Dáil Éireann debate -
Wednesday, 30 Jun 1971

Vol. 255 No. 2

Health Contributions Bill, 1971: Second Stage.

Minister for Health (Mr. Childers)

I move: "That the Bill be now read a Second Time."

This Bill has been introduced because of the urgent need to find another source of income besides rates and taxes to finance the heavy and growing burden of health costs. The means proposed is a scheme of reasonable contributions towards the cost of the health services by those who are eligible for them and who can be regarded as able to pay such contributions without undue hardship.

The persons concerned are those classed by the Health Act, 1970, as having limited eligibility for health services, that is, broadly speaking, eligibility for all the hospital, maternity and preventive services but not for family doctor services. They are those people outside the "full eligibility" category—that is, those with medical cards—who have social welfare insurance, are farmers of £60 valuation or less or, otherwise, are persons with means under £1,200 per annum. I intend to bring before the House shortly a draft of regulations to raise this £1,200 limit to £1,600, to keep in line with the recent increase in the limit for social welfare insurance. The total number of people, including dependants, with limited eligibility, is estimated at about 1¾ million, or 60 per cent of the population.

I will try to sketch briefly the background against which the proposals in the Bill are put forward. I make no apology for once again referring to the galloping cost of maintaining our national health. In 1951-52 the total cost to public funds of the health services was £10 million. In 1961-62, this had increased to £19 million. The estimated cost in the current year is £76 million approximately, or an average of about £25 per head per year, collected out of rates and taxes in proportion to personal incomes. This rate of increase is markedly out of proportion to the growth of national production. Indeed, over a period of ten years the volume of expenditure, that is expenditure at constant prices, on health services doubled. Ireland is not unique in this regard. It may be some consolation to observe that there is a similar trend elsewhere. It seems to be a general phenomenon that the proportion of national expenditure devoted to health tends to increase with economic and social development. There are various reasons for this. It is partly due to the relative lack of productivity increases in health services since they are such heavy users of direct and expensive labour. Other factors are the astounding expansion of medical technology especially in surgery, and the increasing life span of the average man in modern times. The World Health Organisation published a report by Professor Abel Smith in 1967 entitled " An International Study of Health Expenditure" which showed that in the early sixties some countries were spending over 6 per cent of their national product on health. If that trend continues, health services by 1980 would take over 8 per cent of national resources in developed countries and, by the end of the century, perhaps 10 per cent or more.

Problems in financing and organising health care are currently causing worry in many countries. In the United States of America, which has traditionally leaned towards reliance on private finance and organisation, there is increasing recognition that these on their own are inadequate and several Bills to increase public participation in the financing and organisation of health services are awaiting consideration by Congress.

In Britain the cost of the national health services continues to cause concern and proposals have been under consideration for increasing the revenue from charges on patients for prescriptions. In the EEC countries also, considerable examination is being given to the financing of health care. In these countries this is based largely on contributions from employers and workers, with substantial aid from State funds. The report of the EEC Commission on the social situation in the community in 1970 refers specifically to financial problems in that field in most of the EEC countries and in Belgium, Luxembourg and the Netherlands special bodies have been set up to examine these problems. I am aware that in Denmark also a special committee have recently examined the financing of the health services.

I refer to those foreign examples so that the House will realise that we are not alone in facing problems in the financing of the health services. In this country one in every ten of the population spends some period annually, short or long, in an acute care hospital, excluding mental hospitals. The numbers of patients in this category are rising by 3 per cent or 4 per cent per annum. There are similar statistical analyses in other developed countries. Perhaps what I have said also makes the point that we can find no complete answer to our problems in another country. What we have done is to look at systems in other countries and come up with a proposal which has regard to our own background and social structure.

One of the main objectives of the Health Act, 1970, was to reorganise the administrative structure of the local health services in a way that would ensure the fullest possible return for the huge sums being spent. It will continue to be an important function of my Department to give special attention to economy and efficiency in the health services. Nonetheless, we have to face up to the inevitability that health costs as a proportion of national product will continue to grow, as it is unthinkable that we can neglect to apply the benefits of new techniques in the field of community or individual medical care. At the same time, there are many competing demands on national resources for other services —in education and social welfare for example—not to speak of the need for maintaining investment in directly productive spheres so that the basic capacity of the economy is strengthened and developed. The proportion of the Budget which goes to meet health costs has risen from 7 per cent in 1961-62 to 9 per cent in the current year. I need not remind the House that the increasing contribution from the rates has also caused concern.

Since I became Minister for Health this constant and growing problem of constraint on financial resources has confronted me. On the one hand I need additional funds. On the other hand I am under continuous pressure to relieve the growing burden of local taxation. In this House and at local authority meetings throughout the country there has been an increasing volume of protest from public representatives about what the rates are being asked to bear. I sympathise with these protests. I am personally satisfied that, where the local rates are concerned, we have reached the stage where this particular cow has been almost milked dry.

It is thus clear that the traditional sources for health finance must be supplemented in some other way, and preferably in a way which can be shown to be directly related to the services concerned. This is the means which is proposed by the Health Contributions Bill. It is not an original idea. Some form of national insurance or contributory scheme for sharing the cost of health services is common in European countries, and in countries which are more prosperous than ours.

The Bill I am now asking the House to approve provides for an introductory scheme based for employees on a modest rate of contribution of 15p per week—less than the cost of one pint of beer of half a gallon of petrol. It would be collected in conjunction with the social welfare contribution for insured workers. Farmers and other self-employed persons would contribute at an annual rate of £7. This is rather less than the total amount which an insured person stamping a card for 52 weeks would pay—£7.80— and is justified by the fact that insured persons are automatically exempted from the contribution during periods off work through illness and unemployment because of Social Welfare procedure for credited contributions. Farmers will pay their contributions to the local health board and the contributions of other self-employed persons will be collected through the machinery of the Revenue Commissioners. All the money collected will be paid over to me and disposed of in accordance with regulations which I shall make with the consent of the Minister for Finance.

Where it is difficult for a farmer to pay his contribution in one sum to the health board I have under consideration the possibility of enabling him to pay in easy stages by stamping a card or by some other method.

All medical card holders would, of course, be exempted from making these contributions and there is provision for exempting other specific categories where this is thought desirable. In particular, it is intended that agricultural labourers and female domestics will be exempted. Because the employees' contributions will be collected as part of the social welfare stamp, it is not, however, practicable to exempt classes for which there is not a separate denomination of stamp. Hence, employers of most lower income group workers will, in stamping the cards for social welfare purposes, have to include the element for health services. There is no practicable way of avoiding this so that in these cases there will be a liability on employers to meet the cost of contributions. Medical card holders will of course pay no contributions.

I think it would be hard to argue that 15p per week is an unreasonable price to ask people to pay who are getting full protection for themselves and dependants. When the scheme starts hospital services will be completely free to contributors: the present charge of up to 50p per day will be abolished. Charges for out-patient services have already been lifted since April last. In addition, on the introduction of the scheme, the present arrangements under which drugs are available to all diabetic patients irrespective of their means will be extended to other specified long-term ailments, in accordance with regulations under the Health Act, 1970. Other benefits are also foreshadowed in that Act and will be brought into operation at a later date, for example, assistance with heavy chemists' bills and a home help service to keep people from having to get institutional care. I should also refer particularly to the important reorganisation of the child health services which is now operating successfully.

This introductory scheme is expected to yield a gross £5 million in a full year—not a very large sum in relation to the total current costs of health services but a valuable contribution in our present very difficult economic circumstances. From this will have to be deducted the revenue we receive from hospital charges—about £700,000 a year—leaving a net addition to income of about £4.3 million.

Ideally, a scheme of contributions of this sort should be graded to take account of the varying capacity of different people to pay and it would have been my preference that, from the begining, the scheme of contributions should be so designed. However, at this stage it is not possible to implement a graduated scheme since it has many complicated aspects and calls for a good deal of organisation which the Revenue Commissioners, on whose administrative machinery we must depend, will not be in a position to complete for some time. The Bill makes provision for a changeover to this more sophisticated kind of scheme when we are ready for it and a high-level working party has been set up by the Revenue Commissioners to plan the changeover. The rates of contribution which would apply in such a scheme will be fixed by regulations which the House will be asked to approve in draft form.

Draft regulations will be introduced in this session providing standard norms of income for medical card holders with the hardship clause maintained and this will prevent anomalies arising in relation to the rights of persons who are in the lowest income category in the limited eligibility category.

I should make it clear to the House that the impact of taxation in all forms upon the taxpayer has not been the subject of any notable research in this country or in the case of our neighbouring States.

We are reasonably certain that the tax measures in force, taken together with social welfare payments, are progressive in character and based on income levels. We are quite sure of one fact, namely, that there is no large wealthy class of persons earning from £3,000 to £5,000 net of tax and that the distribution of taxation is such that every section contributes proportionately to their total incomes.

The introduction of this scheme of insurance contributions cannot be said to impose a contribution for hospital services that is out of proportion to either the income less taxation and rates paid.

In the 1966 urban household budget inquiry the amount spent by the average household in the limited eligibility group each week on medical expenses was shown as about six shillings; the amount spent on drink and tobacco was 32s 6d. The people of this country devoted 11.14 per cent of their personal expenditure for goods and services on alcoholic drinks and soft drinks. The 15p weekly contribution is a very reasonable insurance premium. The limited eligibility group again I feel can make this contribution and as incomes rise the contribution can be markedly increased.

I would ask the House to support the adoption of this new principle in our health services and recommend the Bill for a Second Reading.

Mr. R. Barry

When most people throughout the country, like myself, heard some weeks ago that the Minister for Health intended to introduce here in the Dáil a Health Contribution Bill, there was hope in their minds that possibly today or some time before the Summer Recess there would be some news of relief for the heavily loaded ratepayers. They will be, as all of us on this side of the House are, sorely disappointed with the Minister's speech this morning.

When reading of any health legislation that was introduced by a Fianna Fáil Minister, those of us with any experience in this House will think we should read between the lines. We go back in memory this morning to the Health Bill introduced by the late Dr. Ryan when he told everyone—and most people believed him—that the Health Bill that he brought in with such a flourish of trumpets would cost the taxpayers about two shillings in the £. That Bill and those days are best forgotten. The unfortunate thing about it is that some of my neighbours in Cork got demands yesterday morning for rates for the current year and they will have the kind of sickness which will need hospital treatment, of a type which the Minister will understand, before the rate collector comes to collect the rates.

Generally we have to read between the lines in legislation brought before us but in this case I do not think we will have to do that because what the Minister wants is spelt out quite clearly in the Bill. Despite all his flowery language and his talk about Luxembourg, the Netherlands and other countries that will not be much use to the unfortunate workers and the small farmers who in effect are asked now to be compulsorily insured and to carry the extra £5 million which the Minister anticipates this scheme will cost.

Does it not mean that in this proposed legislation, the Minister is asking the workers and the small farmers to pay this extra £5 million? Does it not also mean that the only benefit which will be got from this is that the 50p a day will be done away with? Instead they will have to pay something between £7 and £8 per year for the privilege, if they are unfortunate enough to have to go to hospital during the year, of not having to pay this 50p per day. Would anyone in this House suggest that any commercial insurance company engaged in this type of benefit would not give a much better bargain for that money? Would anyone suggest that the Voluntary Health Insurance Board would not give far better value for that amount of money?

