Dáil Éireann debate -
Wednesday, 30 Jun 1971

Vol. 255 No. 2

Health Contributions Bill, 1971: Second Stage (Resumed).

Question again proposed: "That the Bill be now read a Second Time."

Mr. P.J. Burke

I listened to some Opposition speakers this morning criticising this Bill. We have a huge problem here, that is, that expenditure on health services is going up and up all the time. It is no harm to ask anybody who is in a position to do so to make some contribution towards his own health charges. That is not a mortal sin. According to Deputy Tully today everything in the Bill is wrong. He has a free scheme for everything but he avoided saying how we were to subsidise the free scheme. We would all be happy if we could strike oil and say to our people: "We will not ask you to pay rates, rent or anything else. We can provide everything from our mineral resources." We must be practical.

A large number of people are in the voluntary health insurance scheme. I pay about £36 a year into that scheme. Mention has been made of the small amount contributed by farmers with valuations of from £20 to £60, and the whole family is covered. Those of us who are members of health boards know the continual pressure that is on us to have hospital bills reduced or abolished altogether. The day has come when we should realise that we should all help each other. We are a Christian community and we should be capable of realising that. At present £7 would not be sufficient to cover a person for one day in certain hospitals if he had to have treatment. Now he will get treatment independently without having to go to any public man and ask him to have his hospital bills reduced. We are up against this day after day.

There should be a small contribution from every section of our people if that were possible. Referring to this Bill as another Finance Bill is all cod. Up to now children who are retarded mentally or physically and who have been in hospital for many years have been paid for by their parents in the middle income group and possibly the remainder of the family have been neglected. There are a number of sad cases like that. I believe our people should welcome any opportunity to help one another. I was the secretary of a parish council, a voluntary organisation, during the war, and I had about seven people cutting timber. There were about 30 old age pensioners in the area. This was the first time I ever practised Christian socialism. I asked the people who were able to pay a few shillings more to do so and in that way we were able to give timber to the others for nothing. I think it was three cwts. a week.

I back what the Minister has done because I believe it is the right approach. Nobody can say that it is too much to ask from anybody. Charges in hospitals and nursing homes today are very high. A member of my family was in a private nursing home for a few months last year and between doctors' fees and everything else the charge came to about £65 a week. I know that the ratepayers will now pay also but we are all ratepayers. Those of us who are members of the voluntary health insurance scheme are ratepayers and we get no relief or benefit from the health services. Of course there are hospitals and doctors at our disposal and in the case of fevers and certain other diseases the treatment is free. We should be big enough to say: "Let us all try to help one another."

If the Minister were St. Patrick or St. Peter and if he had a golden wand, he could not keep health charges down because more and more of our people are looking for treatment. Our standard of living has improved and our health services have improved. Working conditions for our people are better. People are living longer and they are anxious to go to a hospital or a home in their old age. Possibly they are suffering from some disease and their children cannot keep them at home. As I often said in the old days nobody went to hospital unless he was dying. Trends have changed. Our hospitals and our homes for the aged are more modern and I hope that will continue to be the case and that we will provide the best facilities we can. I should like to see that spirit of independence coming back into our lives again. If the lowest paid workers and people of moderate means paid only £1 a year everybody would realise that he was doing something to help others. In this way the rates could be brought down.

The Minister for Finance can only get money from the taxpayers. We are all anxious to see the cost of living being kept down. We are all anxious to see social services improved. We are all anxious to see everybody getting a better slice of the cake. We must be serious and practical in dealing with this problem. I heard words like "niggardly" and "mean" used by some speakers this morning. The money for any improvements must come from the ratepayers and the taxpayers. All of us pay tax and the great majority of us are ratepayers. All of these moneys go into a central pool. I welcome this advance and my only regret is the Minister has not gone further. The contribution of £7 per annum is very moderate when one considers that a person would not be maintained in a hospital for that amount of money for even two days.

Many insured persons will benefit from the abolition of the 50p per day charge for hospitalisation. Every encouragement should be given to each person in the community to involve himself in voluntary work, even in a small way. As to the collection of the £7, small though the amount is, I thought it might be collected quarterly or by way of stamps but I do not know whether that would be feasible in the case of self-employed workers. There is no use saying that anything introduced by Fianna Fáil is wrong. Deputy Tully enumerated everything that he would wish to see done but as soon as we impose extra taxation for the improvement of services, there is a cry from the merchants of Venice. It is regrettable that this approach has been witnessed here so often. The Minister for Health is making great advances in the field of health and I hope that the lead he is setting will be followed by intelligent people outside. Our people are very good when it comes to helping each other. During the harvest campaign of 1946, of which I was one of the organisers, I remember an old Dublin woman coming to me with two ounces of tea and a half pound of sugar which she wanted me to take for the volunteers because, as she said, she was not in a position to help with the work herself. At the time there were about 80,000 volunteers engaged in saving the harvest and we had obtained permission to buy provisions and, also, we were receiving many gifts. However, rather than offend that old lady, I told the personnel officer to take the gift but to take also details of her name and address so that we could send her four pounds of tea. That is only one example of the goodness of our people. The rates position has got out of bounds but the reason for this is that in order to help certain people, they have been relieved from paying any rates.

Mr. Coughlan

Very few have been so relieved.

Mr. P.J. Burke

There is relief for such people as widows and old age pensioners who are living alone. At least that is the position in Dublin city and county. Of course, I agree that even better facilities are necessary. I appeal to every member of our community to consider seriously what he or she could do to help their fellowmen. There is some good in each of us and there is some bad in most of us. I have admired Deputy Coughlan, for instance, for some of his deeds.

Mr. Coughlan

Thank you.

Mr. P.J. Burke

Deputies should be constructive in their criticism of any legislation brought before the House. It is said sometimes that we are only taking certain measures to get the Minister for Finance off the hook but, of course, any money that he gets must come from the people. If we were an industrialised State we would be in a position to provide free medical service for all our people but that is not the position and, consequently, we must be practical. Our mineral wealth is limited. It is my belief that each person here, regardless of which side of the House he is on, has nothing but goodwill towards his fellowman. In the House, politically, we might tear each other asunder but each one shares a common anxiety that everything possible be done for the betterment of our people.

