population, considerably less than we have. We have more beds than any country in the world. Deputy Kyne thinks that is good but I should not be prepared to agree with him. I have always felt that what we want is fewer and better beds.

Mr. James Tully

All Odearest mattresses.

Mr. P. Hogan

(South Tipperary): As in Britain, no fee is payable by insured persons and specialists are paid not on a sessional basis but on an item-per service basis. The system is administered by insurance funds, not as in Britain, by the State. That is the other country which is predominantly worked on a capitation basis.

Germany has a very complex system worked out in great detail, very formalised and typical of the Germanic mind. It sprang from the guilds, the friendly societies of the Middle Ages, and it was the first country to introduce a compulsory medical insurance system as we know it. It was introduced by Bismarck and that is the system which Lloyd George later imitated and modified when he introduced his own insurance system in 1913. It is, as I said, a complicated system, but it is basically a fee for service system and the benefits are both in cash and in kind. By that I mean that there are medical benefits and also cash benefits and the insurance is compulsory. In Germany, there are 70,000 doctors and of the number of independent doctors, about two-thirds are general practitioners. The system is financed on the insurance principle, employer and employee solely paying insurance, and the employee's contribution is based on a percentage, usually seven per cent or eight per cent of his basic wage up to a certain limit, and there is no Government contribution.

Denmark, in contradistinction, has a voluntary insurance system for about 90 per cent of the population and its medical profession are remunerated on both a fee for service and a capitation system. It is financed to the extent of 70 per cent by the members and 30 per cent by the State. The State's contribution is partly central and partly local. General practitioners enjoy a high level of practice. They do about half the maternity work of their country in their own homes and they have access to hospital and X-ray facilities. In fact, in Copenhagen, the insurance funds have provided a laboratory service completely for the general practitioners who are in the insurance funds. Specialists seek cases mostly by reference, in contradistinction to what obtains in many other parts of the Continent and the family doctor principle is preserved.

Partnerships are rare but they have introduced a duty doctor system which is operated particularly in the large cities and by which the ordinary practitioner does no duty work from 8 o'clock in the evening until 8 o'clock next morning. He is helped by a rota of doctors who are appointed for this particular work. They have divided the remunerative system into what they call Tariff 1 and Tariff 2. Tariff 1 is a capitation system which applies mostly in the bigger centres; Tariff 2, which is a fee for service system, applies mostly in the rural areas. The areas in which these particular systems are applied are arrived at by agreement between the medical association and the health authorities and if there is disagreement, there is provision for arbitration. There is some restriction on entry into practice in the larger centres, but not in Copenhagen, but there is no restriction on practice for any registered practitioner outside the capital. A fee for service system is arranged on an extensive, itemised tariff list and has a peculiar and unusual feature in that it is related to a retail price index.

In Austria, we again have compulsory insurance, free choice of doctor system, and remuneration is on a case payment method and also on a fee per service basis. That payment method is a modification of the fee for service system in so far as it extends halfway between the capitation system and the fee for service system. The doctors are paid quarterly on the number of patient cases which they have treated and not on the number of treatments they have given. Austria is a country somewhat like our own where there is a substantial rural population with, perhaps, an even larger capital, Vienna. The insurance companies there not alone provide funds for general practice but some have their own hospitals. One of the major accident hospitals in Europe, and one of the first to be regarded as an accident hospital, was founded in Vienna by an insurance company and was used as part of their benefits under their insurance system. Afterwards it was controlled and directed by Laurence Bohler, who ultimately became the Director of Fracture Services to the German army during the last war. The financing of the Austrian system is again half by the employer and half by the employee with very little subvention from the State. I may add that in 1939 the German system was introduced but it was ultimately re-cast as not suited to the conditions appertaining in Austria.

In Switzerland which, again, has a voluntary insurance basis for medical services, remuneration is on a fee for service basis. The insurance there covers about 70 per cent of the population. They also have provision, as indeed we have here under our own voluntary system, for a collective insurance system of insurance by groups in a factory. Again, with the number of hospital beds, the general pattern obtains, 9.5 per 1,000 of the population. In general, the figure is about 11.10 per thousand in contradistinction to ours which is somewhere in the region of 20.

There is no uniformity in the system in Switzerland in as much as it varies from canton to canton. There are 25 cantons in the country and three national languages. The general pattern, while varied, is a voluntary insurance system, which, of course, has a free choice of doctor. The system operates quite simply. As in all fee for service systems, there is no such thing as a panel list. The patient merely goes to the doctor of his choice. He pays his doctor, then goes to his local insurance office and is refunded the payment which he has made in whole or in part.