I do not intend going into all the details of the Voluntary Health Insurance Board but after speaking to Deputy Tom O'Higgins this morning I feel he will have quite a lot to say about it. However, I remember when studying his proposed health plan and the proposals in it that he spelt out clearly and precisely the benefits to be derived from that plan and how the money to pay for it would be obtained. It was made clear how 85 per cent of the people would benefit from free dispensary, hospital services and home services on a contributory basis, one-third by the employer, one-third by the employee and one-third by the State. He suggested then that the cost of it would only amount to the price of a packet of ten cigarettes, that was about 1s 6d at that time.

The Bill goes some way towards the Fine Gael thinking on health services but I still believe in a contributory health scheme. This, of course, is one of the first mini-Budgets which we forecast in this House a few weeks ago we would have this year. The only thing we did not forecast was the indecent haste with which this Bill would be introduced. While we agree in principle with the contribution part of the health plan we do not agree that the underprivileged section of our people should be the people called on to bear this £5 million and for that reason we oppose the Bill.

With regard to social welfare and health generally there is throughout the country at the moment dissatisfaction among the people who are called on to provide the money for those services and there is also dissatisfaction among the people who expect to get those services. The regional health authority boards, as we predicted before the Health Act was introduced, now that they have had some chance of proving themselves, are a dismal failure. We should take adequate care of the underprivileged and the deprived section of our community but in this Bill we are putting the load on them. The Central Fund is being relieved of £5 million and no relief is given to the ratepayers. This Bill, for that reason, should be condemned and it should not get a Second Reading.

This party will not be party at any time to putting an extra imposition on the people who are less able to bear it. That is Fine Gael policy on health and social welfare. The ratepayers and taxpayers when they read the papers tomorrow, will not be convinced that there is anything here for them. They will realise that it is the first of the mini-Budgets of 1971.

Mr. Childers

If I may make a point, in order that the debate can proceed in a way that everybody will understand, I hope the Deputies are clear that 30 per cent of the people, the medical card group, are not paying this contribution.

Mr. Donegan

We are quite clear on that.

Mr. O'Higgins

At least the Minister had the kindness not to tax them.

Mr. Childers

So, the underprivileged include, according to Deputy Barry, the 60 per cent group, the middle income category.

Dr. Browne

This problem of health has been with us sufficiently long for the general public to get the impression that the way in which a health service should be organised is particularly difficult and complicated. There is no doubt about the frequency with which we appear to discuss this very important problem of our people, and the number of elections which have been fought on promises that good health services would be provided, but yet every piece of health legislation brought in here appears to be a very grudging step forward towards the kind of scheme which all of us know is needed in this country. Every scheme of this kind, as anybody can see, is simply another very threadbare piece in the makeshift, nondescript jigsaw which constitutes the health services, yet another step away from the attitude of the Fianna Fáil Party in their radical days in regard to the problem of the health services. Nobody knows better than the Fianna Fáil Government who have had such a good record on health legislation what is needed in this field.

To me these makeshifts are simply another manifestation of Fianna Fáil's betrayal of their early idealism in regard to the care of the sick, the unemployed, those without houses, and so on. This Bill is all a part of a very complex pattern. Listening to the Minister's apologia for his pathetic little scheme, one would think that in some way or another he is blazing the trail of a great social revolutionary, that he is a great pioneer, that he is introducing dangerous and hitherto untried schemes to improve our health services. We have been told that a high level group have been established by the Revenue Commissioners in order to work out all the complex tortuosities that will be needed to introduce a means test which will be no more than a reactionary and backward scheme hostile to the working classes. This is to be a new sliding scale means test which will be an advance on what the Minister has in the Bill.

We all know that this insurance principle in social legislation is a device of paternal, benevolent capitalism in its struggle to hold what it has, to resist the advance of social legislation through the acquisition and redistribution of the workers' income in the various social services of one kind or another, meanwhile directed exclusively to preserve the wealth of the wealthy minority. It is true that the minority of wealthy people is small but it is the wealthy minority, its wealth and property, that schemes of this kind help to ensure, whether they be schemes in regard to unemployment, old age or disability. Their prime purpose is to prevent and to obstruct any serious redistribution of the wealth in capitalist dominated societies.

That is the general principle in the EEC countries as well. Even in Britain, the welfare State, there has been no serious redistribution. I repeat that on the question of social legislation Britain is one of the most backward countries in Europe and we are well behind the British in our attitude to the collective responsibility of the community for welfare and care in sickness, in old age, in housing and in other social services. The welfare of the total community is the responsibility of the total community, not simply of the relatively poor, the middle or the moderate income groups.

The Minister has made his usual convoluted case for his niggling, unimportant little schemes, setting off pleasure, luxury, recreation on one side against some sort of self-denial, self-sacrifice, self-abnegation on the other—packets of cigarettes and pints of beer against the contributions for health services. Clearly, the goodies will always come down on the side of contributions to the health services, an infantile over-simplification and a misleading over-simplification of reality. The general inference is that the Minister is more concerned with our general social morality than he is with what is really his main objective, the protection of the really wealthy to see that they will stay as wealthy as they are and that their wealth will not be in any way interfered with or reduced.

Those are the people whom the Minister is protecting. He is not preaching a new form of high morality. He is not advocating a new puritanical outlook as to how the worker should spend whatever he may have. He is simply, consistently as he always has done, advocating and defending the rights of the wealthy privileged minority in this society at the expense of the ordinary workers—the white collar workers, and the industrial wages earners.

In all his other ministries the Minister for Health has always defended the privileged classes. He has always managed to provide a completely humbugging, hypocritical, high-sounding, phrase-mongering explanation as to why he has adopted this peculiarly selfish attitude to the policies he is adopting. This measure will bring in £5 million although it will be reduced by £700,000 by the abolition of the idiotic 10s. a day contribution, which the Minister has at last had the sense to get rid of because it was so administratively foolish.

He is taking this £5 million from people who will ultimately earn £1,600 or under. The people earning £3,000, £5,000 and £7,000 are saved from making any contribution towards this £5 million, although it could be taken from them in some form of taxation. Those gentle souled philanthropists who are about to rape County Meath to the extent of hundreds of millions of pounds worth of our natural wealth and the others in Tipperary and Galway are going to be saved from paying this £5 million because of their tax-free contract with the Government which enables them to take all this wealth out of the country. In order to give them those tax-free benefits people earning £1,600 and under, which is quite a small income these days, will be paying an additional tax because, of course, this measure is simply another form of taxation.

These people are already paying many taxes to protect, as I say, the industrialist with his tax-free incentives in order to make him keep his industry here. These people are paying this additional tax in order to protect the wealthy mine exploiters; they are paying taxes in the form of rates; they are paying taxes in the form of direct taxation, which is the highest in Europe; they are paying taxation in the form of purchase tax; they are, without a doubt, paying wholesale tax; they are paying their national health insurance contribution tax and I am quite certain that the so-called employer's tax is also paid by the consumer. I do not believe the employer pays that tax at all. It is simply treated as an item in the cost of the consumer cost and the consumer pays not only his own contribution he also pays the employer's contribution.

As I have pointed out before this was all thought up in the old benevolent paternalistic approach of resisting and was brought into the 20th century, as cleverly as they have been resisting it over the years, by the great Dublin firm, Guinness. They have provided social services and health services of one kind or another and they have got the reputation of being a remarkably kind, generous and good employer when, in fact, nothing came out of their profits at all, profits went up and up and up, a penny went on the pint and the consumer paid for the services they were providing to their employees. They were one of the first companies to catch on to this magnificent device whereby the unfortunate consumer, the ordinary, average person, believed he was living in an advanced, socially just society, the just society, as we call it. It is simply an accountancy device whereby money is taken out of one pocket and paid back in the form of social services of one kind or another.

No attempt has been made by the Minister to explain why the Fianna Fáil Party have abandoned the principle of their earlier approach to social legislation of this kind. I remember being attacked here pretty violently by a former Minister, Mr. MacEntee, because of my delay in introducing a free, no means test health service, which was based on the free, no means test principle and I have always given Fianna Fáil great credit for it. At that time they had not gone across to the radical change in fiscal policy when they realised that all these indirect taxes were excellent devices for taking money off the ordinary worker, and not only the ordinary worker but the ordinary worker with a large family, which meant that the larger the family the higher the tax. We have seen the change in their enlightened attitude to fiscal policy of the thirties and early forties and now a considerable part of the taxation is borne by the ordinary consumer and, as I say, the larger the family the bigger the consumption and the bigger the consumption the higher the tax. The higher the tax the family man pays the less tax the mine owner, the big businessman and the industrialist has to pay.

I always get the credit for the tuberculosis scheme but I was implementing a piece of Fianna Fáil legislation which had a free, no means test principle. The infectious diseases scheme also had a free, no means test principle. Why have we departed from that principle? The Minister has given no explanation. He has made no attempt to rationalise the desertion of this excellent scheme. At that time the Fianna Fáil Government were well up with the national health scheme, which, for all its defects, broadly was infinitely more advanced in its social morality and social attitude to this kind of thing, robbing the poor to protect the rich. Even if the old people were not treated better in the north, even if the unemployed were not treated better in the north, even if housing was not better, even if education was not better, probably the greatest single impediment, recognised by both the Unionist Protestant and the Nationalist Catholic, against uniting Ireland would be the national health service with all its defects, compared with the Victorian poor law means test in medicine which we have down here. Catholic or Protestant would be very foolish in the north, I have said it many times, and they know they would be very foolish, to come into this kind of society in which these kinds of services are put forward as panaceas for the very frightening needs and demands of health services. One in ten, the Minister tells us, will spend some of his time in hospital.

The Minister has made no attempt to defend his departure from this excellent Fianna Fáil principle. He cannot produce any medical grounds at all for the great achievement of the virtual disappearance of infectious diseases of all kinds—diphtheria, scarlet fever, typhoid, tuberculosis and all these things—directly due to the introduction of these magnificent schemes under the Fianna Fáil 1947 Act in particular. People say it is simply a question of new drugs making all the difference. This again is a dishonest over-simplification of the truth. One only has to look at East Pakistan. There are excellent ways of preventing cholera; there are excellent ways of curing cholera, but look at East Pakistan. There are many countries in which infectious diseases are still rife— typhoid, typhus, tuberculosis, child meningitis. The drugs are there, the medicines are there, the doctors are there, the nurses are there to cure all of these conditions, to prevent all of these conditions, but they are neither prevented nor cured.

It is the presence of the schemes readily available that makes the difference between life and death, life and disease, life and permanent disability, unnecessary illness, unnecessary death. It is the existence of the schemes and the availablity of the schemes. The wealthy people never had any great difficulty in dealing with preventable or treatable diseases. They could always pay their way. As long as they could pay their way they could save their lives and prevent themselves unnecessary pain and disability. Scandalous but true. That is the way society is organised.

