I appreciate that of necessity one must limit one's remarks on a Supplementary Estimate of this kind. Perhaps had I the mental agility of Deputy Dillon I could circumvent this restriction and go on for quite a long time. However, I was dealing with the problem of the crushing burden of the health services on the rates in recent years and expressing the hope that the Minister might be able to indicate the kind of aid he had in mind to cushion the impact of these health charges on the local authority rates.
Committee on Finance. - Vote 48—Health (Resumed).
Debate resumed on the following motion:
That a supplementary sum not exceeding £1,240,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of March, 1968, for the Salaries and Expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain Services administered by that office, including Grants to Local Authorities, miscellaneous Grants and a Grant-in-Aid.
—(Minister for Health).
The Minister would not be in order in doing so on a Supplementary Estimate which relates to the year ending on 31st March, 1968.
The Minister in his short statement, made some reference to the matter. The main bulk of his remarks related to the steep increase in the cost of drugs and medicines which has gone up by 14 per cent in recent times and this represents approximately 18 per cent over last year. I am very pleased to see the Minister's comment on the reasons for this increase. He rightly concludes that the increased usage of drugs is a feature of modern medicine "and since drug therapy and allied preventive medicine practices undoubtedly helped to keep people out of hospital, increased the turnover of the occupancy of hospital beds and made possible a more rapid return of people to their employment, it is a development which we must accept and indeed welcome."
He goes on to speak of the concern at the rising cost. We all share his concern in that regard but I think we have had too much harping of late on the increased cost of drugs and medicines. We would all welcome an intervention by which this expenditure could be reduced but many of us in public life feel that excessive profits are being made on drugs and medicines and that health authorities and county councils are being exploited. We seem to be helpless in trying to resolve the difficulties and I should like to hear the Minister suggest how we can more effectively cope with this problem. Laymen, at any rate, feel that much of this extra cost is wholly unjustified and constitutes unbridled profiteering and very largely exploitation of the sick poor.
I am also concerned that health authorities may be inclined to carry out certain economies in respect of drugs and medicines and to restrict the allocation of them or they may feel inclined to substitute cheaper drugs for the more sophisticated and dearer types which we know doctors are obliged to recommend in these times. That would be deplorable; it would be a retrograde step if anybody concerned with the administration of medicine were to economise in this way by the application of an aspro where possibly penicillin or some other more costly drug was required. The Minister must have due regard to this danger.
The Labour Party particularly welcome the Minister's honest and matter-of-fact appraisal of the situation that drug therapy is such an integral part of modern medicine on which our people are relying more and more. Otherwise, we would have our hospitals cluttered up with patients and would lose countless thousands of man-days of employment. We must not shirk the cost involved.
The adverse comment on the increasing cost of drugs and medicines may persuade health authorities to be more restrictive in respect of granting free drugs and medicines, a service which is much availed of, to persons whom, although they may not have a medical card and may not be regarded as in the lower income group, find it too great a burden to provide costly drugs and medicines for a sick friend or relative in the home over a long period. They would be entitled to free drugs and medicines and many thousands of such families are availing of this service from health authorities. It is a much availed of service and it does all the good work which the Minister acknowledges in his brief here.
I am concerned, but I feel it is true to say, that these comments in respect of the overall cost of the health services on the rates, and particularly the cost of free drugs and medicines, will be a dissuading factor from the health authority point of view and will cause the number of people who will get free drugs and medicine in the future to be restricted. We have a feeling that the means tests in respect of the granting of free drugs and medicines is becoming more rigid of late because people are being actuated by the cost factor and not the need factor.
As far as we in the Labour benches are concerned, the need is the important thing, the need of the health services, the need of a medical card, the need of drugs or medicines, the need of specialist services, hospitalisation, dentures and other such services. It is the need of these things that count. That is the criterion which should be applied and not the cost; if we go on the cost, we will negative all the work which is being done in our health services.
It has been the subject of comment in certain areas that proper control is not maintained over our stocks of medicines and drugs in our dispensaries and repositories in the bigger health centres. I do not want to go into this matter now. I will probably go into it in greater detail on the Minister's main Estimate, because I happen to be a member of the Committee of Public Accounts and this has been a subject of comment there, not so much the cost of the drugs and medicines as the alleged loose manner in which drugs and medicines are allowed to be stock-piled in certain repositories and dispensaries without adequate checks being made. This is a matter to which the Minister and his Department might direct their energies and apply their minds.
I am limited in the remarks I may make on the Supplementary Estimate, but other Members have referred to this, and I should like to say that we must aspire in this House to the speedy implementation of what is contained in the White Paper on the Health Services which was issued about two years ago by the Minister's late lamented predecessor, Donogh O'Malley.