Sweden is often held out as a classic example of a socialist country at its best. Therefore, the Swedish system is worth examining. They have a compulsory insurance system with 100 per cent coverage. The system operates simply by the patient paying his medical adviser for the particular service and then being reimbursed by the insurance fund to the extent of 75 per cent of its cost. In most of those refund or reimbursement systems on which the fee for service method of remuneration is based, there is a varying amount to be paid by the patient, except those who are, of course, poor. This is regarded as being desirable, socially, even, for example, in a country like Sweden which is 100 per cent socialist. It is regarded as being desirable to prevent unnecessary abuse of the system.

Sweden has a slightly higher rate of hospital beds than some of the other countries. It has 15 per 1,000. Its hospitals are run on a county basis. They are financed by local rates and State grants, something on the same basis as our own. Hospital charges, again, are something on the same style as ours, in so far as they are very low. They amount to about one-tenth the actual cost. Social assistance is run by the communes.

Originally, the Swedish system was the insurance system and it had progressed to cover about two-thirds of the population a few years ago. It ultimately culminated in the introduction of the 100 per cent compulsory insurance system by legislation. Like many of those systems, as Deputy Kyne pointed out, there is fusion between the social services and the medical benefits. In most cases the insurance gives coverage, not alone for medical benefits, but also for cash payments during the period of illness. In the financing of the Swedish system the insured person pays 50 per cent, the employer pays 25 per cent and the Government pay 25 per cent, that is 2:1:1.

It is provided that the employee's contribution must not exceed two per cent of his taxable income. It will be appreciated, when I say that the employee must not pay more than two per cent of his taxable income, that the average income of a citizen in Sweden is pretty high. I understand they have a pretty high living standard. The employer's contribution is, equally, fixed at 1.4 per cent of his earnings. Pensioners, or low income people, make no contribution. The usual system in most of those countries for the people who are really poor is that they get their free choice by going to the local insurance doctor; he is refunded from the local funds and they, in turn, refund it from the home assistance service provided by the local communities.

While there is free choice of doctor in Sweden, it has got many remote areas. There are 2,000 doctors in general practice there but they have got 800 district medical officers and these men would correspond, I suppose, to our dispensary doctors. They are utilised to staff the more remote areas where medical men—if they had a free choice—would not be inclined to go. They have a similar system in England where they have, what they call, inducement payments to encourage doctors to practise in the more remote parts of the country and in places where their income would, of necessity, tend to be smaller. I imagine that the Minister will have to accept the position that he, too, will have to pay doctors by some such method to induce them to stay in the more remote areas. The natural tendency in a free movement system—which most of those countries have—is for the doctors to gravitate towards the large centres of population.

The district medical officers in Sweden are also allowed, of course, to have a private practice, again, on the free choice service basis on the reimbursement principle and, like our own dispensary doctors here, they have to provide a 24 hour service. The position of the patient is that he can go to any doctor of his choice, be he an insurance doctor, a district medical officer or a specialist, but the refund he gets is the same. If, on the other hand, he is referred to a specialist, he is allowed a larger refund.

Norway has a universal compulsory insurance with free choice of doctor and reimbursement of 60 per cent to 100 per cent on an itemised basis.

Mr. O'Malley

I must be stupid but what is the point of going over every country in Europe? I do not want to be rude or anything——

Mr. T.J. Fitzpatrick

(Cavan): On a point of order, the Minister has introduced a White Paper; he has asked for comments on it and for help on it. The Deputy is now giving him his experience and his study of the various systems in operation all over Europe. I do not think anything could be more helpful.

Sir Anthony Esmonde

The Deputy is trying to help the Minister on it and the Minister should be grateful.

An Ceann Comhairle

I think the matter is relevant.

Mr. P. Hogan

(South Tipperary): There are two systems of refund in operation in Norway. One is called the patient refund system and the other is called the doctor refund system. If, for example, the fee for a service is £1 and if, by agreement, it is arranged with the insurance funds, that the patient is entitled to a refund of 15/-, he may be refunded in two ways. He may go to the doctor of his choice, pay a £1 and then go to his insurance company and receive back 15/-. Alter-natively, he may pay his doctor the 5/-and the doctor afterwards collects 15/-from the insurance fund. That is called the doctor refund system. That second system probably suits the poorer type of patient better than the first. Both systems are in operation. It is quite a flexible service but the patient can elect to pay or be paid under either type of refund.