It was because we had these schemes readily available under the Fianna Fáil 1947 Health Act that any great advances were made in relation to the improvement of our health services. We have now turned our backs on that. There is no way in which the Minister can justify the failure to continue with these excellent principles. I presume they are not frightened of the Bishops, or maybe they are, maybe this is their real worry. I find it hard to believe that Fianna Fáil could have run that far from their earlier traditions. There is no reason advanced whatever for departing from what we know to be an excellent basic principle in fiscal policy related to the creation of social services in a social democracy of this kind. All the Minister can tell us is that it has to be related to national income, it has to be related to national production. The usual performance. But the Minister is one of the most intransigent defenders of the capitalist system. He says it is infinitely superior to the socialist idea, a most obstinate——

Mr. Childers

The Deputy should not misquote me. I have perpetually said I believe, and Fianna Fáil believe, in a mixture of private enterprise and socialism. I have outlined that at very great length at least half a dozen times. A mixture.

Dr. Browne

"A mixture" are the operative words. "Confused" would be a better one. You can have all sorts of mixtures. You can have a mixture in which one predominates and the other is negligible or not noticeable. That is the one that I would say now dominates Fianna Fáil policy and that is a complete reverse of the attitude of Fianna Fáil in the years 1932 to 1939 when the interest of the mass was the predominating interest in the Fianna Fáil Party and led to major advances in health, social legislation, housing and so on. Fianna Fáil in my view can take virtually all the credit for this because of their preoccupation at that time with a different mixture to the one the Minister has now put forward. The mixture then was the mass against the minority. Now it is the minority's interest against the interest of the masses.

The Minister and the Government can make no defence at all of their present policy or no defence at all of their departure from their own policies. I have tried to show that taxation on the ordinary consumer is infinitely heavier than the Minister would appear to believe. I have referred to national health insurance contributions, purchase tax, wholesale tax and now this new health tax.

At least those with £1,600 a year and under are getting something for it. Unjust as it may be, they are getting something for it, but what about the unfortunate person with from £1,600 to £2,000 or £2,500 or £3,000 who has not got enough to be unworried about ill health and who is at least covered by the new type of insurance but has to pay on both sides? I am referring to the white collar worker who is paying for this scheme through various taxation devices and who is also paying to allow the wealthy Canadians or Swedish or British or Irish or whoever they may be, to dig our silver, or lead or copper or whatever it may be, out of the ground and export it at great profit to themselves, a policy which is now being rejected by almost all of the most backward middle-eastern and African countries.

If he is in any way conscientious he is also paying for the protection of his own and his family's health through the voluntary health insurance scheme, another patch in the patchwork, the pathetic, makeshift patchwork of our health services. That is his additional taxation. The voluntary health insurance scheme is, of course, a very selective scheme. A person is not allowed to benefit from it at all if he has a bad health record, and nobody needs it more than the man with the bad health record. He gets no general practitioner cover. He gets no chemist bill payment, an even greater need than general practitioner cover these days because of expensive drugs. He gets no maternity benefit for his wife, which is probably the costliest of the whole lot and which he is encouraged to qualify for at least once a year if he is a professing Catholic. He is advised not to indulge in responsible family planning and contraception.

So, the lot of the unfortunate person with £1,600 a year and under is bad, but the lot of the person with £1,600 to £2,500 or £3,000 a year is worse. He is the unfortunate who is crushed between the upper and nether millstone. He pays tax to help the people with £1,600 a year and under, and to save the people with £3,000 a year and upwards. Then he pays his voluntary health insurance scheme contribution. Then, in addition to that, like almost everybody in this society, he has to pay tax on his hire-purchase commitments. There are taxes all round. They are most complex.

The unfortunate salaried person or wage earner has a treadmill kind of existence. Everything that comes in at the end of the week or the month is already opted for, somewhere or other: rates, taxation, health contribution, health insurance contributions, social welfare contribution and hire-purchase commitments, in this wonderful society in which the one great thing is to own property. I do not suppose that 5 per cent of the average suburban householders or families own 2 per cent of their property, including their houses. Hire-purchase companies own their fridge, their radio, their television set, their motor car, in some cases their clothes and in most cases their house. This is the great property owning democracy.

These are all taxes which these unfortunate people have to pay and the Minister is making no attempt whatsoever to help them in this piece of legislation. The Minister makes no attempt, and has never made any attempt, to explain why it is that if people are successful in their work, if they get up the promotional ladder in their jobs, this indirect tax on thrift, which is what it amounts to, inevitably hits them. If a person has £1,601 a year he and his family are out of benefit. Contrast that with this continuing plaintiff concern for the wealthy person. Unless he gets this tax concession you cannot expect him to work that hard or to make his business a success. Unless these mining people get their tax concessions you cannot expect them to dig the silver out of the ground. They have to be helped to do this.

It is really inconceivable that any thoughtful, intelligent rulers of any society would attempt to rationalise that kind of behaviour. These people must be helped. These people must be encouraged. Taxation must be reduced. They must be protected at all costs and let the white collar worker or the manual worker pay. I think it was Deputy O'Connor who was told yesterday that we will find ourselves paying more tax, that the Central Fund will have to compensate these people who are being good enough to come in here and take away our natural raw materials and riches, which could have so improved the quality of life for our own people here if we had developed them ourselves. We will have to compensate them for the wonderful prosperity promised to us should we enter the Common Market.

The tax remissions will have to be paid. We have committed ourselves and we will honour our commitments. They will be honoured, of course, by the same tax packhorse now used exclusively, virtually, by the Fianna Fáil Government, the ordinary white collar worker and the manual worker. Their taxes will go up. Taxation will be increased and the promises of the Fianna Fáil Government redeemed at the expense of the consumers. The Minister has made no attempt to defend his present proposals except to say that the money is not available. He says that the rate of increase is out of all proportion to the growth in national production. Whose fault is it that national production has not grown fast enough? Fianna Fáil have been in office, with only a few breaks, since 1932. Is it an act of God or is it a record of consistent inefficiency that the growth in national production has been slow? Might it not be due to this implicit faith that the Minister has in pragmatic capitalism? There may be the occasional spot of radicalism but capitalism is predominant in our society. The Minister tells us constantly that capitalism is the better system. Why, then, does he not make it work? We have been told that each of the other Departments is competing unsuccessfully with each other for more money. There is no Minister who does not come here and say that he cannot get money because all the money available is going to some other service. For instance, the Minister for Education may say that the old people are getting the money while the Minister for Social Welfare may say that it is going towards housing, or that roads have to be constructed.

With the exception of Portugal it can surely be said that we have the most inefficiently run and unjust society in Europe. We have not the money for schools, for universities, for roads, for swimming pools, for the care of the aged, for the unemployed or for the small farmers. Who, then, benefits from living in this society? The only ones who benefit are the wealthy minority. These have a wonderful time. They have an 18th/19th century existence—hunting, shooting and fishing. For them, this is a great place to live. We ask tourists to spend their holidays here but we must tell them they cannot stay for too long unless they can pay their way. Is it possible that the wrong economic policies have been adopted for our problems? Capitalism cannot work as has been proved in the US which is the greatest capitalist society in the world. The only countries in which the mass of the people are better off than in any capitalist society with the exception, perhaps, of Sweden which is ruled by social democratic parties of one kind or another, are socialist countries.

Mr. Childers

If everybody will be able to discuss the entire social philosophy of the State and the philosophy of capitalism as opposed to communism, we shall be here until the middle of August.

Mr. O'Higgins

Why not? This is an important matter.

Mr. Childers

That is all right so long as the Deputy can be here then.

Mr. O'Higgins

The Deputy has been living with this problem for many years.

Dr. Browne

We are dealing here with a very important subject. Our people suffer because of misguided people such as the Minister who, in spite of what anybody can see for himself, continues to advocate policies that have failed time and again at the hands of people who are dedicated in such policies. There is not one Minister who could not use more money but he cannot have it. Nobody can now say that this is a poor country. We have listened to such excuses and explanations for the past 50 years. It is now clear that we are one of the wealthiest countries in the world but the money is in the hands of the wrong people. It is a long time ago since a former Taoiseach, Mr. de Valera, said that if the system does not work, we will go outside it. Surely we are now justified in going outside the system. Makeshift solutions will not solve our serious problems concerning health. We have not been able to solve the problems in any sphere in our society in spite of the fact that we have now a population of a million less for which to provide these services. In so far as health is concerned we are probably unique in that we have had to pay virtually nothing from the Exchequer towards the building and upkeep of hospitals, which expense must surely be one of the most costly components of an efficient health service but which was provided for us out of hospital sweeps funds. During my term of office as Minister for Health, I spent £30 million all of which came from the sweepstake funds.

I shall not develop the obvious case why, down through the years, we have under-used grossly the prerequisites of the healthy formation of our society. Land has been grossly under-used; agriculture has been virtually stagnant for a hundred years; labour has been at least 7 per cent or 8 per cent constantly unemployed; one million people have emigrated and £1,000 million has been invested abroad. The money of the good patriots has built railways in South America and other places but apparently it was not available for development in Ireland. These three prerequisites of wealth have been grossly under-used and that is why we have not the money to finance the services we need. It is nearly as simple as that. Successive Governments have consistently deluded themselves into the pleasant belief that they should and must continue and that there is no other solution.

The Minister talks nearly in terms of regret of the astounding expansion of medical technology and of the increasing life-span of the average man. One gets the impression of petulant impatience because these people continue to live and make demands on the health services when, if they had any sense of patriotism, they would get out of the way and save us having to spend this money. The expenditure of money on our health services started at such a pitifully poor base line—the Victorian poor law health services— that practically any expansion would be a noticeable advance and would mean a significant appreciation in the amount spent.

I have the impression that the motivation behind this proposal is to keep up with the Joneses in the EEC—that somehow we must have some kind of contributory scheme to make us acceptable to the other EEC countries. It is not motivated by concern for the ordinary Irish man or woman. As usual, the Minister sees only one side of the balance sheet. To quote Bevan's words, the Minister has the wonderful capacity of the "desiccated comptometer or accounting machine". People continue to live because of the advance in medical technology. Most of us are glad that this advance has taken place —people who can pay for it are always glad that this is so.

However, there is another side to it. A number of the infectious diseases institutions are empty and are being used for other purposes; I would mention fever hospitals and TB institutions. There are young people who do not get the dreadful diphtheria that formerly choked young people to death because now we spend money on vaccination services. Young people do not get meningitis; families do not lose their breadwinner as they might have done in the past when infectious diseases caused deaths. There are very few bad cripples nowadays—hunch-backs, deformed people and the like. There are very few who spend their lives lying on frames; nowadays people spend less time in hospitals where they are isolated from their families. There are less people suffering pain and distress. Could the Minister not look at health expenditure from that point of view—that there are benefits from the expenditure on health services and, in particular, on the preventive health services?

Even if the Minister is not impressed by humanitarian reasons for spending money on health services, will he not consider that it is good business to spend money for this purpose? There are less people out of work and they are out of work for shorter periods. Would that appeal not influence the Minister? The Minister appears to get some comfort from the fact that other countries are spending more money on health services. Yes, people are becoming more conscious of their responsibilities to their fellowmen. This Christian ethic is being imposed on them by literacy and education and by the example of socialist countries. They are being forced to become more civilised.