In conclusion I commend the Minister for having introduced the Bill. I hope that the people will realise the wisdom of what he is doing. Through these measures the Minister is giving an air of independence to certain people by reason of the fact that they themselves will be making some contribution. Many people will be relieved of having to go to a public representative or some other person to explain that they are unable to pay a medical bill because of the illness of some member of the family. I hope the Minister will tell us how many voluntary health contributors there are in the country.

Mr. T.J. Fitzpatrick

(Cavan): This Bill is a hastily drawn-up piece of legislation. I say that, having read it carefully and having considered the Minister's speech in support of it. It is a Bill that has been rushed through the parliamentary draftsman's office and it comes before this House as a vague and uncertain piece of legislation. It is vague in regard to the benefits it will confer. The only thing certain is that the 50p daily charge for the middle income group will be abolished. There is mention in the Minister's speech and in the Bill about other benefits but they are vague and apparently have yet to be decided upon. It is vague about the amount of contributions that will be levied. At the moment people paying social welfare contributions will be subject to a levy of 15p. Farmers and self-employed people who come within the ambit of the Bill—those whose income does not exceed £1,600 per year and, in the case of farmers, whose valuation does not exceed £60—will pay £7 per year. However, this is vague because at some future date it will be changed and will be related to the income of the person paying social welfare contributions, or to rateable valuation in the case of farmers.

It is vague in regard to the method of collection. At the moment it will be collected by way of social welfare stamps in the case of those who pay contributions and it will be collected in a lump sum in the case of farmers and self-employed people. Again, at some future date it will be adjusted and regulations will be brought in to accept in instalments the £7 per year charge—where it is difficult for the person to pay the contribution in one sum.

That is why I say this was a hastily drafted piece of legislation and that it was rushed through the office of the draftsman at the request of the Minister for Health and the Government. The Minister is a through person and I would not expect him to be guilty of introducing such an unfinished Bill in this House. I do not believe it is accidental that he did so in this case. He is precise in what he says and does, and generally speaking he tries to do a definite job. This legislation will be amended and improved, it will be chopped and changed in a way the Minister cannot tell us beyond saying that there is a high-powered committee working on the matter. Therefore, the question must be asked: why the hurry?

I must look to the Minister's speech for evidence as to why the Bill was produced in this way. The only answer I can find is that it is not a measure calculated to improve the health services or to tidy up the machinery for providing health services. It is nothing more or less than a measure that will bring into the Exchequer £5 million this year instead of £750,000. That is what this Bill really means. It is a mini-Budget that was forecast by the Minister for Finance in a short paragraph in his Budget speech when he announced this measure in the vaguest of terms. I do not blame him because he did not have any information about it. Today it is just as vague. The only thing we know is that the charge of 50p will be abolished and the Exchequer will collect £5 million this year at any rate and maybe for many years to come.

The health services have not improved and I know that statement will shock the Minister for Health. In many parts of rural Ireland it is very difficult for people to get medical attention, whether they pay for it or not. Doctors are demanding a more organised life and the result is that it is more difficult for people to get medical attention. I do not wish to enter into a general discussion of the health services, but the Minister for Health would need to keep a careful eye on the new health boards and make sure they are operated to the advantage of the sick. We have handed over the administration of the health services to health boards that are controlled and operated by the medical profession. It is true that as a result of an amendment put down in this House there is a marginal majority of elected representatives on the boards but it is the medical people and the related professions who control the health boards.

I should like the Minister to explain some points in regard to this legislation. I know he has stated that it is proposed to standardise the qualifications for a medical card and I am glad to hear that. Will the Minister tell us whether it is proposed on the coming into operation of these measures to give a medical card to every farmer who has a PLV not exceeding £20, irrespective of whether he is married or single? If it is not proposed to do this, this Bill will abolish de-rating, if I follow the Minister's speech correctly. A farmer who is not the holder of a medical card will be required to pay £7 per year. If that farmer has not a health card—in the counties I know many farmers with a valuation of less than £20 are not the holders of health cards, but they are derated—he will, nevertheless, have to pay £7 a year. To me this is a direct attack on the derating system and I should like the Minister to deal with the point when he comes to reply. If there is an explanation for it I shall be glad to hear it.

Agricultural labourers, domestic employees and people who hold general medical service cards will not be subject to the contribution of 15p per week if they contribute to social welfare, but their employers will still have to pay the 15p per week for them. This is my reading of the Bill. The employer will not be entitled to recover from the agricultural labourer, the domestic helper or the holder of a general medical service card.

Mr. Childers

The farmer will not have to pay a contribution for an employee in addition to paying his own contribution.

Mr. T.J. Fitzpatrick

(Cavan): I know there is a different rate of social welfare payable by agricultural and other employees. Am I to understand now that the agricultural stamp will not be increased by 15p?

Mr. Childers

That is right.

Mr. T.J. Fitzpatrick

(Cavan): Fair enough. I suppose that will also apply to the domestic employee. There is a special stamp there too.

Mr. Childers

Yes.

Mr. T.J. Fitzpatrick

(Cavan): Take the businessman or other employer who has in his employment the holder of a general medical service health card; he will have to pay a contribution of 15p per week in respect of that employee and he will not be entitled to recover that from the employee. In my opinion that is imposing something like an employment tax on a par with the tax in Britain. It is a tax on employment. This certainly needs tidying up. Deputy Dr. Browne thinks employers will deal with the problem by passing on the cost to the consumer. On the face of it it is a tax on employment. It might even discourage people employing those entitled to general medical service cards.

A single man earning £15 a week will certainly not get a general medical service card. He will have to pay 15p per week and the man earning £30 a week will also pay only 15p per week. That is not fair. That is not social justice. A farmer with a valuation of £25 will pay £7 a year. A farmer with a valuation of £59 will also pay contribute £7 a year. It is difficult to see the justice in that. This is a drift towards injustice. I had occasion to speak about this on the Budget. The lower paid employees had their income tax increased by £12 per year and the surtax payer will also pay only £12 per year by way of increase. That is another manifestation of the kind of thinking there is at Government level.

I particularly want to know from the Minister whether farmers under £20 valuation who do not hold general medical service cards will be rated again because that is what this amounts to. It is no use saying they will pay to the health board instead of the county council. This is really rates.

Mr. Childers

It is not rates.