In France they have a compulsory insurance system again and, traditionally, the French are as individualistic as the Irish. There has been a considerable amount of discussion and agitation between the French medical profession and the French Government down through the years. The French system in general has been mentioned here amongst medical people on several occasions as one which might be desirable or appropriate in this country. It is an insurance system paid on an itemised service basis, with a percentage reimbursement from the insurance funds. It is financed mainly by the employer and the employee and, to a limited extent, by the State. In the medical forms used in the French system they have adopted a code to preserve professional secrecy. In the presentation of each service a code number is used so that professional secrecy is maintained and those operating the insurance fund are not acquainted with the particular ailment for which the patient is being treated. But there is a medical advisory service attached to each fund and the insurance doctor is obliged to discuss the diagnosis or treatment for which he claims payment with the medical authority who is appointed by the central authority.

Only two countries in the British Commonwealth have adopted an insurance scheme comparable with the continental one. These are New Zealand and Australia. New Zealand has a social insurance scheme covering the entire country and financed by a special social security income tax and by Government grant. There is free choice of doctor and payment is on a fee for service basis. The Australian system has been much discussed in medical circles here and an article on the matter appeared last summer in the Irish Medical Journal. It is a system of insurance and payment is on a fee for service basis. The Australian system seems to have given complete satisfaction to the public, the politicians and the doctors in Australia.

For years there was considerable disharmony about it and two Health Bills introduced were declared unconstitutional. It was not until 1950 under a coalition Government headed by Sir Robert Menzies that the present system was evolved. Menzies was assisted by Sir Harold Pagie, himself a medical man, who was Minister of Health and the present Australian Ambassador in Ireland was a colleague of his. The Australian system was introduced in stages. First of all, there was a pharmaceutical service started in 1950 through which they provided most of the antibiotics and expensive drugs. Later they introduced a pension system and in 1952 they introduced hospital benefits. In 1952 they introduced medical benefits covering general practice with which we are mainly dealing in this debate.

These services are financed by a voluntary insurance scheme which covers 71 per cent of the population. There is a 65 per cent refund of charges made by doctors to patients and it is hoped to increase that refund to 80 per cent. The general complaint is that the Government contribution has not been adequate. There is complete freedom of choice of doctor and the Government has remained outside the working of the scheme, has not tried to fix fees or intervene in any way. There is an itemised charge list covering about 900 services and, in effect, the patient still pays about one-third of the cost of his general medical attention.

I have endeavoured to cover in a rather brief fashion a rather extended subject. It will be clear that there is no uniformity of remuneration as from one country to another but, on balance, it would seem that the fee for service payment system is in operation for a large number of the population of this part of the world. On the one hand you have the Russian system, with which I have not dealt in detail, but which is on a purely salary basis under complete governmental control. On the other hand, you have the United States system which is a very intricate system with the exception of the Medicare system which the late President Kennedy, amongst others, helped to introduce to the United States.

I have stressed this question of remuneration and it may seem to the Minister that I have stressed it unduly. However, if he has been reading the papers recently he will have seen conditions in Belgium where the Government threatened to resign and the King had to intervene. It would be very desirable to introduce a scheme in which one can get medical co-operation. The success of any scheme will ultimately depend in a large measure upon the degree of co-operation forthcoming from the doctors who have to run it.

There are objections to the capitation system and equally there may be objections to the fee for service payment system. You cannot have free choice in any of the other systems. We are trying to provide a scheme for people who cannot pay their doctors directly and we are left with a choice between the capitation system and the fee for service payment system. A decision will have to be taken in this country if we are to have free choice of doctor for the lower income groups or any percentage of the people.

I have no very firm or preconceived notions as between one system and the other. I have worked under the capitation system and I have seen its limitations. Doubtless there are limitations to the other system with which I may not be familiar. In so far as the objective in any State system we provide should be to bring it as near as possible to private practice, then I would be inclined to think that the fee for service system is probably better. I am expressing my own personal view. I do not think Fine Gael have ever considered this, and I do not think that as a Party they have got convictions one way or the other on this. I doubt if Fianna Fáil are disthe other. It may be that the Labour Party may be more disposed to a capitation system. They have not said so. Deputy Kyne mentioned it, but he has not ruled out an alternative system.

On page 31 of the White Paper paragraph 42 reads:

The Government propose, therefore, that the general practitioner service organised by the health authorities should be re-arranged so that those whose medical care is paid for by the health authorities will be able to get the same kind of service as others can now get through private arrangement. This proposal involves substituting for the dispensary service a service with the greatest practicable choice of doctor and the least practicable distinction between private patients and those availing themselves of the service.

My own view is that a system remunerated on the basis of item per service would more closely approach that which obtains in private practice than a capitation basis where the doctor is paid so much per year per head.

