It has been a long and hard struggle to get a Fianna Fáil Minister for Health to consider objectively the manner in which our health services should be reorganised. I have always felt it is desirable in relation to any consideration of our health services that we should not be inhibited by the present accepted divisions of the population into particular income groups or by the present system under which these groups are provided for. What I have advocated for a long time is that at some stage there should be an objective consideration by the Government or the Dáil of what kind of health services we should have without regard to what is there at present. It was to that end and with that object in mind that some 18 months ago, on behalf of my Party, I submitted to the Select Committee on Health Services a detailed memorandum setting out the case for the provision of a general medical service, a service based on our requirements in the present age.
In that memorandum, which has never seen the light of day, which has never been circulated to Deputies, there is contained a case for a new approach to reorganisation of our health services. It also contains a plan under which a comprehensive medical service can be provided for the entire population. We seem to forget—and I think this is one of the greatest weaknesses of the White Paper—that we are so far behind all countries in western Europe that even these proposals represent a form of health services which is out of date by some 25 or 30 years.
At present, apart from Finland, Ireland is the only country in western Europe which makes no provision for the general body of wage-earners and persons of limited means in regard to a general medical service. Apart from Finland, we are the only country that insists in our health policy that the average person must, in regard to the provision of medical care, fend for himself. When I say "we" I mean we who live in this part of Ireland because it is worth recalling, as we frequently forget, that our people who live in Northern Ireland have available to them a general medical service as they do in Britain, in France, in Belgium and all the countries on the continent of Europe.
What are we doing here? This Dáil is discussing a very limited and belated approach to the reorganisation of health services which is based on the policy contained in the Health Act, 1953, which has demonstrably failed. This White Paper now proposes a palliative, a bit of papering over of cracks in the 1953 Health Act policy. Where are we going? We are supposed some day to look forward to the reunion of our country: more immediately we are supposed to look forward to the day which, we are told will be no more distant than 1970, when we shall enter Europe. Do we seriously contemplate that the services set out in this White Paper will represent the high-water mark of the manner in which we are going to provide for our people within the European Community? If that is what we contemplate, there must be a great deal of fresh thinking on health services. If we go into Europe in 1968, 1969 or 1970, and even if the proposals in the White Paper are implemented, we shall not measure up; we shall be going in as a limping relative with a system of health services far below what any other country in the European Community regards as a minimum.
It is for that reason that I want to remind the House, as has been done already by Deputy Fitzpatrick and others, that while we are discussing here proposals which we welcome and which we do not want to be in any way ungrateful for, it would be very wrong for any Deputy to think that this little step forward can in any circumstances be regarded as facing up to the problem of health services here. I regret to say that in the entire White Paper there is still perfectly evident the old public charity approach to health policy. There is still the division of people into groups, into the haves and the have nots. There is still the idea that you must make regulations and provide safeguards lest people might get something more than what, on an exact and just means examination, they are entitled to. That kind of approach to the provision of health services is old hat, it is out of date, and I regret that a new Minister for Health, doing his best I have no doubt, should have been sold the idea that in modern Ireland that is the way to face up to health policy.
What are we doing here? We are abolishing the dispensary system and this is claimed to be a tremendous new step. We are hoping to provide a measure of assistance for the middle-income group in respect of drugs and medicines. We are hoping to provide an extension of the district nursing system for persons in the middle-income group and for the chronically sick and for old people. We are hoping to provide an extension of dental, aural and ophthalmic services to additional groups of people. These are the four provisions in the White Paper— abolishing the dispensary system, helping the average family in the middle-income group in respect of drugs and medicines, providing nursing services for the old and chronically sick in the home, and providing dental, aural and ophthalmic services.