Mr. T.J. Fitzpatrick

(Cavan): The Minister may call it what he likes but he will have a difficult job explaining to the small farmers of Monaghan that there is a difference between paying £7 a year to the North Eastern Health Board and paying it to the Monaghan County Council.

Mr. Childers

The medical card standard will not include an income valuation where farmers are concerned. It will be based on the income of the farmer and how that relates to the income of the non-farming community. It could not be on a valuation limit because valuation means one thing in one county and another in another.

Mr. T.J. Fitzpatrick

(Cavan): Then we will have the social welfare officer going out and counting the hens and counting the pigs and seeing how many calves there are.

Mr. Childers

No.

Mr. T.J. Fitzpatrick

(Cavan): Do not let us revert to that kind of thing because that was the most objectionable operation we ever had.

Mr. Childers

We have never got away from it. All the non-contributory social welfare services are based on it.

Mr. T.J. Fitzpatrick

(Cavan): I am glad to have elicited that information. I hope the Minister will rethink this because if there is anything hated and detested in rural Ireland it is the social welfare officer coming out and counting the hens, counting the pigs and going out into the fields, and treating everyone as a liar. I do not say that by way of offence to these officers because, if they treated everybody as being truthful, they might not get the right answers either. This sort of investigation is anathema. I am shocked to think we are getting back to this discreditable system.

Mr. R. Barry

May I appeal to the Minister, in Heaven's name, not to bring back that system?

Mr. Childers

In many counties medical cards for farmers are given on an income basis and not on a valuation basis. There are one or two counties which are supposed to use a valuation basis. Many are using agricultural incomes. This obtains over the whole range of non-contributory social welfare. It has not been abandoned.

Mr. T.J. Fitzpatrick

(Cavan): That is news to Deputy Barry in Cork and news to me in Cavan.

Dr. Browne

It is a disincentive to group farming.

Mr. T.J. Fitzpatrick

(Cavan): Anyway, they will want to know if we are getting back to that system as the recognised way of issuing health cards. I also want the Minister to deal with this waiting system. This bit of startling news has put me off my train of thought; I was about to compliment the Minister—I think I have done so —on setting a standard for health cards all over the country because there was a different standard between one county and another. That leads to grievances and to public representatives not knowing where they stand.

It is a great pity the Minister did not postpone this effort until he knew exactly what he was bringing before the House. I imagine that when the Budget was being drafted problems had to be attacked in every way with a view to presenting as manageable a Budget as possible in the political atmosphere prevailing, the Taoiseach and the Minister not knowing when they might have to face the people. They discovered this way of taking £4.3 million out of the Budget. That is the beginning and end of the operation.

Mr. Childers

I have been dealing with it since 1970.

Mr. T.J. Fitzpatrick

(Cavan): That is only last year.

Mr. Childers

The beginning of 1970.

Mr. T.J. Fitzpatrick

(Cavan): The Minister will agree that very little information was given about this proposal in the Budget and equally little about another proposal to introduce a system in lieu of the dole for disabled persons. We got a vague hint about that but have since heard nothing about it.

Generally, that is all I wish to say. I am most disappointed with the present performance which does less than justice to the Minister for whom in a sense I am sorry because I believe he was driven in here to collect this £4.3 million long before his scheme was prepared and before receiving any proper advice or proposals from his Department. I object to the Bill because I believe it is the beginning of re-introducing rates on small farmers. A system whereby a man with a £59 valuation and a man with a £25 valuation pay the same contribution to health is unjust and a system whereby a man earning £15 per week and a man earning £30 a week make the same contribution is unjust and cannot be justified.

Perhaps as Deputy O'Higgins said it is an indication that the Minister at last is thinking towards a general health service based on insurance and on equality and on fair and equitable contributions. To that extent, I suppose it is to be welcomed but it is a very thin end of the wedge and only a very slight indication of the Minister's thinking. As Deputy O'Higgins also said, it is significant that the Minister had not the nerve to mention insurance in the Long Title of the Bill. The 50p per week charged to the middle income group has stood at that figure since at least 1961 and, perhaps, longer and the Minister, I suppose, had not the courage to increase that or to wait until he had a proper scheme to put before the House. I suppose he found himself on the horns of a dilemma in that he had given an assurance a couple of years ago that further increases in health charges would be borne by him or that he would ensure health charges would not increase further. On the one hand, he had given this assurance and on the other health costs were going up and he had to do something. This is the net result. The Minister may think we are very ungracious but if he considers—he knows it perfectly well— he will realise that the end result of this operation is to collect £4.3 million for the Exchequer. It certainly does that but nothing else.

Mr. Childers

I gave the Deputy wrong information. In fact, the Minister for Finance in 1968 said they were going to start examining the feasibility of introducing an insurance scheme. This is being slowly digested ever since.

Mr. T.J. Fitzpatrick

(Cavan): Very slowly if this is the result.

Dr. Byrne

While we all want free hospitalisation for the majority of people I think the Bill the Minister has introduced has some dangerous aspects which merit comment. It is important to bear in mind that in the past 20 years or so public expenditure on health has risen from approximately £10 million to £76 million a year. Much of the money is spent on the maintenance of general and specialist hospital beds. I am wary of the possibility of patients opting to be treated in hospital completely free of charge when they could be efficiently treated at home. However, because of the present medical services set-up it is very often too expensive for a patient to remain at home. Successive budgets and legislation have not provided for medicines or medical care at home for those who can ill afford it, apart from medical card holders. We saw an example of that in last year's Budget which contained a turnover tax and increased the cost of medicines for human beings at the same time exempting the cost of medicines for animals from turnover tax.

I should have liked the Minister to introduce, what I would regard as the first instalment of legislation of this kind leading to a comprehensive medical service, a measure which would deal with the majority of the population at general practitioner level. Unfortunately, we have now reached the stage where patients can ill afford to buy the medicines prescribed for them and in the area outside medical card holders and below the £1,600 a year level doctors more and more find themselves prescribing for private patients the cheaper preparations rather than those they would like. Very often the incomes of the patient dictates the type of drug prescribed. Whereas medical card holders have all the drugs and hospital services available to them, people outside this category have not the general practitioner service available to them. In some cases of illness which would necessitate perhaps two weeks medical attention, it would be an economic necessity for the patient to enter a hospital. The maintenance charge for a patient in a specialist hospital can be up to £16 a day. The figure of £700,000 mentioned by the Minister as a saving is a doubtful figure. It should be related to the projected increase in the number of patients who will now enter hospital. This is something which the British Government observed. When they introduced their national health service they anticipated that hospitals would be closed as a result of the anticipated improvement in the general health of the population. They found, in fact, that they had to build more hospitals. This is a possibly dangerous aspect of this legislation.