There are some other points arising out of the Bill itself which we will deal with in greater detail on Committee Stage. If the scheme as set out here goes through, could the Minister at this stage tell us what he proposes to do about the general practitioner service? Is it the Minister's intention that this service will be available to those people earning £1,600 per year or less in the new scheme being negotiated with the Medical Union and the Medical Association?

In this scheme what is the arrangement about payment for drugs? Drugs are a very important new development in health services, as the Minister said, and there are a great many people who use drugs of one kind or another as a result of therapeutic advances. One gets the impression that the Minister is going to leave this matter open: there will either be a contribution towards payment for drugs or there will be a special appeal in certain cases, as there is at the moment. A person who is not now eligible can apply for assistance but this is a very clumsy way of working. The Labour Government in Britain departed from the original principle by introducing charges for prescriptions and it looks as if the Tories will move even further away from that principle.

The Minister talked about assistance with chemists' bills. What has he in mind? Illness can strike very suddenly and unexpectedly. Bills have to be paid. When the patient is well again and back at work the whole dreary process of applying for assistance with chemists' bills is more than most people can stomach. The existing scheme has been availed of to only a very slight extent. There is a means test. This means test, where health services are concerned, is something nobody seems to be very clear about. Bad as the existing means test is, the new sliding scale will be worse unless some special body devise a scheme which will work fairly and efficiently.

I object to these means tests on ideological grounds. The main objection is to the creation of different qualities of health services. Certainly that was the evolution in the past. A stronger argument against a means test is the necessity for setting up a bureaucratic control exercised by people who will interpret the regulations according to the law rather than according to the spirit. Such a bureaucratic machine is very costly, so costly as not to be justified.

A scheme which does not include free medical supplies is one which is bound to increase the fears of people. Illness does not lend itself to the Minister's accountancy type of actuarial approach. People do not choose to fall ill and, when they do fall ill, it is a very frightening and worrying experience, not only for them but for their families. Illness is something every normal person tries to avoid. No one wants to be faced with chemists' bills, doctors' bills, technicians' bills. For that reason people tend to delay going to the doctor and that means delay in diagnosis and delay in diagnosis means a worsening of the patient's condition and that worsening results in an increase in the cost of treatment and care.

The Minister professes to be worried about the cost of our health services. He may feel he is making a saving by putting in these charges of one kind or another. The 10s per day charge was removed simply because it was not worth the cost of collection. The Minister may appear to save money but in the long run the saving will be vitiated by the cost of the treatment required. Fears with regard to health services that can be removed should be removed and, if such fears are removed, the Minister will save a good deal more money. There is no general practitioner scheme in the VHI scheme and there is no domiciliary or out-patient care service. I suspect that is one of the reasons why the Minister is now so very concerned about the degree of bed occupancy. The only way a person can benefit under the voluntary health insurance scheme is by going into hospital. It is in a sense an illustration of the way in which medical practice can be changed in its orientation by ministerial policy or the policy of the Department of Health. Nobody doubts that there are many people in hospital much longer than they need be; that is generally accepted, because support services, laboratory services and so on, are not available before the person goes into hospital. He goes in on Saturday, stays Sunday and tests start on Monday and nothing is done for the person until Friday or Saturday—five days wasted. I am sure the Minister knows about that.

These seemingly over-generous attitudes to social and health legislation— to me simply humane attitudes—in the end, save money. The Minister has already experience of that in relation to the health services, how the number of people falling ill from infectious diseases is practically negligible and very limited because of enlightened health legislation introduced exclusively by the Fianna Fáil Party. There is no case for the perpetuation or extension of this serious departure from that excellent general principle—general, free-of-direct-payment, no-means-test principle of the earlier Fianna Fáil Party health legislation.

Mr. Healy

We in public life know the increasing demands by more people than ever before for better health services. People who in the past had mentally or physically handicapped children were inclined to hide them away. Now they are encouraged and are sufficiently enlightened to bring them for treatment, with great benefit as a result. I do not intend to speak at length on this because it seems to me that increasing services demand more money which must be provided. When I hear, as I did this morning, talk about the late Dr. Ryan's Health Act and how much it was supposed to cost I am amazed that we should talk like this because at that time I remember quite well, while 2s or 2s 6d was mentioned, the services available now were never envisaged. It was only the thin end of the wedge, a beginning, but it was a great breakthrough. I would remind Fine Gael speakers who mentioned this that as far as I remember they bitterly opposed that Act and I do not understand why they should now talk about it as if we should still be at that stage without having made any progress. There is no comparison, thank God, between the services now and what were then available. If we have to reduce expenditure, does that not mean cutting out services that are essential at present?

I believe we must continue to improve services and make more services available and somehow find the money to do so. The services now provided are improving rapidly. As the Minister said, it now costs £72 million from the Exchequer as against less than £10 million in 1951-52. But we can see the results: we have first-class medical advice and services; nursing conditions have improved out of all knowledge— they probably need still more improvement—and so have the conditions of hospital staffs. We have improved hospital equipment, some of which is very expensive, and it is now available at several centres. The hospitals themselves have been improved and we have provided clinics. Research work is being done: one could speak at length on the improvements even in the past ten years. This is all necessary and desirable but money must be found for it.

Mental services are being improved but we all know there is tremendous work still to be done before those services can be brought to a satisfactory position. Mentally and physically handicapped adults and children are now being cared for and treated sympathetically and to their benefit. Placement officers have been appointed to look after them so that the treatment of their ailments is not the final word; they will be so placed as to be useful members of society. These steps were not even envisaged 20 years ago. It can be said that we had other problems, slum dwellers and infectious diseases, which were hereditary through the conditions in which we lived and which are now eradicated. We still have a tremendous amount to do and money must be provided.

The previous speaker referred to the socialistic system and what could be done under it: I shall not follow him on that because we are working, rightly or wrongly, under a different system and the funds must be provided under that system. Personally, I am satisfied so long as there is a clause in the legislation which prevents undue hardship. This is mentioned in the very first paragraph: "...a scheme of reasonable contributions towards the cost of health services by those who are eligible for them and who can be regarded as able to pay such contributions without undue hardship...." That is the safeguard about which I am most concerned. I have worked since their inception in a health authority who have been, I would say, almost benevolent in their interpretation of the hardship clause. I have yet to meet a public representative in Cork who has a fault to find with the interpretation of the hardship clause in regard to the granting of medical cards or reduction of hospital bills. That is a very import-and section of the Bill and should satisfy many people.

It will be a great relief to many people to know that when they or any members of their family are hospitalised they will be free of any bill. We in public life should also be relieved because people are continually coming to us and saying that the 10s per day should be reduced. One of the things I regret is that they get the bill as a lump sum at the end of their stay in hospital when it has mounted to perhaps £10, £15, £20 or more and they find it difficult to pay even though it is assessed only at the rate of 10s a day. We have been requested to have it reduced to 6s or 5s a day and have had to make representations because the payment involved a certain hardship. In most cases, if the amount was not reduced, deferred payments would be accepted. The fact that people need not worry about hospital bills for themselves and their families is a great relief which is well worth contributing towards as an insurance policy. It is an insurance policy and as such should be welcomed. I am not one of those who believe that everybody should get everything for nothing. It is right that people should learn to be thrifty, to put something away for the rainy day, to save for health purposes just as they do for holidays and other things.

There is a case to be made for providing relief for the person who has a good income but who has to meet heavy medical expenses because of the presence of a handicapped child or a chronically ill person in the family. Those who enjoy good health are the wealthiest people in the community and they should contribute towards those who are not in that happy position. It is a duty and should be so regarded. We are urged to help the poor not only of our own country but of other countries. We should need no urging to help those who are ill and in need of medical care. The thing that I welcome even more than the State expenditure on medical services is the tremendous upsurge in voluntary help which is given so willingly and generously by hundreds of people to those less well-off than they are. In the city and country of Cork there are many movements absolutely depending on the voluntary assistance that is given so generously. May I mention in particular the Mental Welfare Association who have done tremendous work for patients in mental institutions, taking them out, reading to them, bringing them to the theatre? This is something that we can be very proud of. No matter what the State may be able to do in the future, it will never be able to replace the voluntary organisations. It should be realised that there is always need for the voluntary worker, that his or her services are irreplaceable.

This money is needed for the expansion and improvement of the services. We may differ as to how the money may be raised and as regards the people who may have to pay it but there is no difference of opinion about the fact that the money is necessary and that it will be well spent. On this premises the Minister has gone to great pains to see that those who benefit in future, as we all may, will pay something, that those who are unable to pay will not be asked to pay and those who have to pay are those who can afford to pay without hardship. For that reason I welcome the Bill.

Mr. O'Higgins

That people should be encouraged by insurance to provide while in good health for the hazards of illness in their own case and in the case of their neighbours is a sound social principle and one that has been advocated from these benches for many years—a sound social principle because by means of community effort, by means of social insurance, the community can supplement, but not supplant, the efforts of people to provide for themselves. That is the basis of the claim for social insurance in our health services.

To the extent that this Bill smacks of insurance it does merit attention though I note that the Bill in its Title denies the insurance content. The Title is the "Health Contributions Bill" and, frankly, I am not surprised. In my view, this bit of legislation is a tawdry exercise in public deception and it is put forward by a Minister for Health who should be thoroughly ashamed of his proposal. Indeed, it is in keeping with the last 20 years and the whole sordid story of the exploitation by Fianna Fáil of the problem of ill health in this country for short-term political purposes.

Reference has been made to the Health Act, 1953. Deputies who were in this House at the time can well recall the claims made on behalf of that kind of legislation. The people were promised under the policy enshrined in the Health Act, 1953, as a Bill going through this Dáil, that there was going to be a new era in health services, that without cost to themselves a paternal State was going to provide developing health services for the sick and the needy, the underprivileged and generally for the mass of the people. In the general election of 1953 the Fianna Fáil slogans were: "Should wealth buy health?"; "Vote for Fianna Fáil to ensure free health services". Of course, that was not true, it was not accurate, and it was in itself an exercise in public deceit just as this Bill is. There was no intention of providing anything adequate in the way of health services free for the people, because it could not be done; our resources could not have permitted it; but the people were fooled into believing that that was what would happen and, of course, the proposer of the legislation and of the policy contained in the Health Act, 1953, in the events that had happened, did not have the responsibility placed on him to see that Act put into operation. Unfortunately, that was my lot.

As Minister for Health I undertook to Dáil Éireann, despite my views on the policy contained in the Health Act, 1953, and the views of my party, that if it were possible at all I would see that the Act was fully implemented before I left office. That undertaking was fully discharged. What was the Health Act, 1953, and its policy? It was, in effect, a re-enactment by this Dáil at that time of the poor law relief system of medicine that had represented the public charitable disposition of the imperial Parliament of a century ago. We had the dispensary system of medicine—no longer called such—available for those who, in the terminology set out in section 14 of the Health Act, could prove that they were totally unable to provide for themselves and their families by their own industry or other lawful means. In other words, it was incumbent under that Act on a person who had been promised free health services by the Fianna Fáil Government to prove that he was a pauper. Having established that and having gone down on his knees before some employed inquirer, he came out with the badge of entitlement, the medical or blue card.