We have a memorandum here from the Irish Medical Union and I think they, too, would fear that in the conditions obtaining here, particularly in the rural community, an item per service basis of remuneration would be more satisfactory. In some European countries they had a capitation system provisionally which in most cases has given way to an item per service remuneration system. By and large, the reimbursement system or refunding system, in so far as it is more closely related to the system of private practice and the independence associated with it, would appear to be the better of the two. I accept the fact that it may be somewhat more expensive. It depends entirely on the level of reto more abuses than the other system, because every system is open to abuse. Anything of that nature which is free or partially free is open to abuse by the public or by the doctors, but there are statistical controls which are carried out by the medical profession in most countries, and usually a word from the insurance fund that a doctor might be overprescribing or transgressing in some other way would suffice, and there is usually an arrangement by which the doctor could be brought before a disciplinary body of his own colleagues to be fined or suspended. That system is in operation in other countries and there is no reason why it could not be made to operate here.

I have little else to say on this White Paper. There are several other things one could discuss, or one might like to discuss, but we will have another opportunity on the Supplementary Estimate which will no doubt arrive later in the year to discuss the other aspects of our medical services. I should like to talk about the possibility of group practice and the question of our accident services. Both are subjects which need airing, review and discussion. Indeed, another matter which might profitably be dealt with is the medical education of graduates and undergraduates and perhaps the maternity services.

I spoke last year on the question of centralisation and decentralisation in our medical services. On that occasion I advocated the centralisation of our acute medical services on the basis that it was impossible to provide the type of services which modern society demands, and in view of the increasing specialisation in medical practice, to provide the type of service we would like to provide in small units. That day seems to be gone. The trend is otherwise and we cannot reverse it. Probably originally we were wrong to build the county hospitals because we cannot provide the medical manpower and the variety of medical personnel either financially or in the numbers we need in the present comprehensive services. What will have to be done in the years to come will be very difficult.

the two items together. I know that the

On the other hand, we probably centralise too much our chronic work in so far as we tend to perpetuate the old poor law system, the workhouse system, and to keep our country homes as large central institutions to which our old people are sent. About half of the cases in those hospitals are there for residential care, and about half can be classified medically as chronic. It is clear that they do not require any highly concentrated nursing services and it would be better if they could be sent to smaller centres near their own homes. The saddest feature of the county homes is the old people in them, 40 miles from their relatives and never seen by them again. Perhaps they pay them one visit and no more. We have many small district hospitals and I do not see why a ward in those hospitals could not be set aside for some chronically old people. Naturally, doctors like to have patients for whom they can do something, and the tendency would be for any hospital doctor to deal with an acute medical case in which he will feel the satisfaction of doing a good day's work, and consequently there is less interest in looking after old and feeble people.

We must remember that these people are our own, that they are with us, that we have a moral responsibility which we cannot avoid. In so far as we have to look after them. I believe the move to centralise them in country homes is a bad one. They should be kept as much as possible in their homes and when that is not possible the most desirable development would be to provide little homes within a reasonable distance of their old home where they could be kept with people whom they knew instead of being transplanted to central institutions which is too much for them.

Mr. James Tully

This debate involving the White Paper and the Health Estimate has developed into a spate of statistics which might be all right and probably is all right for those who are giving them. I think a bad mistake has been made in debating muneration that is agreed upon. I do not accept the notion that it is open Labour Party, Fine Gael and the Government agreed to have them debated together but when one finds an Estimate for £17,337,000 being debated in the House with scarcely a reference to the fact that the Estimate is before the House, and when one hears a speech from the Minister with a bare reference to the figure of the Estimate but with no comparison made with last year and no details of how the money will be spent, one wonders if the whole idea was to avoid going into details: "They will talk about the White Paper anyway; it does not matter about the Estimate". That appears to be the general approach and I am very dissatisfied that we have not got the usual details before us of an Estimate of such size.

I am aware that a few days ago the heads of the Estimate were published by the Department of Health but in his speech the Minister did not make any reference to any specific head. We just had repeated references to the White Paper. In so far as the White Paper is concerned, the first thing that struck me, having read it, was the similarity between it and our document of 1958. The Minister says it cannot be put into operation before November, 1967. That is a nice convenient date—leave it for two years and anything you say now will be reasonably safe.