Some simple form of legislation should have been introduced with a view to relieving patients who suffer from mild to moderate illness and are best treated in their home environment. I suggest that provision might be made for the abolition of turnover tax on all medicines for human use. Even in this Bill the Minister could make provision whereby, on a contribution basis, a group of 20 drugs essential for general practitioner service could be made available. This would create a very good system and at the same time prevent over-hospitalisation because of domestic economic factors.

The type of modern hospital treatment should be considered. The hospital authorities concerned are responsible for the patient and there is a far greater tendency towards X-raying and laboratory investigation than there was ten years ago. The cost of X-rays and laboratory investigations is increasing phenomenally and is in no small way responsible for the increase from £10 million to £76 million over the last 20 years. This part of the Bill, though very welcome and very necessary, is, perhaps, dangerous because there is no provision at general practitioner level, the front line of medical service, to help patients financially to overcome illness. This is a realistic hazard in relation to this Bill. I would urge the Minister to consider introducing legislation as soon as possible to provide therapeutic medicines for patients outside the medical card system. The greatest hardship is caused to persons who take ill and who have not got a medical card.

The Minister mentioned the amount of money collected in taxation and rates. It is of great importance to remember that not only have we milked the cow almost dry in regard to rate collection but that many people are certainly not paying rates in proportion to their personal incomes. Many people are paying far more in rates than their personal incomes can tolerate. This legislation is welcome from the point of view that it is hoped it will reduce the burden of rates in respect of increased hospital charges for this particular group but I am dubious about the figure of £700,000. I consider that that is a guess rather than anything else.

The Minister mentioned that the number of persons, including dependants, with limited eligibility, comprise 60 per cent of the population. I should like to know whether the amount which he estimated will be collected involves the 60 per cent with limited eligibility plus the projected 30 per cent who have the medical card? Will the contributions come from this 90 per cent of our population?

Mr. Childers

Only from the 60 per cent.

Dr. Byrne

It will be the 30 per cent of the population who hold the medical card who will be paying the contributions and the employers will be carrying one-third of this increased contribution which is projected at £5 million. I cannot but feel that it is another form of selective employment tax because they will be paying over £1½ million. It could mean that a person with a medical card coming to an employer who is in business in a small way could be victimised. If two persons apply for a position with such a person, one having a medical card and one not having a medical card, and it costs more to employ the man who has the medical card, it is fair to assume that the man who has not got a medical card will get the employment.

The provision of these services at no direct charge to the patient apart from his contribution is a very doubtful matter. Can we, in fact, provide sufficient beds? Are there sufficient beds available for these people and their dependants? In reply to a question I asked today I was told there are over 500 children on the waiting list in Temple Street Hospital for ear, nose and throat operations.

Mr. Childers

A Leas-Cheann Comhairle, do not let us get into a debate on the entire health services.

Dr. Byrne

I should like to see facilities available for these patients. I have said many times in this House as the Minister knows, that there are not sufficient well-organised hospital beds on the north side of the city.

An Leas-Cheann Comhairle

The Deputy is aware that this Bill is dealing with contributions.

Dr. Byrne

I had hoped to see introduced before the recess regulations providing free service for people suffering from specific illnesses but that is not included here. There are many sections in this Bill which do not appeal to me. I do not think the 50p a day which the patient in hospital had to pay was as great a burden as the cost of general practitioner services and the cost of medicines. I do not want to say anything more but as the Minister's brief mentioned the hospital services and the cost of running them I feel I should be allowed to comment on them.

An Leas-Cheann Comhairle

The Deputy is aware that it is a question of costing. It is not a question of dealing with hospitalisation.

Mr. Carter

I have listened to various speeches on this Bill which deals with the financing of the health services. As the Minister pointed out in his introductory speech costs rise year by year. One only has to look back ten or 20 years to see how costs in our health service have risen. There is no doubt that costs tend to rise more quickly in an intensified labour unit like the health service because any adjustment in the pay or conditions of the people employed always brings about a corresponding increase in costs.

Those of us who are members of local authorities will have due regard to the pressure at the present time on the rating system and in this context we would be glad of any move designed to remove the burden from local authorities. We know that if costs have increased the scope of the service has been extended. Any expansion in the scope of hospital services or any upgrading of the facilities in the auxiliary services tend to make for higher expenditure.

Substantial progress has been made in the last number of years in controlling the incidence of disease in general. We have made relatively good progress in the field of preventive medicine. This is very apparent when one considers that we have reduced the death rate from tuberculosis from thousands to hundreds. In 1945 the number of deaths from tuberculosis was 3,694 but since 1967 the death rate has lowered considerably.

Preventive medicine has greatly reduced the rate of infectious diseases. The infant mortality rate has dropped dramatically in recent years. If we want this sort of service we must be prepared to ensure that the cost of the service is met in an equitable manner. There is no doubt that in years to come we shall have new problems because other diseases are gaining ground. Some may be attributed to the affluent society in which we live and I refer here in particular to heart disease. Chest diseases have gained ground in recent years. There is also the problem of psychiatric ailments which require expensive treatment and a high degree of specialisation. This trend in psychiatry will continue to take up the time of hospital units and specialists and so far as can be foreseen this will apply in the immediate and even long-term future.

There are also special problems arising from the fact that people are living longer. They will need more attention by way of housing, nursing and specialisation. We may expect to see more frequent changes in the health system if we hope to deal successfully with these problems. A number of branches of the health service, especially of the auxilliary health service, will expand in the coming five years. The service as we have known it in the past was broken into three parts—the general medical service, the middle income group service and the higher income group service—and was worked out on a selective basis. This arose from the fact that we had to have regard in every Budget year to the amount of money which this House would vote to the Minister for Health for those services. The service was and is available free to the lower income group and to the middle income group at a very modest charge.