I should like Deputies to take stock of what we are proposing to do. This is 1966 and in 1957 as Minister for Health, I announced a decision to alter the dispensary system, to modify it in order to provide for poor people a choice of doctor. That was nine years ago. I announced it just prior to the general election of 1957. I was not in a position to implement that decision because of a change of Government. Following the change of Government, I, on behalf of my Party, persisted in the idea and I tried to encourage the new Minister for Health, my successor, to accept that the choice of doctor, even while retaining a form of general medical service confined to poor people, was essential.
I made many speeches in this House; I spoke many times throughout the country to try to get that small penny to drop. I might as well have been out in the middle of a field baying like a lunatic for all the impression I made. It availed nothing. Through 1957, 1958 and 1959, right into the 1960s, anything that I said or Deputies in my Party or in the Labour Party said, fell on deaf ears. It was impossible to convince the Minister for Health that a small limited change of that kind to provide for poor people a choice of doctor could be made. In fact, may I remind Deputies that in pursuance of my idea at the time, and which is largely accepted now, I proposed that a number of the temporary district medical officer appointments in this city should not be filled and that instead a pilot scheme providing for a choice of doctor should be embarked upon in Dublin city? My successor, Deputy MacEntee, rejecting that idea proceeded to fill all these dispensary posts permanently. Indeed, as Deputies will recall, that led to considerable difficulty in certain parts of this city.
The decision to fill the posts was a decision to reject a very modest decision which I had announced as Minister for Health and the proposal which I had made that an effort should be made, even within the policy of confining a general medical service to poor people, to provide a choice of doctor. In relation to these matters, while towards the end of the 1950s the thinking in my Party was merely along the lines of providing a choice of doctor within the general medical service, we proceeded then in our thinking to go further and by 1960 and 1961 so far as the Fine Gael Party were concerned, we began to realise that providing a choice of doctor and abolishing the dispensary system were only temporising with the problem of reorganising the health services. We carried out some thinking in depth and we came to the conclusion some years ago that if we were to keep abreast of other countries, we had to contemplate, to the extent possible within our resources, the provision of comprehensive services, services which would be available to the bulk of the population, which would provide not merely a general practitioner service but also ancillary services, a hospital service, nursing service and so on.
It was as far back as 1961 that we detailed our policy of providing a comprehensive health service based on the principle of social insurance. I should like to recall to Deputies the fact that in the autumn of 1961 we incorporated our ideas in a Dáil motion. It was a motion in which we called for the introduction of a comprehensive health service based on social insurance. In the discussion on that motion, on behalf of my Party I gave to Dáil Éireann the details of our thinking in that regard. That was five years ago. Our motion was answered by the Government in an amendment tabled by them which sought to refuse the terms of our motion and proposed the setting up of a Select Committee. That is how the Select Committee on Health Services came into being. It was the Government's answer to our proposal, to set up a Committee to discuss the whole matter.
I do not want to make any criticism of the manner in which that Select Committee functioned. I hope that some day, and I believe the sooner the better, the Dáil will order the minutes of that Committee to be published. If they are published, Deputies and the country will see the frustrating experience that Deputies serving on that Committee who were interested in the reorganisation of our health services had to experience. I, and the other Deputies of the Fine Gael Party and the Labour Party, served long hours on that Select Committee, trying, day after day, to convince the representatives of the Government on that Committee that a change was possible, that it could be brought about, that its bringing about as a result of our common deliberations would achieve what we all desired, the removal of health and health policy from Party politics.
There was not one Deputy who seriously worked on that Committee who, at the end, was not convinced that its purpose was merely to prevent discussion of our health policy. It was in sheer desperation that in the dying days of that Committee, I was charged by my Party to prepare a memorandum setting out in detail what the Fine Gael Party stood for. I hope that some day this memorandum will be published so that the public and Deputies may see the depth and, I believe, the probity, of our thinking on this matter.