Nobody can blame the Minister, having adopted that attitude, if he does not do something to put it into operation. I agree that the proposals in the White Paper are desirable: most of them are things everybody in the House would like to see in operation. If money is to be found for anything it should be found for the improvement of the health services. The Minister is as well aware of this and is as anxious to do it as we are. It appears that having drawn up this scheme and having spent, as we know he must have, a tremendous amount of time and study to produce the document— he says he did not see our document of 1958 and we know that to reach similar decisions to ours he must have spent a lot of time and study on it— it is just too bad the Minister finds the money is not available.

I do not blame the Minister for that. In fact, I am sure he is most anxious to improve matters. A disturbing feature is that at this early stage we have all the vested interests in the country trying to get their spoke in, trying to say what should and should not be done: "It is a good scheme but do not touch us; it is a good scheme but make sure the interests of certain sections are protected". Let me say at this stage that from personal knowledge I know that most of the dispensary doctors are dedicated men and women who do an excellent job, but included in the group are people who, while they are prepared to accept a reasonably well remunerated post with living accommodation, as soon as they get that post they start laying down rules under which they will attend or refuse to attend people who are unable to pay for medical attention. Whenever the telephone rings they are not available. The telephone may not ring at all or it may appear to be engaged. They are not to be telephoned after 10 o'clock in the morning except for private cases.

The Minister does not know of all those cases but it will be possible to give him details. There are doctors who have not got the necessary medicines. The dispensary depot where dispensary medicines are kept may not be reached. The doctor can only prescribe in such cases and the patients must go to a chemist and pay more than they can afford. These are things requiring immediate attention and I am very disappointed that no effort will apparently be made before November, 1967.

I think the three speeches we have heard—by the Minister, Deputy Fitzpatrick from Cavan and Deputy Kyne —were the best made in the House for a long time. I think Deputy Kyne's was a masterpiece, covering more ground in an interesting way than most people are capable of doing in a debate of this kind. However, it does not matter what speeches are made or what decisions are taken in this House as long as we have a situation where conditions are allowed to continue after our decisions have been taken. Something is very wrong. If a vacancy is declared for a dispensary doctor in any of the popular parts of the country, at least half a dozen applications are received and after the post has been filled the people who want free medical services will be put under a compliment before they can get them.

The vast majority of the dispensary doctors give excellent service but we have the few black sheep who made the last Health Act almost unworkable in the areas in which they operate and who will, despite anything this House does or the Minister may do, make the new Act unworkable. From the debate so far, it might be assumed that the only payment made to doctors is the salary for their posts. In respect of the insured worker who needs a certificate for the purpose of drawing sickness benefit, the doctor is paid from the insurance fund. There has been a suggestion that in future payments should be made by patients and three-quarters of it refunded afterwards. Do we not all know that people in this income bracket might not have the necessary money when the doctor calls and the doctor says: "It is just too bad. My fee is so much and I must be paid?"

That is the sort of thing we must guard against. Insured workers have been paying fairly hefty insurance. It is important that people who require medical treatment should get it, not because they hold medical cards or go to the doctor with cap in hand but because they are entitled to it as of right. Even if a little extra has to be paid for that treatment, the important thing is to preserve the patient's right to get it.

Reference has been made in a document issued by the Medical Union to this question of patients' rights. The way to preserve a patient's rights is to ensure he does not have to beg for medical treatment. Unless very definite rules are laid down by the Department, I am afraid when the new scheme is in operation, if ever, we will have the same system as we have now, where to my own knowledge a workman's wife was made to stand one and a half hours outside a doctor's door. Her daughter needed treatment and had been referred to the local hospital. She was referred back to the doctor for examination but it was not the dispensary day. Because it was not the dispensary day that unfortunate person had to wait an hour and a half until the doctor thought fit to attend. That is an isolated case. It only happens occasionally. But if it happens once a year anywhere in this country there is something wrong with our medical service.

We heard a lot about the way hospitals have been run. I live in an area pretty close to two good hospitals in the neighbouring county. The local authority of which I am a member realised that if there was an urgent case the sensible thing to do was to send the patient to the nearest hospital, which was across the border in another county. The Parliamentary Secretary to the Taoiseach made reference to rates. He said that because counties around the city, including Meath, were using the voluntary hospitals they were able to keep the rates down because they were getting free treatment. Either he was joking or knows nothing whatever about the way the medical services operate. The cost per patient per week is very much more in a voluntary hospital than in the County Hospital in Navan. The extraordinary thing is that the medical card holders in the county in which the hospitals I refer to are situated cannot avail of them but must go 20 miles to the county hospital. If the Minister is serious about improving the health services he should ensure that the interest of the patient must come first. This matter of trying to ensure the county hospitals are full before patients are directed elsewhere has resulted in considerable hardship to patients in the area to which I am referring.