The higher income group was catered for by a voluntary health insurance scheme, if this group wished to take advantage of that scheme. As good as this scheme is and was the number of people availing themselves of it indicates that while people may be interested in health from an academic point of view they are not prepared to take advantage of a scheme which offers them a good deal more in terms of hospitalisation, et cetera than any State scheme could offer.

Arising from that, and from the fact that the Government and the Minister are aware of the position arising from pressure on the rates, this limited insurance scheme comes before the House. It is right that we should be limited in insurance in so far as it relates to providing an element of finance for the health scheme. If one accepts that, as the Minister has pointed out, the present health service costs £76 million a year and if one relates that to the figure of £25 per head of the population in our circumstances and having regard to the size of the insurable group one must recognise the naked fact that no insurance scheme we could provide here could be deemed a comprehensive scheme.

I said we were limited in our activities in regard to health. I would be prepared to argue that we were prepared to make the best use of the money voted by this House to gain the best results we could by way of curative measures and medicines. It would have been a grave mistake to start a comprehensive insurance scheme here which I think would fail.

Deputy O'Higgins mentioned this morning that he proposed a comprehensive scheme in 1965. He did but he did not tell the whole story and he should have told it. He also said that the Select Committee on the Health Services foundered when he presented this scheme. This is not so. Deputy O'Higgins did present a scheme. We did not agree with it because we thought there were too many holes in it. He presented it not merely to the committee but he presented it afterwards at the 1965 election. I am not aware to date at any rate that Deputy O'Higgins found great favour for his scheme. The vast majority of people know very well that if it takes £76 million of a vote from this House to underwrite the health of the community we could not formulate an insurance scheme which would support or return to the Department of Health that sort of money. We have also the experience in Britain where they had and still have in many ways, a comprehensive scheme. We know that the Exchequer had to step in to support this scheme. We have further evidence of the fact that the late Lord Beveridge who was the forerunner, if you like, or the foremost promoter of social schemes in the past, admitted in the evening of his life that the insurance fund was being robbed and that the Exchequer would be called on to come to its aid.

I want to make the point here that if we had a comprehensive insurance scheme on the scale envisaged by Deputy O'Higgins, our expenditure would not merely be £76 million but £106 million. What sort of a contribution would we have to get from every participant in the scheme or every insurable person to bring in that sort of money? We must be realistic and limited, as I said, because we are a limited liability company. We can only extract from the taxpayer in any given year what he is reasonably able to pay. When we talk about the redistribution of national income we must be realists.

Therefore, the point I am trying to make is that I much prefer a scheme of this kind which applies to roughly 1¾ million of the population and is limited in its scope but yet is designed to get the best out of each branch of the health service, and yet designed to see to it that waste will not predominate and that excessive spending will be avoided, and that whatever money is devoted to the health service will be spent in a realistic way, namely, on better measures to secure a better health service for the community.

Both Dr. Browne and Deputy O'Higgins contributed, each in his own way, to the provision of a better health service and let me pay tribute to them for doing so. Even if they did, I doubt that it is realistic at this point to say that the socialist system would provide a better health service. I do not think this is evident even in Eastern Europe and certainly not, I would say, in the Communist countries. Be that as it may, I will not go into that matter now except to say that I hope we will be able to work this insurance scheme and apply it to the group for which it is designed. I also hope that the medical profession will take up the terms of such an insurance scheme and apply them in their everyday work.

As I said before, we do not want to have the name of having what Deputy O'Higgins would refer to as a comprehensive scheme and, at the same time, having to come in the back door and subvent such a scheme from the Exchequer. In my opinion this is more or less a smoke screen. I would not think that in our circumstances it would work because we have not got the scope or the grounds, shall we say, for such a comprehensive scheme except at an enormous cost to those who would be insurable.

Mr. Donegan

The first thing I want to deal with is the initial statement by the Minister that:

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.

It is a very nice distinction as to whether or not an insurance contribution for a specific purpose which was previously paid for out of rates and taxes is another tax. I do not think the wage earner is terribly worried one way or the other about whether he pays the 15p specified by the Minister with his insurance stamp, or with his PAYE, or by direct taxation on an article carrying turnover tax or wholesale tax or coming under the ordinary budgetary provisions.

The fact is, of course, that this is another mini-Budget. The figures given in the Minister's speech are quite clear. W are taking from the people £4.3 million where we were taking £700,000. This is a mini-Budget of £3,600,000. Last November an iniquitous corporation profits tax was imposed on companies in addition to their other taxes. They had hoped to put that money into capital expenditure to defend jobs and create new jobs. A row was kicked up about that and at the time the figure for part of the year was precisely the same. It was £3.6 million and £6 million for a full year. We now have a mini-Budget imposed on us of £3.6 million in a full year. There is no doubt that this is an extra tax.

Members of my party never said they would not impose taxation. Of course, you have to impose taxation if you want to provide services and, of course, if you want increased services you must increaase taxation. Two questions then arise. One is how you raise that taxation and what is a fair and proper way to raise it. The second is what are the services you are going to provide. Are they proper services? Are they services that could be provided in a better way by some other means, or are they services that should be provided at all? The position is that people who at one time or another might have to pay 10s per day in respect of themselves or a relative in hospital will now pay 15p per week which is a considerably larger sum in most cases.

I agree with the insurance contribution system but I would have thought that the Exchequer's contribution towards health could have been made to bear this impost. The Minister's speeches of a month or two months ago suggested that he was removing hospitalisation charges from the middle income group and that this was not to be taken as being political or as being of voting advantage to his party. The truth is that this is an attempt to camouflage an extra charge on the people of £3.6 million per year. I would have no objection to this extra taxation if it resulted in the provision of extra services but perhaps the Minister would tell us what extra services are being provided in this Bill. Perhaps he would say that he is increasing the income level at which those in the middle income group can avail of hospitalisation in a public ward.

The increase in the income limit from £1,200 to £1,600 is nothing more than political expertise and opportunism. When the 1953 Health Act was introduced this figure was if my memory serves me right, £800 per year.

In succeeding years during which the value of money decreased considerably, that figure was increased to £1,200. That increase to £1,200 was not for the purpose of including more people but was set because of the decrease in the value of money. I should be surprised if the Minister could prove that more people were eligible because of the increase. The increase was necessary because of the decrease in the value of money and also because of the galloping inflation which is due almost completely to successive Fianna Fáil Governments.