The main Estimate deals with policy.
I appreciate that, but I think it is pertinent to point out that this was a promise made and this is what the people of Ireland are still awaiting, the liberalisation of the means test for the medical card, the abolition of our archaic dispensary services——
These matters do no arise on the Supplementary Estimate.
The Minister should give serious consideration to the implementation of this promise.
These matters do not arise. I pointed out to the Deputy that they are not relevant to the Supplementary Estimate and he agreed on that.
Could I express the hope that the Minister, having regard to the importance of this pronouncement, would avail of this unique opportunity of commenting on it when he is replying?
The Minister would not be in order in doing so. The Deputy will have an opportunity on the main Estimate for Health of discussing these matters.
We are at one with the Minister on this Supplementary Estimate. We only wish it was a much larger amount so that we could implement all the things we desire in order to give our people the comprehensive health services which we feel are their due. There are certain flagrant defects in the services at the present time. I do not know whether I am in order or not in discussing this matter, but it is a very vexatious one in my constituency, that is, the inability to secure dispensary doctors.
That does not arise on this Estimate. The Deputy may not range over the whole field of health administration.
There are very many other matters which we could go into at this stage but obviously we are not allowed to do so.
The rules of order of the House do not permit it; it is not a matter for the Chair. These rules of order operate and there is nothing I can do about it.
At any rate, we accept this Supplementary Estimate for what it contains and we share the views of the Minister in relation to the cost of drugs and medicines, to which he adverted. I have given my comments on that score, and we can only hope we will get an opportunity of deliberating on the matter in greater detail when the main Estimate comes before the House at which time the Minister will be accountable for all the other defects to which we wish to refer and which at this juncture we are precluded from discussing.
This debate, in fact, did range over a number of matters which are not strictly relevant to the Supplementary Estimate; in particular, I have in mind Deputy Ryan, in his reference to certain undertakings given in 1966. In so far as he was relevant, he dealt with the paragraph in the White Paper where an undertaking was given by the Government in regard to rates, and he quoted from the White Paper the paragraph which dealt with the decision of the Government at the time. This decision was to the effect that the rates would not bear any portion of the 1966-67 increase and that for the future the cost of extensions of the health services and any new services provided would also be met by the Exchequer.
Last year I dealt with this matter in replying to the main Estimate. I think it no harm to reiterate what I said to Deputy Ryan and to those who accompanied him on behalf of Dublin Health Authority when we discussed the situation in regard to 1968-69. I then made it clear to the representatives of that deputation that even if the Government had given an undertaking in 1966 that the rates would never again bear any increased cost, it would have had to go back on that undertaking because this would lead to the situation where even the Minister for Finance ultimately had absolutely no control over the expenditure of the health authorities. In point of fact, this undertaking was not given except in regard to 1966-67 but even so I said then that I was, and I repeat now that I am, concerned with the extent of the burden on the rates of the cost of health services and I gave an undertaking that during this year the Government would reconsider the whole question of the structure of financing health services.
Deputy Ryan seemed to think that this undertaking could be discharged forthwith. I do not think this is reasonable. I would not expect that deliberations on this, in which several other Departments are concerned, the Departments of Local Government and Finance, to name but two, would be completed in less than another two months or so, and the consequential changes that will have to be brought in after the Government have taken decisions in principle will obviously take some time as well. One way or another, I would sincerely hope that this will be the last year in which the present system of financing the health services will operate. Not merely do I appreciate that the health element in the rates is heavy but I feel also that it is not as heavy as the propaganda in relation to the increases would lead the public to believe. I have my own ideas as to what the new method of financing the services should be but I do not think it would be appropriate for me to mention them because that would be only my own personal view and would not have the endorsement of the Government.
In regard to Deputy Treacy's concern about the application of the means test, I do not think that there is any foundation for his fears in that regard. Certainly there is no foundation for the fear that health authorities restrict themselves in any way in regard to the ordering of drugs. These drugs are ordered by the doctors who operate the health services and there is absolutely no evidence whatever that doctors skip in regard to the drugs they order. If anything, they probably order too liberally, leading to a lack of control and the waste which Deputy Treacy mentioned. That is the reality and, in any case people, the sick poor in particular, all of whom have medical cards, are not being in any way restricted. As the House knows, the proportion of people with medical cards has steadily increased, not very substantially but at the same time it has increased so that this, again, would indicate that the means test is not being rigidly applied. My own experience is that the health authorities vary considerably in regard to the application of the means test. Some of them I have regarded as being unduly restrictive and others, the vast majority of them, are very fair. In any event, there is the hardship clause which can be used for the benefit of those people in the middle income group who, it is considered, are being asked to pay too much. I have given every encouragement to health authorities to operate this hardship clause liberally and with the greatest possible humanity.