Reference is made in the White Paper to the wiping out of the extra charges. This is one of the anomalies that have been allowed to continue down through the years. One of the hospitals beside where I live can carry out an X-ray at a cost of £3 3s. 0d. But instead of having the X-ray there patients from this area are brought, either by taxi or ambulance, 24 miles to the county hospital and back home again. Would the Minister hazard a guess as to which is the cheaper way of having the X-ray? Why has not some system been evolved by which patients can have X-rays in the nearest hospital? The same applies to most out-patient treatment. They cannot have it in the nearest hospital but must go to the hospital in the county. As a result, there is an excess charge either for an ambulance or some other car to take the patient over and back. This system seems to be in operation in most counties. Before we introduce a new health system, the old system should be overhauled.

We also have this position. A patient goes to hospital and is examined by the doctor. Perhaps the doctor sends him home again saying he does not require hospital treatment. But the patient feels he does and goes to a doctor other than the dispensary doctor. He is sent to a hospital somewhere in the country and examined by a specialist. The result is that the specialist's fees will not be met by the local authority because the patient did not go through his own local authority in the first place. This sort of thing goes on and on. There is no reason why with a bit of commonsense it could not be easily dealt with.

There is also a situation arising now, of which the Minister is aware, where there is grave discontent among a certain section of hospital employees. Under the present system ambulance drivers are required in many cases to work 24 hours in order to provide service. The trade unions concerned have been trying to get the county managers to agree to some system by which the men would be paid a reasonable wage and by which an adequate number of ambulances and drivers would be available. A new association has been formed outside the trade union movement. I understand the Minister has been approached to meet it. I hope he is sensible enough not to cut across the trade union movement in this matter. The Minister must seriously consider what is to be done about the whole ambulance service. It is entirely inadequate. When you see the same man who started to drive an ambulance at 8 o'clock one morning still driving it at 2 o'clock the next morning, there is something wrong with the system. Yet that is the situation in this country. Recently I saw an experiment to try to provide a 24 hour service. It resulted in the drivers concerned finding themselves on almost 24 hour duty. It is something which requires urgent attention. Small blame to those involved if they complain and say they cannot give the service required of them because they do not get a chance.

We also have—this is something which has been mentioned on more than one occasion in this House—the situation in which patients going into hospital are required to pay a certain part of the cost—10/- per day. The Minister referred to the fact that this 10/- per day is the exception rather than the rule; they do not pay the full 10/-; usually they pay much less. In answer to a Parliamentary question, it would appear that the average amount collected runs somewhere around £3,000 to £4,000 per year per county. Is there any reason why this charge should be continued? It causes a great deal of annoyance to those who get it hard to pay. It costs a great deal to investigate and find out whether or not they should be asked to pay and the people who collect it do not appear to receive anything worth talking about. In my own county it is something in the region of slightly over a penny in the rates annually. Most other counties are, I think, in the same position.

He was not an insured worker. He was in that vague middle-income group and he has not got £1,200 a year. It is only a point, but is happening, and I am sure the county managers who have been consulted by the Minister and whom the Minister has advised from time to time would be able to give him the necessary information, if he requires it. They have it at their fingertips because all of us from time to time have made representations to have the charge reduced, and unsuccessfully.

With regard to the issue of drugs and medicines, as Deputy Kyne remarked, the Minister's predecessor issued a circular saying that in certain circumstances drugs and medicines could be issued free of charge through the local authority to people who were either paying for expensive drugs over a short period or less expensive drugs over a long period. This has worked reasonably well but usually the person concerned has bought a considerable amount of drugs before he eventually succeeds in getting the local authority to accept responsibility because the local authority will not pay for drugs bought prior to their decision to accept responsibility. That is something that should be changed. Any delay causes a great deal of hardship for those who are unfortunate enough to be unable to pay for their treatment.

Nearly all the proposals in the White Paper relate to future improvements. The biggest snag is the fact that they are so far away in the future. If the Minister gives a choice of doctor, he will certainly do something very desirable. All of us know cases in which a family has fallen out, for one reason or another, with what was the family doctor and they are reluctant to go to him when they fall ill. From that point of view a choice of doctor is essential.

The Minister earlier said—he was corrected by Deputy Kyne—that there are people who may not be ill at all but who insist they are ill and insist on attending the doctor. That type of person is usually very ill; if he were not, he would not be pretending to be ill. If he does not need ordinary medical treatment, there is another type of treatment which could be recommended for him.