While people will now pay an extra 15p per week by way of insurance they will not be entitled to free medical services outside of hospital unless they are in the lower income group. This increase to £1,600 will do no more than bring us back to square one no matter what figure the Minister may give for the number of people who are likely to derive benefit because of this increase. Because of increases in wages and salaries there has been a constant decrease in the number of people in the middle income group who qualified for benefit and this increase, therefore, will do no more than bring those people back into the scheme. It will not mean that more people will be eligible for benefits than were eligible since the introduction of the 1953 Act. Instead of doing what would have been the fair and decent thing—having an increase each year related to the consumer price index—there is now this increase of £400. If there had been a yearly increase in the figure the increase now by £400 would, of course, bring in more people, but that was not the case.

It is important that everybody who reads the newspapers tomorrow morning will discover that he must continue to pay for his doctor outside of hospitalisation unless he happens to be in the lower income group. Let us consider what that means. It means that the medical card system is not being abolished. It means that there will still be blue cards, green cards, pink cards or cards of any other colour depending on what local authority area one happens to be in. This is no consolation to those people who must, when seeking benefit, give details of all income they have and hope that somebody in an office will decide they are members of the lower income group. There is real hardship in borderline cases where the person who does not qualify may have an income of only £50 more than the figure set for eligibility. Such people are in dire need because of the cost of drugs and medicines. As we all know, the cost of drugs and medicines has increased all over the world to an extraordinary degree. While it can be argued that drugs now are very effective the fact is that a man might not be able to pay for the drugs which his sick child might require.

If a person is adjudged as not being within the lower income group he has no recourse, according to the 1953 Act, except to the hardship clause. As a member of the North Eastern Regional Health Board I asked the chairman at a meeting—I do not know if Deputy Tully was present——

Mr. Tully

I am always present at meetings.

Mr. Donegan

Of course. I should have said that I am not aware whether Deputy Tully is a member of the committee. I asked the chairman, who then referred the question to the chief executive officer, what was the position in relation to a hardship case in the lower income group. My interpretation of the 1953 Act in this respect is that there was provision for hardship cases and if the county manager considered a case to be a hardship one, he could take action. I was told that the position is that at the top level of the middle income group there is no appeal. As I understand the matter the chief executive officer must deal with whichever officer is designated by the local authority in so far as the lower income group is concerned. I would not mind if, instead of being 15p per week, the contribution were to be 45p per week and if people in the lower income group and those who have just a little more than the figure set for the middle income group, could avail of these medical services. Of course, the proper way of providing health services for our people would be, as defined in the Fine Gael health policy, to include 85 per cent of our people in a contributory scheme.

The few who, at the moment, are disqualified from benefits, will be brought within the scope of the new figure. No extra services are being provided in this Bill. In a full year the Bill will result in an extra £3.6 million in taxation and presumably the 15p per week contribution will eventually be increased whereas the charge for hospitalisation of 50p per day brought the Exchequer £700,000 each year. I am taking the Minister's figure of £4.3 million. When £700,000 is subtracted there is £3.6 million left.

Mr. Tully

I think the £700,000 comes from the £5 million.

Mr. Donegan

In fact, it is £4.3 million? However, it does not abolish the medical card system or the means test.

The Bill does not supplement the contribution from the Central Exchequer to the rates. The position is still the same except that on 1st April there was the transfer to the health boards of the financing of health services Under a certain agreed formula levies will be made on the local authority areas for the operation of health services. I would draw attention to the fact that, whereas in the financial year ended 31st March, 1971, two supplementary grants were given by the Department of Local Government to local authorities, before we struck the rates in mid-March we were informed by circular that the two grants would not be paid. The grants were introduced by the Minister's predecessor, Deputy Seán Flanagan. At the time Deputy Flanagan said that it would be a grant of everything above the existing figure of 50 per cent in cash which was falling on the rates. Within four months Deputy Flanagan had to step down; he was obliged to say that he could not guarantee this and that it was for one year only. Since that time local authorities have had a certain percentage of their health expenditure paid for by the Department of Health.

A circular was sent to all local authorities before they struck the rates this year—I speak on this matter as Chairman of the Louth County Council —informing them that there would not be any supplementary grant in regard to excess expenditure. In County Louth the figure to be considered was £38,954. What will happen in the North Eastern Health Board when consideration is taken of the excess amounts which Counties Meath, Louth, Monaghan and Cavan enjoyed in previous years? The action of the Minister, in taking the last penny and not giving any increases in service, bodes ill for the ratepayers.

This Bill increases the amount of money available to the Minister. There is nothing to help the ratepayers, there is nothing but a future in which the Minister has forecast escalating health costs. From this it appears the ratepayers must pay more, the Exchequer may pay more but it will be helped to the extent of £4.3 million by the action of the Minister.

Deputy Carter commented on the Fine Gael health policy. First, he spoke about no Exchequer contribution or rates contribution and finally he spoke more accurately about the Fine Gael policy. Deputy Carter and I sat on the select committee on health and he should know that the Fine Gael policy provided for one-third payment by way of contribution from the Exchequer, one-third by way of contribution from stamps and one-third from the rates. However, that was not to provide what we are enjoying at the moment. It was to provide medical care and drugs outside hospital. It was regarded as a fair way of taxation.

There is no doubt that the Minister has nailed the Government's colours to the mast in regard to the methods of financing health services; it is to be by way of increased contributions from the insured worker, by adherence to the 1953 Health Act, to the iniquitous system of medical cards and it means that for the majority of people there will not be a health scheme outside hospital. The people must provide for themselves, they must pay the doctor's expenses and the cost of medicines and drugs. Anyone who has been obliged recently to attend the doctor and obtain medicines knows that nothing can compare with the escalation of charges in this regard.