The dispensary system of medicine under the Health Act, 1953, was Fianna Fáil's gift to the Irish people. There were means tests. It was my unfortunate obligation at that time to endeavour to put the Act into operation. In doing so, I made it clear that I did not believe it was right or proper that we should try to advocate a paternalistic attitude towards health services. In the first place, I do not think that this is possible, and anyone who advocates that type of approach is asking people to look forward to never-never land. I believed that the State had a direct responsibility to supplement what an individual could do for himself, his family and dependants—supplement but not supplant. Believing that, I suggested that there should be some immediate examination and appraisal of the possibility of health insurance in this country. Some people said at that time that such an idea was just not feasible because we did not have the centres of population and the large sectors of people in industrial employment, such as are found in England, on the Continent and elsewhere and which make such a plan feasible. The inquiry continued and the first fruit of that investigation was the suggestion of voluntary health insurance outside the Health Act services. I am not going to talk on that subject. It is history now. That proposal was criticised, attacked and jeered at but the scheme went into operation and has been a very significant success.

Following that experiment in insurance my party in particular considered the feasibility of providing a comprehensive medical service based on the principles of social insurance. The inter-Party Government had left office at the time, but the work went ahead. What we sought to do was to provide for all persons a full domiciliary, medical service with free choice of doctor, free hospital services, free specialist services and a free mother and child service. It was part of the proposals that all services and medicines would be provided free of charge to a section of the people who had been known as the lower-income group, and who had subsequently been called "those entitled to full eligibility", but to a sector of the population totalling 800,000 people. In relation to others, the scheme envisaged the provision of drugs and medicines at half cost based on a national list, and the provision in the same sense of dental, ophthalmic and other medical appliances. The scheme also envisaged an adequate domiciliary nursing service for the sick and the aged and the development of measures for the home treatment of people. That was what we proposed to achieve. The result was that we were able to put forward, ten years ago, a viable scheme based on the existing hospital and specialist services under which all these services could be provided for a contribution of 1s 6d per week from each employed person, a similar contribution from the employer, a contribution of 2s per week from each farmer and a contribution of 2s per week from each self-employed person within the scheme. The ambit of the scheme covered 85 per cent of the population. The State paid its one-third and would continue to pay as a contribution towards the scheme the cost of providing the full services for the 800,000 people in receipt of social welfare assistance of one kind or another.

I mentioned that ten years ago, based on the existing hospital services, a scheme along these lines could have been financed for a contribution by a worker equated to the then cost of ten cigarettes. Of course, our proposal was ridiculed by the then Fianna Fáil Government. In fact, I remember a Minister for Health at the time saying: "What you are proposing is a poll tax on people. You are proposing to tax people at the rate of 1s 6d per week. We could not have that."

Fortunately, however, these Fine Gael proposals at the time attracted considerable public support and sympathy, and although I was well aware that the Fianna Fáil Government had no intention of implementing them, probably because they had emerged from this side of the House, nevertheless, political expediency at the time dictated that something should be done. As a result a Select Committee on Health Services was established some years later. I do not want to go into the history of that committee. Suffice it to say that it was intended to bury in the limbo of forgotten things all proposals in relation to health policy and its development. However, I went along to that select committee on behalf of my party. After the period in which submissions were taken from different bodies and different associations concerned with health, most of whom recommended the introduction of a health insurance scheme, I eventually submitted, on behalf of my party, our concrete, detailed, costed proposals, and the Minister has them available over there if he asks his advisors on his right-hand side. These proposals were detailed in relation to the cost of a general practitioner service at the time, because it was only that stage that had been reached at the select committee.

What was the result? The very instant the Fine Gael submission in my name was presented to the select committee, an emergency meeting was held by the then Minister with his advisers, and the select committee never met again. That was the end of it. It never reported. It never made any recommendations. It suddenly blew up because of the circulation of a Fine Gael document indicating the feasibility of a comprehensive national scheme based on insurance.

What happened then? We had subsequently the circulation to Deputies of a White Paper on Health Services. We had all the feinting, the dodging and the shop-window display that something was going to happen, but nothing ever happened: a White Paper on the Health Services followed by an alteration of health bodies, a change eventually in the Health Act of 1970 —a play on words. The term "lower income group" was dropped and instead of that the term "full eligibility" was used. The term "middle income group" was dropped and the term "limited eligibility" was used. You had all this posturing, this verbiage but, fundamentally, no progress whatsoever. There still remained the dispensary service. There still remained the means test. There still remained the medical cards. There still remained the situation in which we as a community were the only community in Western Europe who had not provided in some fashion for a comprehensive medical scheme for the entire people.

After all that, the Minister comes in, in a hurry, with his miserable little Bill, a Bill circulated to Deputies on Saturday and Dáil Éireann asked to take it today. The mountain has been in labour and what a puny mouse has emerged—the Health Contributions Bill, 1971. Our people have a saying that they do not like to buy a pig in a poke. What is the Minister asking the people to do under this enlightened legislation today? He is asking all the workers, all the small farmers, as a group, to pay £5 million and he will give them back £700,000.

That is what this Bill is about. It is nothing more than that. The cost of providing free hospital in-patient services to those from whom it is collected —and in many cases the collection is not effected—is £700,000. At the moment the small farmers and the workers have out-patient services available without charge. For the in-patient service they pay 50p per day if they are in hospital. There are the other existing services: the provision of drugs for diabetics, longterm illnesses and so on, the operation of the hardship clauses and all the rest of it. The one thing in respect of which there is a charge is the in-hospital service of 50p per day. The Minister says: "This is grand. Every worker will pay 15p per week from this on. Every farmer will pay 25p per week from this on. The total contribution you will give me is £5 million and I will drop the £700,000."

I do not think there has ever been a more daft proposal put forward. It is not as if new services will be provided; not at all. What is there is there and will continue to be there, the only change being that the 50p a day goes and for that every worker will pay 15p per week and every farmer 25p. You pay £5 million to get away with £700,000.

If anyone went around trying to sell 7p for a £5 note he would be locked in one of the Minister's institutions very quickly but that is what this House is asked to do. This Bill was introduced by the Minister this morning as if it were an enlightened piece of legislation marking a great step forward in the progress of social thinking. It is no such thing. The Minister is being used as a pawn by the Minister for Finance and this House is being used, by using the motive of a better health service, to tax the workers and farmers and shift from the Central Fund on to the backs of the workers and small farmers a burden which up to now has been borne by the Central Fund. That is what this is about.

The sum of £4.3 million is going to be collected in taxation from those who are affected by this legislation. May I use the phrase used so often by former Ministers for Health in relation to insurance: "This is a poll tax." It is a capitation tax imposed on people who get nothing in return except what they have already. I do not understand the thinking behind this. I do not understand what it is hoped to achieve. Of course the costs of health services have increased and are increasing. All these things will continue to cause apprehension and anxiety to the taxpayer and the ratepayer and everybody affected, but is this the way to solve the problem?

The trouble with this kind of legislation is that it will get insurance a bad name. When people are forced to contribute to something which they have enjoyed free for many years past they will react against the whole idea of social insurance and that is what I fear. I suggest very seriously to the Minister that he take this tawdry proposal away and think again. This proposal does at least give some evidence of a conversion in Fianna Fáil towards the whole idea of health insurance but why not make a proper job of it? Why not investigate now the feasibility of a comprehensive health scheme including the general practitioner health service, the service for the handicapped and the underprivileged and all the other services? Of course it would be much dearer now than it would have been ten years ago—it would not be financed by the cost of ten cigarettes—but it is a worthwhile proposal because it would remove for ever the appalling situation in which the development of health services in different parts of the country depends upon the exigencies of local rates. It would remove a situation in which different standards seem to apply in different parts of the country because of local financial considerations. It would make people realise that the improvement in health services was something they were financing themselves. It did not come from any paternalistic State or any paternalistic health authority. I believe we could do it. It would be worth the further study involved to scrap all these bits of legislation which we have now and get down to the job of distilling and developing a national health policy in accordance with the traditions, instincts and history of our people.

Deputy Browne was perfectly right when he suggested as a possible explanation for this Bill, apart altogether from the obvious financial one, that with Europe looming up we have to appear to wear some suit of clothes. We could not go ino Europe at the moment. They would look at us as though we were some sort of queer insect brought in from outside. They would say: "You have no comprehensive health services." They would not understand the delayed kind of thinking which would permit that sort of situation to arise. Is this an effort to put up some pretence in Europe that we are doing something worthwhile? If so I do not know who is going to be deceived. It amounts to nothing. It is a frothy bubble. With the advent of Europe it would be much better if a new examination could be made and the whole matter of health policy removed from political controversy.

If the Government thought that kind of development would be possible I can assure the Minister he would get every co-operation from this side of the House. If he wants an all-party examination again he will get our help provided the target and the aim is to provide a comprehensive scheme which is available to almost all the population so that we can get away from the present system which is based on the erroneous idea which operated at the time of the Famine, when it was considered that a dispensary system of medicine was all that was necessary to meet the needs of the starving, dying people. We must get away from that idea. If we could develop the idea that every man who is in good health and is working should contribute each week so that a fund would be created by means of which ill health affecting any of his neighbours or himself could be paid for, everybody would know that he was providing this himself; he would know where the money was going and that no poll tax was involved and that his contributions were not being used for any other purpose. In that way certainly and with assurance we would be moving in the right direction.

Mr. Childers

There is no comprehensive system of insurance in Europe.

Mr. O'Higgins

I suggest the Minister re-examine that because it is not true.

Mr. Childers

There are enormous subsidies either from the State or from the municipal authorities for the hospital services. The Deputy should be honest about that.

Mr. O'Higgins

I can assure the Minister that is not so. There is one in England, there is one in the North of Ireland, there is one in Belgium and there is one in Germany.

Mr. Childers

No, the insurance paid almost nothing to the health services.

Mr. O'Higgins

There is no comprehensive insurance.

Mr. Childers

They only have a minute proportion. The rest is general taxation.

Mr. Carter

How much does the Exchequer contribute to the scheme in England?

Mr. O'Higgins

I do not know. I have examined the commission on the costing of the health services in England. It indicated roughly about one-third.

Mr. Childers

The insurance pays only a minute proportion of the total cost of the hospital services.

Dr. O'Connell

We in the Labour Party are very much opposed to this Bill. We think it is a fraud and a farce. It is obvious to us that Fianna Fáil have now aligned themselves with the wealthy classes. Here we see 10 per cent of the population excluded from this. These are the people Fianna Fáil have decided should not come under this scheme. They are not expected to pay any money towards this service even though they avail of this service. If the Minister is thinking of contradicting me on that I would refer him to sections of the Health Act. The child health services are available free of charge to the wealthy classes under the Health Act, 1970. They will not pay one penny towards this scheme. This is further proof that Fianna Fáil have aligned themselves with the wealthy classes and decided once again to tax the middle income group. This is selective taxation which we will not condone and will oppose with everything we have.

The Minister gives us his reasons for this and he spells out the services which will be provided under this Health Contributions Bill. He talks about the in-patient service. We know that only 15 pence per day is collected on average for the in-patient service. We also know that the cost of administration is as high as 50 per cent so that, in fact, only £350,000 is collected from the in-patient hospital service. I cannot see how it requires a Health Contributions Bill to provide that service especially when the Minister will collect £5 million. I saw this some months ago. I opposed it. I thought it was an attempt at a new form of tax levy on the middle income group exempting, once again, the wealthy classes. I wonder why the Government could not have delayed this. I think it is another blunder by the Minister for Finance in an effort to get in money fast. This Minister has made many blunders over the past year and this is another. He has decided to try this new manoeuvre to collect £5 million in taxes. The benefits it will provide are negligible.