It is when one recalls these events that one experiences some surprise at the naïve statement contained in paragraph 53 of this White Paper where it is stated that the Government are aware of proposals recently made for the extension to the whole community of the general practitioner service, with free choice of doctor. I wonder how long it is necessary to keep on speaking before someone listens to what you are saying. The White Paper was published in 1966 and it refers to the Government being aware of proposals recently made. As far back as 1961, my Party moved Dáil Éireann to approve of the idea of a comprehensive medical service available to the entire community. In the years subsequent to that, we pursued that idea, endeavouring to convince the Government that it was necessary in the interests of the nation and possible with our resources. If paragraph 53 of the White Paper means anything, it means that the Government have only recently been made aware of all that we have been saying.
It is a pity that this closed mind approach to this important matter of health services should still persist. In the White Paper we are now getting the first small step forward. We are abolishing the present dispensary system to the extent that we provide a choice of doctor. That represents for Fianna Fáil now the Fine Gael thinking of nine years ago. Apparently Fianna Fáil have now reached the stage we reached almost a decade ago. How much longer will it be before a Fianna Fáil Government, if still there, will recognise the necessity for a general medical service available to the entire population?
I do not like to prophesy in this matter, but if our common hopes are achieved and if, next year or the year after, or the year after that, we find ourselves subscribing to the Treaty of Rome and entering the European Community, how quickly will it then be realised that a general comprehensive medical service is absolutely essential? If we do not do it within the European Community, we cannot possibly hope to survive. We have to have our health services and our general social legislation at least at the same level as already regarded as necessary amongst other European countries.
It is not a very large step. One of the difficulties I know the Minister for Health has had to contend with in even announcing these limited steps in this White Paper has been the complete rejection by his predecessor of all our proposals. He has made a limited step from that complete rejection by his predecessor but he has not been able to do much. One of the troubles has been the rejection by his predecessor and by the Taoiseach of our ideas for financing the health service. Fundamental to the idea of a comprehensive health service is social insurance. It is only when people realise that progress in social legislation and health services must be removed from payment by general taxation and local rates that proper progress can be made.
That idea is fundamental to our policy. It was rejected out of hand by the Taoiseach and the previous Minister for Health and it is because it was rejected that these limited proposals are contained in the White Paper. We all know well that if we are to try to finance health services by general taxation, we will be up against problems that no Government can adequately deal with. If we are to try to do it by a wedding of general and local taxation, we will be up against a difference in standards. That is one of the troubles we have had in the health services under the 1953 Act.
In some health authority areas, the indenting on local rates has been so hard that a lower standard is accepted because a health authority manager just cannot afford to increase the local rates bill. So since 1953 we have had different standards in different parts of the country because in some areas the ratepayers cannot afford to meet the added bill. In that respect, the Minister has announced that in so far as the cost of increases in health services are concerned, he will freeze the rates contribution. That is a slight step in the right direction, but it still leaves the problem which he is facing here and now that in so far as the cost of health services generally is concerned, it still has to be paid for by the general body of taxpayers, and so he can do nothing.
These White Paper proposals are merely put forward now so that they may be discussed, and all our discussions here will not achieve anything unless in the end money is found to implement them, and if money is found to implement them at the end of next year or the year after, whenever the green light is given, what will we achieve? We are to provide a choice of doctor for people who will be confined under regulations made by the Minister with the caution:
As a wide extension of the operating of State organised medical services has not been demonstrated to be necessary, the Government would regard it as undersiable. I would not therefore propose that the limits to be fixed by the regulations would be such as to include a high proporation of the population.
That is a clear warning that even when the abolition of the present dispensary system comes about, it will still be confined to the section of the population who at the moment are roughly covered by medical cards. There still will be the means test approach, the parsimonious approach. Why? Because to do otherwise would be to make the burden on the taxpayer undesirably high. When this bill is footed by general taxation, when can one expect another step forward? The plain truth will be that there will again be the old struggle between the Minister for Finance, anxious to keep down costs, and the demands of the Department of Health and other Departments to increase the quality of the services, and whatever progress is made in the general quality of the health services will be won after a struggle between the Minister for Health and the Minister for Finance.