I do not mean that as a criticism of doctors. I accept that a doctor must change his car every two years, I appreciate the running costs, the cost of secretarial help and of maintaining a surgery. I am thankful for the services our doctors are providing. The plain fact is that in this city at the moment, if one calls a doctor to the house, the average fee is £2. If one goes to a surgery the average fee is £1. If one gets a prescription the average cost of that is somewhere between £1 and £2. This is the sort of money that we, even though we say we are ill-paid and have many expenses, can afford. It is the sort of money that the man with £2,500 a year can afford but it is not the sort of money that the person earning £13 or £14 a week can afford. This very day I had a case which I sent to the officer seconded by Louth County Council to the North Eastern Regional Health Board; it concerns the wife of a farm labourer, with seven children, who did not get her maternity grant from the North Eastern Regional Health Board. I am certain the position will be corrected but, if she were on the dividing line, where are all the rest? Where is the £1 for the doctor? Where is the £2 for drugs? Where is the money for food, for shoes, for clothes? I neither want to weep nor to adopt some sort of socialist line. Quite frankly, I believe in neither socialism nor capitalism. This country is far too small and ways of life are too intermingled to produce any theoretical brand of either socialism or capitalism. We must deal with facts. There is need for change. The only change provided in this measure is the garnering of £4.3 million into the Exchequer.

I do not want to go into detail about the Fine Gael policy for health. It is well known. One of the ways a certain politician, no longer in party politics, adopted to impress the people was continuous repetition. This bored some people but he did get across to a great many exactly what he wanted to do. We, in this party, fail in this respect because, if we keep repeating something we know to be good, we end up boring ourselves. We are not the sort of people who can get up at every crossroads and keep repeating what we are going to do. We believe the people know and once or twice is enough to tell them, or perhaps, at election times, at Ard-Fheiseanna and on party political forums. The basis of our policy with regard to health is one-third/one-third/one-third. Under that scheme 85 per cent of the people would have their medicine paid for and a choice of doctor, where possible, inside as well as outside a hospital.

We seem to be heading in the same direction in which the USA has gone; we seem to be driving more and more people into hospital, people who do not really need hospitalisation, people who, with modern drugs and modern facilities, could be attended to in their own homes. If we encourage hospitalisation we will escalate health costs more and more and we will create a situation in which doctors, because of pressure of work, will send people to hospital in order to get rid of them, placing an extremely heavy charge on people in general.

There is no increase in this Bill in the valuation provision for farmers. I know that the argument is that the valuation stays the same but the income should increase; if the valuation was producing a certain income in 1956, 1961 or 1963, the argument is that, as that income increased, there was no need to increase the valuation because all one was doing was including more people and placing farmers in a preferential position. The fact is that the farmer's net income has not increased pro rata with the fall in the value of money. It has not increased pro rata with the increases in wages and salaries paid to industrial and other workers. The £60 valuation today does not signify an income of £1,600. This Bill, therefore, as well as doing nothing for anybody, is unfair in this respect. We know what health costs are and farmers can be just as sick and need just as expensive medicines and medical attention as anybody else. What has been said here many times is correct : the first valuation figure, namely £50, and the present valuation figure, namely £60, are both unfair from the point of view of income fixed for the middle income group in other occupations.

The Minister said nothing about this. He was lax in this regard and, when he comes to reply, he should certainly say something because he knows there is widespread dissatisfaction all over the country with the figure of £60 valuation. My information is that if there was a farmer with the valuation of £62 or £63, and if there was great hardship, if, for instance, there were other members of the family disabled or unable to earn a normal livelihood, if that was a further charge upon that farm, and if the officer seconded by the local authority to the health board decided that that particular farmer was not a hardship case, then, as I understand the present situation, there is no appeal. I would be interested to know if, in fact, this Bill does create a situation in which there can be an appeal. As I understand it, at the moment there is no such appeal.

Fianna Fáil have failed as far as health is concerned. From 1953 onwards—that was the year in which the Health Act was born and, if ever there was a Caesarean birth, that was one— there was room for change. Looking back one sees the Gilbertian approach to the Deputy Dr. Noel Browne mother and child scheme. Surely since those days, when that Caesarean birth took place and the 1953 Health Act was produced and we were told it would never cost more than 2s in the £ on the rates, there was room for some change. The fact is that the 1970 Health Act establishing the health boards and the 1971 Health Act which increases the figure for people in the middle income group to keep pace with the loss in the value of money and various other things, have fundamentally changed nothing. We are still back in 1953 and the breath of fresh air that we hoped would enter the Department with the present Minister did not arise.

I make no secret of the fact that he is a man for whom I have a high regard. He will accept that this is a political criticism on his political performance and involves no personal animosity. The health system is stagnant; we still have our rotten medical card system; we have no choice of doctor outside hospitals. The great majority have no doctor under a health scheme outside hospitals and no provision of drugs outside hospitals. At the same time, we have the degrading situation whereby people must prove themselves, in the words of the 1953 Health Act, to be unable to provide by their own efforts medical care for themselves or their families.

Minister for Health (Mr. Childers)

I should like to thank the House for the generally constructive way they have examined the proposals but I must remark that it seems to me that the Fine Gael Deputies were divided in their opinions. Many of them commented on the Bill as though it provided merely for an increase in taxation and was not the beginning of an insurance contribution scheme. Then, having criticised it, both Deputy Fitzpatrick and Dr. Byrne said that as there was an insurance element in it they welcomed the Bill. I do not know how to take the attitude of the Fine Gael Party towards the Bill since practically all of them condemned it and, at the same time, they gave the impression that they recognised that the Bill as a method of raising money for health purposes on an insurance basis had at least some merit even though they did not like the characteristics of the Bill.

Health services, as I have already indicated, will cost more and more and more. Whether they are paid for by taxes, rates or insurance contributions or by a combination of all three it is absolutely certain that the whole community in proportion to its income, the lower income group paying less proportinately than the higher income group, will have to put aside more and more savings for health. I say that without fear of contradiction. It will happen not only here but in other countries. A question we can discuss at length and without much profit is whether the present method of levying taxes and rates and now this new contribution is a reasonably fair one or whether anyone can prove it imposes too great a burden on any section of the community. I want to be absolutely honest with people outside and I say that this growth of health costs is a reality beyond all doubt. It is due to the growing specialisation of hospital services, to the extension of services provided by this Government with the consent of the House and, of course, at present it is due to a gross inflationary situation which inevitably affects any service where the labour content is of the order of 70 per cent.