The out-patient services are available free. It was not economic even to arrange for collection of the amount payable for out-patient services so the Government found it economic to dispense with payment for out-patient services. That is why they are provided free so that is no benefit. We can omit that. On the in-patient services they have only collected an average of 15 pence a day and administration costs 50 per cent. That can be eliminated. The infant care service has been available and is available to all under the Health Act, 1970 so there is no reason whatever for the introduction of this Bill. No genuine reason has been given by the Minister for Health for it.

I came into the Dáil in 1965. It was obvious in that election campaign that the people were dissatisfied with the health services so a White Paper was prepared and after dilly-dallying and pussy-footing over the years it is only now we are seeing some kind of agreement being reached with the doctors. It is obvious to me that the reason the Minister has agreed on the latest offer and the reason he made this latest offer is that he is assured now that some income will come to pay for this service from this Health Contributions Bill. This is very obvious because he cannot even gauge the number of items of service which a person may have or year by a lower income group patient. He said he would agree and I dare-which will be used in the course of a say had the negotiators held out a little longer he would still have agreed and there would have been a final, final, final offer knowing that he would have obtained some of this £5 million to finance this scheme. This is exactly why he is doing this.

I wonder why the Minister could not even have extended this scheme to include the upper income group, that 10 per cent, the 300,000 people who are exempt from this. I wonder why he did not include these and, perhaps, with a graduated set of payments charge them 30 pence per week. This would have brought in £4.8 million in the year. We are entitled to charge these people and I do not think any director with £2,500, £3,000, £4,000 a year would object to 6s a week towards the health services, more especially as they are availing of the services already. The child health services are free to them and now I shall explain how the hospital services are free to them.

They can go in and are being admitted to general hospitals for general check-ups. They are being charged the full hospital charge but that does not take into account the subsidy paid by the Department to voluntary hospitals to cover their deficits. Therefore, this upper income group are getting a subsidised service. They are not paying for this through any health contribution and, again, it falls on the middle income group to bear the burden of this.

It has been obvious to me over the past few years that when improvements in social welfare benefits are granted to various groups like the disabled and old age pensioners the burden again falls on the social welfare contributors. In every case their contribution is increased. These are the people who are asked to finance all these benefits. It seems the Government are determined once again to impose an extra burden on this same group.

What will happen to the person above the £1,600 a year limit who is working overtime? Also, under the 1970 Act the income of the spouse was included and if their incomes exceed the £1,600 limit what will happen to them? We should pay special attention to these people because they will be outside the new scheme. The fact that the payment is made by the employer for the medical card holder makes it very embarrassing and humiliating for the medical card holder. His personal affairs will be known to the employer. This places a stigma on him and he could be discriminated against since the employer might not want to continue to employ him if he is told that he must pay the contribution. This gives rise to an anomalous situation. It should have been possible to make some other administrative arrangement instead of asking the employer to pay for the medical card holder.

I wonder why the small farmer is penalised. He is asked to pay but the large farmers with the large ranches are not included in this scheme. They form part of the 300,000 people who are exempted from the scheme but can still avail of the hospital services free. We in this party want the health service to be a comprehensive service embracing all groups and providing a proper service, including a general practitioner service and a specialist service. If those in the upper income group do not want to avail of these services, they should be compelled to pay and, if they feel for snobbish reasons or any other reasons that they do not want to avail of them, we say by all means let them pay for a private service. We would have no objection whatsoever to that, but they should be compelled to pay. If a proper scheme was proposed we in this party would support it wholeheartedly, knowing that there would be no discrimination and no means test. If we could rid the health service of this iniquitous means test we would have achieved something very useful for the community.

We know that at the moment we are discriminating against the lower income group. We are humiliating them and placing a stigma on them. We are forcing them to give details about their household. We have inspectors calling on them. We are making life intolerable for them. We are forcing them to prove that they are impoverished, and to prove that they are entitled to a free service. Why be hasty with this Bill? It is badly drafted. As I said, it is a farce and a fraud. If we had devoted a little more time to it we could have produced a Bill which would bring in enough revenue to provide a comprehensive service. This could be done within the next year. It would not involve putting a tremendous burden on the Exchequer. It would relieve the people who are most in need and it would force the wealthier classes to pay. If we could do this we would have performed a very useful task.

This Bill might be regarded as the forerunner of a proper comprehensive service if it embraced the 300,000 people in the upper income group. If we had imposed a levy of 30p per week on those people, we would have ensured that, even though they might not want to avail of the service they would be paying for it, just as the lower income group and the middle income group will be paying for it under this Bill. It has been obvious to all that health costs were becoming a bigger and bigger burden on families. People are realising this more and more because of the difficulties they are experiencing. We have never endeavoured to spell out who is entitled to free medical services or, as the Minister said in the Health Act, 1970, who is covered by full eligibility. This has never been determined. I could never say. It depended on how good a case you could make or on how a person could state his claim for a medical card. People had to disclose intimate details about their household and their illnesses to civil servants. I always thought this was very dangerous.

People are discontented and disgruntled because they can see that, in some instances, the family next door with a better income gets a medical card and they do not, for no apparent reason. If we had devoted more time to this we might have been able to establish elegibility and to go a step forward and make the service available for one and all. Since the Minister and his predecessors have spent so many years in discussing with the medical profession the terms for a fee per item of service method of payment, and since it is obvious that agreement is being reached, it should have been possible to avail of those negotiations to include the people who are excluded and thereby provide a proper comprehensive service. The hospital services and the out-patients service are available and it should have been possible to go a step further and make a general practitioner service available to all and sundry with a small extra contribution under a proper Health Contributions Bill.

This Bill provides nothing. It is an attempt at the selective taxation of the middle income group. There is no doubt about that. It provides nothing in return. I see no purpose in it. I do not see the need for rushing it through the House. If there were any social reason for it I would say yes, but there is none. It is purely an attempt by the Government to obtain more revenue from that already harassed and overburdened section of the community. This is wrong and we will oppose the Bill with everything we have.

Mr. Dowling

I should like to welcome this Bill. I am not surprised at the attitude of the Labour Party in opposing it and wanting to defer the benefits which will accrue from it. It was interesting to hear Labour Party speakers state their opposition to an improvement in the health services and suggest a deferment of the Bill for a year. These are the same people who, over the past months and the past years, have been demanding better health services and now, when better health services are being provided under this Bill, they are opposed to the improvements they were crying out for over a period. Such hypocrisy is not new to this House but we now have in concrete terms the sentiments of the Labour Party spokesman in relation to the improvements in our health services that will result from this Bill. These people must remember that they cannot ride two horses in the one race. It is now clear that the Labour Party intend opposing the proposals in the Bill for the betterment of the health services but this comes as no surprise to us. The fact that at this moment the Labour benches are deserted is in itself an indication of their lack of interest in the Bill or, for that matter, in the health of our citizens.

Down through the years Members of this House have contributed to debates concerning health and the views expressed, regardless of which side of the House they came from, were considered and have been used in the formation of our health services. It was difficult to know what Deputy O'Higgins was speaking about on this occasion. He referred to the voluntary health service. This service is very good but bad risk cases are not accepted and consequently the State must make provision for such persons.

Much has been said already about what is proposed in the Bill and while much of this concerns the situation as it was ten or 15 years ago, we are concerned only with what is the situation now and what it is likely to be in the future. In any case, the position ten or 15 years ago is very different from the position today. Various Health Bills have had rather peculiar passages through the House at one time or another. I have no intention of going into details about Health Bills that were responsible for bringing down the Government of the day because our concern is that something constructive be done to provide the best possible health services for our people.

There has been much demand for better health services and on this occasion the demand is being met and it is my hope that in the future we shall be in the position of being able to improve all services. One feature of the Bill is that the 50p per day charge for hospitalisation is being abolished. This is to be welcomed because the charge has imposed hardship in some cases because of the inability of persons to pay. Another feature of the Bill that is particularly welcome is that the provision of free drugs for such persons as diabetics is to be extended to cover persons suffering from other long-term illnesses. The Bill provides also for persons of limited eligibility in that they will be helped to meet the heavy expenditure involved in the purchase of drugs, medicines and appliances. Many people must take drugs for a long period of time and I understand that because of the cost of such drugs, some people could not take the amount prescribed by their doctor with the result that the amount which they did take was of no advantage. This provision, therefore, deserves widespread support.

The extension in the home help service, too, is very welcome. This will ensure that there are available as many hospital beds as possible for those who must have hospital treatment. Other provisions of the Bill that are very welcome also are the progressive development of the child health services and the extension of accommodation for the mentally handicapped. We are all aware of the necessity for extra accommodation for those who are mentally handicapped. I am sure that no group of people would deny to the Minister any contribution to ensure that the mentally handicapped are accommodated. This section of the community has been neglected for a long time and it is gratifying that efforts are being made to ensure that additional accommodation will be available. I hope that the Minister will pay particular attention to this section to ensure that they receive the assistance they require.

There have been references by Deputy O'Connell in relation to the postponement of the services. There have been too many delays in regard to the provision of services under the Health Act. In regard to the free choice of doctor, the delay in this case has been caused by the doctors themselves. People have been deprived of the service because the issue that concerned some people was who was getting the most money out of it. To hold up this Bill for another 12 months, as suggested by the Labour speaker, would deprive the most needy section of the services they require.

I hope the time will come when we can abolish the medical card system and have a fully effective service that can be operated without having to use medical cards. If we have a completely free service contributions at a higher rate will be necessary. The entitlement to free and comprehensive medical services is desirable in many ways but there is a responsibility on those who can afford to pay.

The sections of the Bill that appeal most to me are those in relation to the mentally handicapped and home help which assists in the care of the aged of whom we speak so frequently. Finance is necessary to meet all the demands but I am sure that no one will object to contributing in order to ensure that their future and the future of their children are safeguarded by the additional benefits that will be derived. Neither will they object to increased contributions being requested of them if it means that the people who are in need of services are able to obtain them.

I hope the Minister will continue on the lines he has been developing during the years. He has filled his position as Minister for Health with foresight and dignity. I have attended quite a number of functions and the view expressed by learned people was that the Minister has an extensive knowledge of the matters on which he speaks. In this he is unlike some people who speak quite frequently on matters about which they know very little.

To all those who have made contributions to our health services during the years—as Ministers for Health— and as Deputies—I would say that they did a good job. Any Deputy who makes a constructive contribution in regard to our health services deserves credit. I support this Bill and I hope it is but another step to ensure that those who need help will get the assistance they require.

Mr. Hogan

This must be the worst Bill introduced in this House because it is the shortest contribution Deputy Dowling has made in any debate.

Mr. Moore

That is because it is a good Bill.

Mr. R. Burke

All the rest must have been very bad.

Mr. Hogan

Deputy Dowling is usually capable of most lengthy contributions. This Bill is a fund-raising Bill; it is merely a taxation measure. It could equally have been introduced by the Minister for Finance because all it does is to provide for extra funds for the Exchequer. There is nothing in the Bill about the provision of new services nor are more people benefiting from the services.