That is axiomatic. It is bound to develop unless somebody, from today, begins to realise that the only logical way of providing against ill-health is by getting people intermittently, weekly, to pay while in good health for the cost of ill-health. It is one of the most fundamental concepts in relation to any way of beating health problems—the idea of a health insurance fund under which people in good health are asked to contribute the cost each week of ten cigarettes to cover the entire family.
It is only in that way that we can provide a general standard and that we can ensure that standards can be kept in touch with those obtaining in other countries. It is because there is not an acceptance of the principle of social insurance that this White Paper and the policy it contains is so limited, so confined. On this side of the House, we believe that in so far as our general health policy is concerned, the things we advocated in aiming at a just society are still valid. We believe that the ideals contained in that policy document are still sound, and while we must and do generously accept what is proposed here, it is very far short of what I believe is required.
It is indicative of the whole approach to this problem that in the White Paper no effort is proposed to provide hospital services. There should be free hospital services for ordinary people of limited means in this country and I fail to understand the mentality behind a policy which says that a workman who goes to hospital should be compelled, while sick and unable to earn, to meet hospital bills. That is an approach Victorian in concept that should have no place in modern thinking. We should have a system whereby every working man will be encouraged to stand on his own feet, encouraged to provide by insurance against the day when he becomes ill so that when he is ill and perhaps unable to earn, he will not have the added anxiety of hospital bills mounting up against him.
This absurd system is to continue under the White Paper. The only move in the right direction is to remove the absurd specialist charges introduced by Deputy MacEntee as Minister for Health in 1957. It was a wrong thing. The policy in this White Paper is merely building up on the Health Act policy and that policy, in my view, was wrong fundamentally. This is merely adding palliatives to try to deal with fringe cases, to try to paper over the cracks and make the health services something they cannot be. There is still the means test approach, the failure to stand back and examine the whole problem objectively. I do not want to go into any greater detail on these matters. My views and those of my Party are well known. I should like to add just one or two other things.
There is a proposal here that, while retaining a general medical service for people who establish the need on means test and in accordance with regulations, there would be some provision in aid given to persons who do not qualify under the regulations, and who are in the middle income group, in respect of drugs and medicines. Again, may I say that this is obviously an effort to meet the large volume of evidence adduced to the Health Services Committee which established beyond doubt—to my mind, at least— that the cost of drugs and medicines when sickness strikes in the home to the average family was crippling? I am going to prophesy that, if the Minister introduces a scheme whereby aid in respect of drugs and medicines will be given, if the expenditure exceeds a certain sum, he will find that just will not work. Once he introduces this, he might as well accept the necessity for some scheme of general application to help people in regard to drugs and medicines.
Our proposal in that regard, contained in the memorandum submitted to the Select Committee, involved the recognition that drugs and medicines should be available freely to all sections, outside those who are unemployed, sick or in receipt of social assistance, with the insurance fund paying half the cost. I believe the Minister for Health, whoever the will be, will sooner or later be forced to accept that necessity. Once you start providing that expenditure over a certain sum will be aided by health authorities, you are opening the door, and you might as well stand back and accept the necessity for new thinking with regard to this.
The White Paper also proposes the extension of the district nursing services. That again is something I welcome. We have advocated it for a long time and it is part of our policy.