Could I ask the Minister to elaborate on what he calls the hardship clause?
Certainly, this is the clause which allows a health authority, where a middle-income group of patients are concerned, to pay the whole or any part of the cost of a patient's drugs or medicines and, indeed, also allows the health authority, if they consider it desirable, to pay the 10/- a day charge or reduce it to 7/6, 5/- or 2/6. As I say, I have encouraged health authorities to operate this clause with humanity so that where a person has had a long illness, is in the middle-income group and is not in the voluntary health insurance scheme, that having paid what the authority considers a reasonable amount, paid what could reasonably be expected on his income, the health authority will pay the remainder.
And in regard to hospitalisation?
Also in respect of hospitalisation. They can reduce the 10/- a day charge or remit it or they can remove it. Where the lower income groups are concerned, I think that far from it being the sick poor who are likely to suffer it is the opposite, because the sick poor have medical cards and the doctors order drugs which I am satisfied they think best, but people not in the medical card category from time to time may get drugs which are, perhaps, less effective than they would like. Deputy Ryan said he got the impression that the 42½-hour week or 85-hour fortnight for nurses had not been implemented everywhere. I want to make it clear that I have encouraged all health authorities to apply the spirit as well as the letter of this change in regard to the 85-hour fortnight and I have actively encouraged them to get the number of nurses considered necessary and to do so without delay. In general, this process has gone on virtually to completion.
I think it was Deputy Kyne who mentioned the situation in regard to overtime. He stressed the desirability of giving nurses overtime instead of time off. This is something on which I should not like to pontificate. The system of giving time off instead of overtime is one which in many cases may suit the nurses concerned. Usually it is a matter of arrangement between the health authority, the hospital and the nurses. Normally, every hospital is staffed on a level above average demands. In other words, I have no terribly fixed ideas about this matter. I would see no objection to paying nurses overtime if this were the local arrangement. I would also see no objection to giving time off, if that suited.
As I said before, I do not agree with Deputy L'Estrange that the means test is operating at its worst; Deputy L'Estrange, of course, is given to hyperbole. The means test is not operating at its worst. The Deputy also said he would like to warn doctors in the dispensary medical service against charging medical card holders. I dealt with this matter before. I can only say now that I have little evidence that this is happening and no evidence that it is happening on any substantial scale. Of course, I absolutely agree with Deputy L'Estrange that doctors in the dispensary medical service, who are paid to give, and are obliged to give, service to medical card holders free of charge, should not, under any circumstances, contravene the rules in this regard.
Deputy Ryan talked about married women being employed. Any time there have been applications from health authorities, such as Dublin and, more recently, my own County Mayo, for the employment of married nurses because of shortage locally, I have acceded to the request that they be paid other than the minimum salary. It will, I presume, always be the policy to give preference to unmarried nurses. It is right, I think, that that should be the policy, but I confess I personally look forward to the day when, if married women, or any women, for that matter, are employed in any occupation for which they are qualified. they will be paid in accordance with their experience. This is something towards which we should, indeed, rapidly and progressively move.
I should point out that the Exchequer is paying this year £2.2 million more than the 50 per cent which the Act obliges the Central Fund to bear. Last year the figure was £1.9 million, giving an overall contribution by the Exchequer last year and this year of between 55 and 56 per cent. The fact that the total contribution this year will be in the order of £21 or £22 million gives the lie to Deputy Ryan's suggestion that the Government are welshing on the undertakings they gave in the White Paper in 1966.
The White Paper began by pointing out the complexity of the proposals and stated that the expenditure on developments could not be undertaken in existing financial circumstances and stated clearly that, in publishing their plans for the future development of the health services at that point, the Government's object was to promote planning in the expectation that, when this planning and preparatory work had been carried out, financial circumstances would be such that the changes could then be made without strain on the economy. In point of fact, in the last three years expenditure on health services has increased by about £6 million, perhaps more. In the last six years, or so, the overall cost of the health services has almost doubled from £21 million to £40 million. The fact that it is necessary to bring in this Supplementary Estimate today in order to give more money to local authorities is proof that the Government, far from failing to implement the promises in the White Paper, have steadily and progressively done so.
I conclude by thanking the Members of the House for their contributions to the debate and I express the hope that by this time next year we will no longer be discussing the impact of increased health charges on the rates. That is my earnest hope.
Hear, hear.
Vote put and agreed to.
Supplementary Estimates Nos. 45, 46, 51, 44, 36, 47 and 48 reported and agreed to.
I understand that, by agreement between the Whips, it is not proposed to take any further business.
The Dáil adjourned at 3.50 p.m. until 3 p.m. on Tuesday, 2nd April, 1968.