The Minister mentioned that charges for out-patient services have been lifted since last April. Out-patient services have been always a nominal type charge. If my memory serves me correctly, these out-patient charges have a rather peculiar history. They have been described as the "dog licence fee". When they were introduced the charge was 2s 6d for a surgical consultation or consultant's fee. The service one gets in return may cost £10 or £20. The charge was fixed at 2s 6d. Later it was advanced to 7s 6d. That is a good number of years ago and, as far as I recollect, it goes back to earlier legislation here. When Deputy Dr. Browne was, as Minister for Health, introducing some modification of the health services the proposed modification was objected to on the grounds that it was contrary to faith and morals. I could never understand the objection. Later on there was a change of government and the same objections were rumoured, but they were resolved very simply; consultation took place between a person whose name we may not now mention in this House and the Cardinal at the time and this very abstruse problem was resolved by putting a charge of 2s 6d on out-patient services.

Mr. Moore

We had a good government then.

Mr. Hogan

I can recall that at that time this charge was described as the "dog licence fee". The fee was not commensurate with the services provided but that was the fee which provided the escape clause to regularise the position; by paying this fee a man was supposed to fulfil his moral obligations. I could never understand it and this "dog licence fee" always amused me. It was a clever manoeuvre and it took the Fianna Fáil Government out of a cleft stick. The "dog licence fee" was abolished last April and I cannot understand the Minister mentioning it in his speech this morning. The charge no longer exists.

The Minister also referred to people who need assistance in the purchase of drugs. This assistance is already there and has been for a number of years. It is covered by the hardship clause. Every Deputy is familiar with this because he has to write to the local authority and ask that constituents be considered so that they may have their drugs provided free or at a reduced rate. Those in the middle income group enjoy that concession and have done so for a number of years. I can see no reason why it should be mentioned by the Minister here.

Home health services and child health services have been available for years. Nothing is said here about an expansion of these services. It is certainly not spelled out. I am puzzled as to why these matters were raised by the Minister in his introductory speech. These services are already available free or almost free.

One of the great difficulties is that there is no general practitioner service. We have more hospital beds per thousand of the population than any other country. This may be grounded in history. Hospital beds were provided from three sources—the Protestant community, the religious orders and, in our time, the State. There has not been any great degree of integration of these services. Indeed, they often overlap. The net result is that we have more beds per thousand of the population than any other country. I believe this Bill will accentuate the trend towards institutional treatment. This is a very expensive way of treating patients. It is not always the best way. I am certain there are many people in hospitals who could be treated at home. If one had a hospital from here down to Naas one could get people to lie in the beds provided the beds were free.

The difficulty always is to make the best use of the beds. My own experience is that hospitals which can always provide a bed and which have no waiting list are not making the best use of their beds and are not getting the best turnover. The middle income group, some 60 per cent of our population, have to pay the doctor and, at the same time, they are compelled by law to contribute to an insurance scheme under which they will get services free inside an institution. In that set of circumstances the natural tendency is to bypass the doctor and look for the more expensive method of treatment. They may get an x-ray thrown in. The mild pneumonia patient could be treated at home by the general practitioner. That was the practice in the past. Today that patient goes into hospital. By doing so he is saving money. He is insured and his argument is that, since he pays for the services, he should get them.

The pattern is similar in the VHI. That scheme does not cover domiciliary treatment either. This is the principal defect in this piece of legislation. The Minister says the numbers seeking hospital treatment are increasing at the rate of 3 to 4 per cent per annum. I believe that this Bill will accentuate that increase. I admit the amount contributed is small and I have to modify my prognostications on that premise, but, when people are compelled by law to contribute to a scheme, there is a natural tendency to look for some return. The increase will be accentuated unless there is some thinking in the pipeline; the Minister may have some idea of introducing a compulsory scheme for domiciliary services. So far these have covered only 30 per cent; the other 70 per cent have to provide out of their own resources.

It is true that health costs have increased inordinately all over the world. That trend will continue. Medicine is becoming very sophisticated and, therefore, more expensive. Machinery, equipment and the evolution of new specialties all contribute to the cost but, if people want these services, they must be prepared to pay for them. I see no other way out of that. If the people want narrow specialisation it means that the type of service provided will become more expensive. For years we have enjoyed a very cheap medical service at general practitioner level from the State's point of view. The dispensary services were provided at a pretty low figure but we forget they were subsidised by the private practice of dispensary doctors, private practice derived from the middle and upper-income groups. I can recall when dispensary doctors were getting about £200 a year and providing their own travelling expenses. There was tremendous competition then for dispensary appointments. Now, when much higher salaries are paid, we cannot get them.

I think this Bill derives from the fact that, like many services provided by the Government, it has been difficult to secure direct payments for services as they are given. In every county council the usual practice is for people who get hospital bills that they feel are too high to go to local councillors who go to the local manager who reduces the bill under the hardship clause. I think only a small percentage of people pay the 10s per day they are supposed to pay. This has been the tendency from the very beginning. It is not altogether due to political pressure exercised by county councillors but is partly due to the fact that the executives in county council offices say: "If we do not get it in direct payments by sending bills to people we can do it more easily by adding 2d to the rates." From the administrative point of view the temptation was there not to go after the recipient of the service but to make it a county-at-large charge by adding one penny or two pence to the rates.

This is the first insurance approach by the Government to financing the health services and limited though it is and open to criticism as it is, particularly as it is not a comprehensive service and is unbalanced, even it has been forced from the Government. I was on the select health committee established some years ago of which there are still two Members in the House, Deputy Browne and Deputy O'Higgins. I can recall that the attitude of Mr. MacEntee and, I presume, the attitude of the Fianna Fáil Party in these days, was entirely in favour of the retention of the dispensary system. The question of free choice was rejected and opposed by Mr. MacEntee who very much favoured the dispensary system because he said it was very cheap and it was very easy to sack the doctor. To his mind, these were the two outstanding virtues of the dispensary system.

Financing medical services by insurance was completely rejected by him. Because of our agitation on this side of the House people became alert to the idea of insurance and the associated idea of free choice of doctor. It was only on the eve of an election when the late Deputy Lemass saw that free choice of doctor might be important on an election platform that he suddenly decided that the Fianna Fáil Party would agree to that principle. Further, to emphasise his attitude in the matter he simultaneously announced that Mr. MacEntee would not be again seeking a ministerial post. In other words, the insurance principle and free choice of doctor were forced from Fianna Fáil by agitation on this side of the House.

The Minister has mentioned that the cost of the scheme is small. He said the contribution would be "a large beer". I do not know why Ministers always seem to speak in terms of beer or cigarettes. These are favourite expressions of the present Minister, "small beer" and in some cases "large beer". We are improving when he has advanced to the large beer in this case. He says farmers will pay £7 per year and people stamping cards will pay £7.8. It is also obvious from the explanatory leaflet that farmers will pay extra for farm labourers and domestic servants as they will, apparently, be covered by their insurance stamps. This contributory scheme will cover the middle income group on an income basis shortly to be raised to £1,600 and on a valuation basis of £60 and will cover the entire family. It will mean the abolition of all direct charges for hospital treatment which at present are netting £750,000. For that gain we will pay £5 million.

Mr. Childers

So that there will be no misunderstanding, farmers will not pay the contribution on their stamps for their farm labourers.

Mr. Tully

Because farm labourers have the lower rate for stamps he will not pay it at all.

Mr. Hogan

He will continue to be classified as lower income?

Mr. Childers

They will be paying contributions for themselves and their relatives covered in the limited eligibility scheme.

Mr. Hogan

Thank you. Perhaps the Minister would explain what extra service the public will get for the extra £5 million they are being asked to contribute. The middle income group are being asked to pay an extra £5 million instead of the £700,000 which is already being collected. When you examine that £700,000 you must deduct the expenses of collection which one Deputy here estimated at 50 per cent. You also have to deduct from it the moiety of £700,000 contributed by the upper income group and I would guess that £700,000 would be largely contributed by the upper income group through the Dublin hospitals. That would leave the net payment from the middle income group, if there is such a figure available, fairly low, much less than £700,000. So, if we brought that figure back to say, £200,000—I am now in the field of guessing——

Mr. Tully

The Deputy is in good company. The Department of Health are also guessing.

Mr. Hogan

——the middle income group are being asked to pay £5 million for something which they previously got for a couple of hundred thousand pounds and without anything being provided in terms of extra service or extra people serviced. My criticism of this measure is that it is in effect merely a financial measure and should be more properly considered and brought in here by Deputy Colley rather than by the Minister for Health. He will be the beneficiary, not the Minister for Health. It would save the Minister for Health going into the Cabinet and asking for extra money that he has collected on his own but it is nothing more than a Finance Bill. The old means test is still with us. The health card remains and is being retained. There is no prospect of any reduction in rates as a result of this measure, no prospect of any reduction in taxation generally but a large select group, the middle income group, are being asked to participate in this opening gambit and it is only an opening gambit of a fund-raising operation without the people concerned getting anything extra in return. I do not know what percentage of the population the middle income group would be but if the figure is to be raised from £1,200 to £1,600, I suppose the middle income group would in future constitute more than 60 per cent of the population. Taking it at 65 per cent, that means that out of 2,800,000, 1,800,000 constitute the population from which this £5 million will be got.

In that respect I feel that this is a take all measure. It reminds me of the little spinning top. The Minister comes in and spins his little top and it comes up all the time at "take all". There is no give-out on the part of the Minister Deputy Childers, that I can see in this Bill.

There is little further one can say on this measure. I think it has been forced on the Government, not by any measure of conviction, but merely as a desperate effort to support a failing economy, a desperate effort to get in funds for the Revenue. The Minister for Health has now become a Revenue Commissioner in effect. Even at Budget time when every Minister for Finance comes in and looks for extra money for this, that and the other thing, he always gives something in return. He does try to redistribute in some fashion the wealth of the community. He taxes or pretends to tax those who have more than they, perhaps, should have and to redistribute it to those who are less well off. Here is an example where the Minister comes in and asks for £5 million, or almost that, say £4¾ million, extra money from 1,800,000 of our population and is giving absolutely nothing extra in return.

Mr. Tully

Deputy Hogan referred to the Minister spinning his little top. I do not know about that but I do know that there will be a considerable number of people blowing their top when they discover what this Bill has in store for them. I would hate to accuse the Tánaiste, for whom I have very high regard, of deliberately trying to fool certain sections of the community but very definitely somebody is trying to fool them and somebody has been trying to fool this House. When somebody starts to talk about a Health Bill of any kind one immediately starts to think of improved services. Indeed, we have been seeking improved services under the last Health Act for some time. It seems to have run into very heavy weather.

It appears to me as if this Bill is an effort, not to improve the services, but to correct a mistake which was made by somebody because when certain arrangements were made under the last Health Act which was passed here it was discovered that no provision had been made for the financing of it. I am a member of a health board and if I am wrong, perhaps, the Minister will explain where I am wrong when he replies but, as I see it, this Bill is devised, as has been said, simply for the purpose of raising the wind and in spite of the fact that originally the Minister for Finance was under the impression that the amount raised would be £3 million and the Tánaiste, in a reply to a question from me, said that as he had not the exact figure he could not say, he now realises that it will be over £5 million. I am sure that news was welcomed by the Department of Finance. This appears to be for the sole purpose of making money available to run the new health services until something else is thought up. In fact, it seems to me to be the imposition of a collective tax on certain people.