The fourth provision here is the extension of dental, aural and ophthalmic services to additional groups of people. I was sorry to read that in the White Paper. It is not an objective or realistic approach. As Deputy O'Connell pointed out, it would be much fairer to admit that these services are not there at the moment for any group of people, not to mind additional groups. Do Deputies realise that under section 21 of the 1953 Health Act it was solemnly legislated that these services should be provided in accordance with regulations not only for the lower-income group but for the middle-income group, the bulk of the population? That was provided by a section in an Act of Parliament 13 years ago. These services never went into operation. They were never provided. Indeed, when I became Minister for Health, after I had entered into a solemn commitment to Deputies that I would implement the Health Act services—although I disagreed with the fundamental policy of it—I had a costing in relation to the provision of dental services and the other services in accordance with section 21. I found at that stage that under the manner in which the section laid it down, the cost was absolutely prohibitive. That was away back in 1954. Having learned that, I went to every local authority in this country. I concealed nothing. I told each health authority these services could not be provided and that the very best I could hope to do was to ensure that a beginning would be made in building up a proper school dental service; but beyond that, except in the case of absolute medical urgency in respect of bad teeth, nothing but a very limited public dental service could be provided.
My views as then stated have been repeated over the years. The dental, aural and ophthalmic services are no more than rudimentary. It is not because we have a shortage of dentists. We have plenty of them. There is no trouble in getting dentists, provided we pay them. Of course, it will not be possible to provide dental, aural or ophthalmic services of a specialist nature out of taxation. It just cannot be done and it is much more honest to admit it cannot be done. The only way any such service can be provided is under a scheme financed by weekly contributions. If that is accepted, then a great deal is possible. If that is not accepted, very little can be done.
We see here the extent of the thinking of a new Minister in regard to what is possible. Once a health policy continues to envisage the taxpayer paying by yearly injections the cost of health services, there is going to be a barrier all the time. Therefore, I feel considerable regret that there should be a promise of the extension of non-existing dental, aural and ophthalmic services. They are not there at the moment. It would have been far better if the White Paper merely contained an assurance that an effort would be made to provide these services for poor people. If we started by doing that, we might be doing something worthwhile.
I hope anything I have said will not be regarded as being in any way unduly critical of any person involved in the definition of health policy here. I do not intend it in that way, but I am very concerned about the continuance of a policy which I regard as unsound. Sooner or later we will have to stand back and have regard to the resources of the country and the best way of planning the service we should like to see here. We can do a great deal by community effort. We can do a great deal by having regard to the ordinary sentiments and habits of our people. I do not believe that anyone would object to paying a weekly sum in order to make provision for ill-health.
When I introduced the Voluntary Health Insurance Bill in 1956, I was told by some doubters that it would not succeed and that it would, in fact, require heavy subsidisation from the State. I believed in the idea of insurance. I believed in the fundamental good sense and decency of the ordinary people. I believed it would be possible, if the State gave the lead, to encourage people to provide against ill-health. I made a statement at the time which was regarded as being ill-advised; I said that the idea of voluntary health insurance would be the first social welfare scheme in western Europe that would not cost the taxpayer a penny. I am proud to recall that the hope I expressed then has been fully borne out. Innately the average father, or head of a family, likes to feel that by saving a little or by not spending a little each week or each month, he will be able to put aside, with other neighbours in a sort of community effort, something that will help somebody when ill-health strikes. That is the justification for social insurance. I believe it is the only way in which we will get a proper extension of health services and the kind of health services that will enable us to look forward to the reunion of this country without misgivings and to entering into Europe also without misgivings. If we do not to that, we shall always, have a problem.
In conclusion, the Minister and the Government have thought it necessary to have this White Paper debated here. I can understand the desirability of having a general discussion on health policy, but, after this debate, I sincerely hope it will not be found necessary to delay the implementation of these modified and limited proposals. Any step forward is worthwhile; any breakthrough is welcome. If we can get away from the monolithic approach to health policy, the approach we have experienced over the last decade almost, that will be a good thing. I should like to see these proposals implemented as quickly as possible after this debate. I look forward, as I have always looked forward, to the day when we will have an end to controversy on health. Health policy has bedevilled our circumstances here for far too long. There have been outrageous charges and countercharges. It is about time we realised we are a very small country with a problem which is limited in its nature; if we only have the faith and determination to solve it, we will make progress, and make it rapidly.