The worst difficulty of all is where, even in a thickly populated area, one finds a doctor not available. At the present time, because of influenza, doctors are literally run off their feet, even in country districts. Possibly the answer to the doctor problem in most of the bigger areas is the rota system. It is most unfair to expect a doctor who has been on duty all day to go out night after night to treat somebody who is ill. Nevertheless, there should be a doctor available and, particularly where there are three or four doctors living around a big town, there is no reason why there should not be a rota system evolved so that at least one doctor would be able to have a rest during the day and be available for night-calls.

I had the experience some years ago of being the only person in my district who had a telephone. I often spent hours at night trying to get a doctor, and every doctor I phoned would either be out with a patient or, having been out on one or two cases, was feeling unwell and would be unable to answer the call. It brought home very forcibly to me the necessity for having some system other than the one we are operating for the purpose of treating people who are ill.

The likelihood of the disappearance of the dispensary system was mentioned here. Under the existing system we still have—some people will deny it; most doctors will deny it and most county managers will deny it—unheated dispensaries, dispensaries which are supposed to open at 10 o'clock but do not open until 12 o'clock, possibly because the doctor is away somewhere else and is unable to open the dispensary in time. No medicines are kept at the dispensary and the doctor may say to a patient: "Come to my house at 3 or 4 o'clock and I will have a bottle ready." That person who is ill may have a bicycle with him or may not even have a bicycle and have to walk to the house which is perhaps four or five miles further away. All this tends to bring discredit on a system which, by and large, is not so bad.

The original Health Act, if properly administered, should be working reasonably well, but the greatest difficulty of all is the blue card or the green card system. The medical card is issued under certain conditions and there is a secret code. The House heard Deputy Hogan talking about a secret code which is used in France, but there is some secret code used here whereby it is decided whether a person is entitled to a medical card or not.

Mr. O'Malley

Except that no one knows what the code is.

Mr. James Tully

I shall tell the Minister what it is. However, one finds that Tom Smith who is earning £9 a week and who has a wife and four young children, is refused a medical card because of his earnings, and then Tom Brown who works with him at exactly the same job and who has £2 a week more and two children less, has for some extraordinary reason, got a medical card. It is bad enough for a person who thinks he is entitled to a medical card to be deprived of it, but it is worse when he finds that his neighbour or his workmate has got a card, though he knows the workmate is much better off financially than he is. The only way in which the matter can be rectified is to report the situation, as he sees it, to the county manager. This usually results in the second man losing the card, at least for a while, but the man who reports it does not succeed in getting a card for himself. That soon stops that sort of report.

Reference was also made to the county home system. A great deal of money is being spent on county homes, including one in County Meath where a new home has been built. These homes are well looked after. Both the nursing staff and the other staff of the homes seem to take a special interest to ensure the people there are comfortable. However, the unfortunate person who has to go into one of these homes and who has been living in a reasonably comfortable home of his or her own can never be really happy. I mentioned here before something that an old man told me in the county home. Because he and his wife were unable to look after themselves at home, they had been brought to the county home and when they came to the door, one went to the right and the other went to the left and that was the last they saw of each other. Both had been put to bed and they were unable to leave it except in a coffin.

I do not know whether we shall ever reach the stage of making accommodation available for old couples to live together. An effort should be made to do that. I cannot see how small homes around the country could be run, as was suggested by some Deputies, because one could not afford to put staff in them. No matter how small the home would be, there would have to be staff to look after them and under the present system that would not be so easy. Some effort should be made to meet the requirements. It might have been all right 50 or 100 years ago to say that the man should go to one side and the woman to the other side and that that is the way it should be left. In a Christian country there should be greater consideration given to old people, many of whom have reared big families and whose families have gone off and left them there to fend for themselves. It amazes me when I hear people talking about the respect we have for our aged. All anybody has to do is to go into any of our county homes to realise what little respect so many people have for their aged parents.

In regard to the Minister's White Paper, possibly we will say he has not gone far enough and that he has taken far too long to introduce the proposals. But no matter what the Minister may do, he will find that, as long as he goes on the lines laid down in the White Paper, and even if he wants to go very much further on this road, he will get the full support of the Labour Party.

The choice of doctor is one of the greatest benefits that can be given to the people. Not alone will they have choice of doctor but they can also get to know whether or not they are entitled to free treatment, having regard to family commitments. They will know that if under a certain income or if they comply with certain conditions laid down, they will be entitled to a card.

Mr. O'Malley

Family income no longer counts.