When the health committees were set up under the last Health Act arrangements were made for the appointment of a number of CEOs and under them a number of other people who would be carrying out the work, and for the setting up of headquarters and the appointment of committees of various kinds to help to operate the Health Act as it was to be revised. As I have said, nowhere can I find provision made to pay for these extra things. I would be the first to give fair time to see how a new arrangement such as is proposed under the Health Act would work but I see no provision made to cover the very substantial expenses which will be incurred. It has been truly said that, so far, the Health Act has not provided any improvement in services and is costing a great deal more than the original health legislation was costing. When this new Bill was mentioned I had an idea, which may, perhaps, seem peculiar to the Minister, that in some way an effort was being made to provide many of the things which we on this side of the House have been talking about for a very long time. I was more than disappointed to find that all it does is to propose that those who go to hospital and are liable for 10s per day, if they are in that peculiar type of class known as the middle income group, will not be asked to pay after 1st October the 10s or 50p per day they are now required to pay.

It appears to me that the State will collect £5¼ million and the health authority, out of the rates or from some other source, will pay the 50p per day to the hospitals. It is as simple as that. At present the position is that people in the middle-income group, who do not have a medical card and are not "filthy" rich, are expected to pay 50p a day when they go into hospital. It has been my experience that if the breadwinner, and it is the breadwinner who has to pay this extra impost, goes to hospital on very rare occasions the local health authority pay the 50p or make arrangements so that at least the person concerned does not have to pay it. I thought the Minister would start off by deciding who is entitled to a medical card but he says he is going to bring in regulations some time to make that decision.

Mr. Childers

This session.

Mr. Tully

The Minister did say that earlier this year and we are getting very close to the end of the session.

Mr. Childers

We are bringing it in this session definitely.

Mr. Tully

Before the Recess?

Mr. Childers

Yes.

Mr. Tully

The sooner that comes the better but it is rather a pity it was not published before this Bill was introduced because at least we would then know who was being excluded. The Minister may not be aware of this —I suppose he cannot be aware of everything that is happening—but since the introduction of the health boards a considerable number of medical card holders have had their medical cards withdrawn, not because they are not entitled to the medical cards but first because those who are now administering the Health Act are not as well aware of what the situation was as the people who were previously administering it, and second, because it was felt that in some areas, according to answers given in this House, the percentage of the population in a particular area in posession of medical cards was rather higher than it should be and consequently an effort was made to try to cut down the number of medical cards.

If the Minister made an order saying what the income limit would be we would at least know where we stood. He mentions the question of the medical card and he mentions the question of the farmer with a £60 valuation. If I remember correctly when the Health Act was first introduced the valuation was £20 which brought it to £1,200. Perhaps the Minister has forgotten that the move upwards to £1,600 will leave a rather peculiar position, because the farmer can reasonably claim that he still has to go by certain regulations if his income is only £1,200, whereas the insured person's income is up to £1,600.

Is there any good reason why a number of other matters, particularly the domiciliary services for which these people will still have to pay, could not have been included in the scheme proposed even if it meant putting a charge on more than the people who are referred to here? The Minister pooh-poohs the question that anybody should suggest that 15p is too high a charge. Perhaps the Minister has forgotten but it is just as well to remind him that his colleague the Minister for Finance has already put on an impost of £11 income tax, which is over £18 a year, and works out at about 40p a week out of a working man's wages, and in addition it is now proposed to deduct £7.80 for health.

Is there any reason why some arrangement should not have been made not by the addition of 15p but by the addition of a much smaller amount on all insured workers in order to give them something which they have been claiming for years as a right—a free medical service? I believe this could be done. I know a number of people who work very hard in order to make ends meet and when either they fall ill or a member of their family falls ill they send for the local doctor. With all due respect to the numerous doctors in this House there are doctors who believe in getting their pound of flesh when attending a patient and insist on being paid for their services. Indeed, when some go to a house they apparently first refer to the fact that they will have to be paid before they even look at the patient. These people would be very glad to pay a few extra pence if the domiciliary services could be given free. The Minister did not think of that; he decided to put 15p on all insured workers who do not have a medical card.

I do not know whether the Minister knows that those who have a medical card today may not have it tomorrow and those who do not have a medical card tomorrow may have one the day after. There is a continual change over and back with medical card holders. It is going to be extremely difficult to keep track of those who should or should not pay this amount. Is it the Minister's intention that if they are in a certain category when the Bill is passed and the first collection is made that they must continue to be in that category for a period of, say, 12 months?

In addition, I should like to know how he proposes to collect the £7 a year from farmers and self-employed people. It is very easy to write it into a Bill: "It shall be done" but collecting it is an entirely different matter. Apparently this Bill, which was first mentioned during the Budget, and has had a few brief references made to it during the years has apparently not yet been thought out fully because there are so many imponderables in it that even now the Minister, if I asked him, I am quite sure, could not say how it is proposed to do a number of things which it is suggested in the Bill must be done after the Bill has been passed, or with effect from 1st October next.

Is there any reason why the Bill should not have been made to apply to very many more people than it does apply to? Why say £1,600? Some people may find this a rather peculiar thing but there are people in receipt of £1,600 a year who find it extremely difficult to pay hospital bills and ordinary medical expenses. The Minister is, of course, aware that the trade union movement and many other people asked the Minister for Social Welfare to increase the limit for insurability to a much higher figure than £1,600. Of course he said £1,600 and there it must stay for the time being, anyway.

The Bill is badly thought out. Those who have drafted it are as far out in their estimates of how it is going to work as they are in their estimates of what it is going to bring in and what it is going to cost. In one section the Minister says that certain low income people—he mentions specifically farm workers and domestic servants— because their rate of insurance stamp is lower can be exempted without any difficulty. He says further on that other low-paid workers cannot be exempt because there is no difference in their insurance stamp and that of higher paid workers and that in such cases the employer will be requested to pay for the stamp. He also says—I have been trying to find some type of rebutting clause which I have not found— that the employer has the right to collect back from the worker any health insurance which he has paid for that worker. When the Minister is replying I would be glad if he would show me where it is stated in the Bill that the insured worker, who has his health stamp paid for by his employer, is not required to refund that out of his wages. So many sections of the Bill appear to me to be contradictory—as do indeed, the explanations given by the Minister—that I cannot see how it is proposed to make the measure work. One of the things which should be taken note of is that the Minister refers to the people who will benefit— I would put a question mark after the word "benefit"—as the limited eligibility group. The Minister says:

Again I feel that the limited eligibility group can make this contribution and as incomes rise the contribution can be markedly increased.

In other words, the Minister is giving as a throw-away in the last few lines of his speech a warning that this is the thin end of the wedge and that as soon as this is the law there will be very little difficulty in pushing it up when the Minister feels like doing so. It reminds me of the introduction of the turnover tax. It appears that the Minister has at the back of his mind that he can increase this when it suits him.

We have been asking for graded payments and graded benefits for social welfare insurance for many years without much encouragement from the Government. One or two noises have been made to the effect that the matter was being considered but we have not got any concrete example that this sort of thing could be put into operation in 12 or 18 months time. We have here a suggestion, without giving it very much consideration, that it is the intention of the Government to introduce this type of payment which can be increased if and when those who are paying get increased wages and, indeed, in the section of the Bill it is suggested that the idea is to apply on existing wages a graded scale at a later date when it suits the Minister to do so.

I am rather touched by the Minister's suggestion that he has had investigations made in other parts of the world as to how health services are being financed. The fact that he starts off with the United States of America makes me laugh when we know that the one thing you must not do in the United States, if you have not got plenty of money, is get sick because if you do then nobody cares about you unless you are able to pay your way. As far as Britain is concerned may I repeat what one of my colleagues said earlier? The Minister said:

In Britain the cost of the national health services continues to cause concern and proposals have been under consideration for increasing the revenue from charges on patients for prescriptions.

May I point out that this is under a Tory Government which it appears will not be there very long to make any regulations good, bad or indifferent. The suggestion that we should try to base any legislation we are proposing here on what is being done at present in Britain is too ludicrous to pursue it any further.

The Minister, of course, is referring in this case to the charges on patients for prescriptions. I am surprised in view of the fact that he makes no comment at all on what should happen in this country with regard to payment by patients for prescriptions. Does he know that one of his predecessors, who was not terribly popular in this House as an administrator, did, in fact, introduce a regulation whereby in hardship cases prescriptions could be paid for by local authorities and that if this is administered properly there is no reason why we should have to introduce special legislation to deal with it? Is he aware also that the home helps which he talks about have been in operation in many cases for quite a long time?

This appears to be a piece of legislation which is dressed up to look like something which it is not. We have heard of mutton dressed as lamb. This looks like a particularly ancient piece of mutton which is being dressed up as lamb. We have taken a bite of it now and we realise that it does not taste too good. It is hasty legislation. It is an attempt to put across something which has been badly thought out, rushed into the House for one reason or another and it will not achieve what the Minister says it will achieve. There are many things which could have been regulated and improved in the Bill if the Tánaiste was anxious, as Minister for Health, to do so and it is just not good enough to put before Members of this House a Bill such as this which suggests that all that is worrying the middle-income group as far as health is concerned is the 10s per day which they are supposed to pay if they go into hospital. It would be a very good exercise on the Minister's part if he would withdraw this Bill and present a Bill covering the matters which he must know are affecting the people concerned, if he would arrange even if he has to twist the arm of his colleague, the Minister for Social Welfare, to increase the insurability limit very considerably, and if he would ensure that the limit would be high enough to cover those who are unable to pay for health services at present out of their own resources.

I think the Minister is well meaning. I would take it that he considered when this was mentioned to him that it was, perhaps, a step forward. I am trying to point out to him that it is not the step forward he thinks it is and that, while some people, who are ill and who have been caught for 10s per day when they could not afford it, will welcome the introduction of something like this, very many people will be terribly disappointed because, when they heard this Bill was being introduced, they thought it was something very different from what has been put before us in the last few days and, indeed, what has been explained to us by the Minister today.

It is not too much to ask that this Bill should be entirely redrafted. We have redrafted enough Bills over the past couple of years. Some of them have been introduced here and after debating them for months it eventually dawned on the Minister concerned that they were absolutely unworkable and they have been taken back and presented in a different form. I hope the Minister will do the same with this.

The Tánaiste may feel that I am being pretty harsh in my comments on this Bill. I want to assure him that if I am harsh it is because I meet every day in the week people who will be affected by this Bill and people who are expecting something from it. I should like to see something better being produced than this sham because a sham it is. It proposes to do things which I believe it cannot do and it ignores completely the things which it should be dealing with. It is not the type of legislation which this House should have before it now. It is something which might possibly have been dealt with by a full committee of the House and would be amended in this House by the Opposition Parties if we got an opportunity of doing so but we cannot because it would involve finance and, therefore, all such amendments must come from the Minister's side.

Debate adjourned.