Mr. James Tully

When I refer to family, I mean husband and wife. I am aware that the children's income is being disregarded, which is a good idea. We have all had experience of county managers assessing the non-existing income from the family where there were children who were looking for money from their parents instead of giving money to the parents. What they were earning was counted against the family when they applied for medical cards. Incidentally, there is one other thing which the Minister might consider. Dublin County Council have recently introduced it and I suggest it should be done in other places. If a check is being made on income for a medical card, it is wrong that the employer of the applicant should receive a circular from the local health authority stating that an inquiry is being made for health reasons. It does give the wrong impression. Dublin County Council have recently altered their query form because it was found to be causing embarrassment. I suggest that other local authorities might be required to take the same step.

As far as we in the Labour Party are concerned, we are prepared to support the Minister's proposals, but we want them to go very much further. We want free choice of doctor. We want the free medical service, that is, free to the patient, to be paid on an insurance basis. We want the payments to hospitals, which at the present time are more of a joke than anything else, to be discontinued. We also want the issue of the necessary drugs and medicines to those who require them made easier, and we want the Minister to bring forward the date which he has set "not earlier than 1st November, 1967" to, possibly, 1st November, 1966.

Mr. P.J. Burke

It gives me great pleasure to support this Bill and the White Paper. This measure concerns every single person in the nation. There is not a man, woman or child who at some time or other in his or her lifetime does not need to go to a doctor or to get some treatment of some kind or another. The health services are very much bound up with the lives of our people. If one escapes illness oneself for a time, usually a relative needs treatment of some kind by some doctor or hospital. The present young Minister has taken his position very seriously and in a very short time has tried to do something worthwhile to improve health services. The choice of doctor is a big advance, as is the choice of hospital. No matter how it was boosted, the dispensary system was still associated with the old red ticket of bygone days and getting rid of it was a great step forward. I want to pay a compliment to the dispensary doctors who were in many cases distinguished men doing their very best and in earlier days very poorly paid.

It is the democratic right of every citizen in a free country to have the doctor of his choice; if we cannot achieve that, we have failed to do something worthwhile. I cannot over-emphasise how much this will be appreciated by all concerned. Everybody has likes and dislikes and freedom of choice of doctor and hospital is a great boon for a patient. Even though St. Kevin's Hospital in Dublin has been brought thoroughly up to date, staffed with the best available surgeons, nurses and doctors and splendidly equipped, many people, both in Dublin city and county, do not want to go there. It will take another generation to remove the old stigma even though it is now a first-class hospital. A choice of hospital gives the patient a "lift" that was never before available. In the case of St. Kevin's, every possible improvement has been made; the name and the atmosphere have been changed; the old walls have been taken away, but old associations are hard to kill and it will probably be another generation before the past is completely forgotten. While much has been done since the State was founded, much still remains un-done.

The present Minister had local authority experience as Mayor of Limerick; he had grown up with the authority and he had seen what was needed. He is now applying his experience in his Department. It is not possible in certain rural areas to give a choice of doctor and that will have to be another day's work, but at least in these areas there will be a choice of hospital and specialist treatment. The old dispensary system with the queues waiting for attention for perhaps a long time, is going and that is a step in the right direction. The doctors who have been appointed were appointed on merit and were highly qualified men, the best that could be got, but the time had come when the change was necessary and I am delighted it is now being made.

The provision of free drugs for the middle-income group is another very big advance. The cost of drugs fell heavily on people who for instance were buying their own homes. I know of this in my own constituency and in Dublin city. Both Dublin Corporation and Dublin County Council, I suppose, have lent over £20 million under the SDA scheme to people buying their own homes. These people, while subscribing to the health services, were not entitled to any concessions up to now. While they might be able to meet the doctor's fees, the purchase of exclusive drugs was beyond them. As a member of the Dublin Health Authority, I had to appeal to the CEO to alleviate the hardship involved for these people in trying to buy drugs. The doctor might charge 10/-, 15/- or £1 but frequently when one went to get the drugs he prescribed, one had to pay £2 and this, perhaps, repeatedly. I know people who had to get drugs for certain ailments which cost them £3 per week. They had only low pay and were repaying loans on their houses and they could not carry on. They had to ask their public representatives to do something. The Minister has come to their aid and these people in the lower middle-income group who are finding it very hard to exist will welcome the new provision.

It might be asked why they did not join the Voluntary Health Scheme. That would mean that they would be provided with the drugs while they were in hospital but it is not easy for a man on a moderate income who is purchasing his own home to cope with all his outgoings, even if he has £15 or £16 a week.

Progress reported; Committee to sit again.

The Dáil adjourned at 10.30 p.m. until 3 p.m. on Wednesday, 2nd March, 1966.

Dáil Éireann debate - Tuesday, 1 Mar 1966