If the inflationary element can be contained with, shall we say a continuation of the spirit that was shown and is so evident this year in the employer-worker agreement and if it can be, perhaps, even more attuned to productivity, next year this element in the increased cost of services may be reduced. I hope everybody seeking higher wages or salaries will examine how much they will inevitably have to pay for health services in one form or another and that they will realise this is completely inescapable because, whereas the average labour content in any service in industry in any case would be something in the region of 40 per cent to 50 per cent, inevitably there are more people involved—and rightly so—in the health service and so the cost mounts.

Having said that, I want to make it clear to those Deputies who suggested that there was no warning in regard to proposals to have insurance contributions that this is not the case. The Minister said quite clearly in his Budget Statement, as reported in volume 253, column 709 of the Official Report of 28th April, that there would be introduced in the House a measure dealing with the collection of insurance contributions. He indicated that the total revenue that would be available from that source in the current financial year would be £2 million. Were it not for the £2 million available this year, while it does not specifically relieve us of an increase in rates, either taxes or rates would have gone up more than they did.

Some Deputies have spoken as though it would be possible to reconsider the whole method of charging for health services and they have suggested that, perhaps, there could be some radical change on a large scale in the method of providing the money as between taxation and rates and insurance contributions. They have suggested this could be done and would be acceptable to the people. I have already indicated my belief that the present system of taxation is progressive; that it taxes those in the higher income group more than those in the lower income group. I believe the burden is spread reasonably fairly.

Any radical revision of the methods of collecting the revenue required for the health services involving, for example, very large insurance contributions that might be pay related covering not only the general medical services but also the cost of hospitalisation, even if it did result in reduced taxation and reduced rates would result in very severe political conflict. I do not know any country in Europe which in the past ten years has been able to make radical changes of this kind. Everywhere I see adjustments from time to time, adjustments in taxation, in property taxes, in social welfare contributions whether for health, social services or disability, retirement or widowhood. I see only adjustments; I cannot see any evidence that people are able to make radical changes and I believe if I were to introduce a measure with such a radical provision there would be tremendous criticism from the Opposition because once you start interfering seriously with the method by which people pay each year a contribution in taxes, rates or insurance you inevitably give them the feeling they are not personally benefiting by it and that they will be paying more than they should in relation to other sections of the community. So that if we had a revolutionary change I do not believe it would be acceptable to the people. If anybody can cite to me an example of a country that did this, that was democratic and the people had the right to elect their own government, I should like to hear it.

Having said that, I will go on and be perfectly frank and say that in this country taxation is proceeding on a gradual basis and is being gradually altered and, if one section of the community appears to be suffering, there are reliefs arranged in the Budget either by way of allowances for income tax, allowances for farmers in the form of rate relief or else social welfare services are increased. There are modifications each year. There are no violent changes. Even when the turnover tax was first imposed the level imposed was extremely small and was partly met for those with large families by increasing the social welfare allowances at the same time and increasing the children's allowances. So, when I am criticised for putting before the House a Bill for an insurance principle I have no apology to make that the amount to be raised is small because I do not believe there is any other way of introducing this change. If I were to introduce a Bill here today, even if it were pay related to some large sum such as 45p per week and if I were to explain that there would be such and such reliefs of taxation and rates, I believe there would be very widespread agitation outside the House and I do not believe Deputies themselves would be able sufficiently to analyse the position no matter what information I gave them in order to judge properly the merit of such a revolutionary change. I stand open to contradiction on this but I certainly make the statement with the utmost sincerity.

It would equally apply to the introduction of a very large and immediate turnover tax even if it were accompanied by very big increases in children's allowances and social welfare services, so that the Minister could say it was not regressive taxation, that it was taxation based on current expenditure and that there was no need for anyone to feel that those in the lower income group and with large family responsibilities would be adversely affected. Even if the Minister could get consent that that was the case and it was agreed in the House—that would not happen—I, nevertheless, feel the impact on the community would be too severe.

This is my own personal opinion fortified by what I have seen taking place in other countries and by studying the complex position that obtains in the various countries in Europe where the systems of payments for health vary from country to country, vary in relation to the impact of rates and taxes and insurance. They are varied and it is quite evident that in the case of each one of them they have been developed gradually.

I should like also to repeat what I said on Second Stage, that there are some countries where because of being free for a long time have had certain advantages in education that we were not able to have in the 19th century, such as Denmark, that developed a very fine co-operative concept in regard to agricultural production and insurance and which, I suppose, at one time was the most highly developed country in the world co-operatively. The Danes alongside of this developed a very good and excellent health insurance scheme wisely conceived and wisely administered but they found and have been finding ever since that the costs of hospital services have mounted so greatly and so explosively that they have had to dismantle the perfect element in their almost perfect insurance scheme by imposing very heavy taxes of one kind or another in order to pay huge subventions to the co-operative company running the insurance, in order to enable the health costs to be paid.

I can give other similar examples. I am sorry to tell the House this because there are countries with a longer period of freedom, with developed education services, where they tried this insurance principle and the system is breaking down and in these countries there is a mixture of insurance, rates and taxes of one kind or another. So that there is no country to which we can look at this moment and say that even allowing for the difference in our economic and social conditions, if we could adopt the machinery of that country, transform it, modify it, to our own circumstances, we would end up with the perfect insurance system. It does not exist. That is why I say that in introducing this insurance system we are doing it on a modest scale to begin with and will watch and see what the results will be.

It is equally true to say—I must make this clear—that one could not go very much beyond 15p per week without its being changed into a pay related scheme and the whole question of pay related social insurance and pay related health insurance charges is under immediate study and review, as the Minister for Social Welfare has informed the House and, as the House will appreciate, this involves very big changes in administration methods but it is true to say that if this insurance method of contribution is found satisfactory and does not impose undue burdens and, in the light of experience, works well, any further changes to a great extent in the upward direction of the contribution would have to be pay related. I give that undertaking to the House that when it grows in extent, quite obviously, there will have to be a pay related element in it.

Dr. Browne

Is that for the same 60 per cent or the whole community?

Mr. Childers

The middle income group. Somebody asked a question about the contribution of local authorities for health services. Local authorities will contribute about £30 million in 1971-72 to health services and about £10 million of this comes from the agricultural grant, leaving £20 million from the rates proper. If Deputies want to measure the effect of this contribution against the total amount levied for rates, they can examine these figures.

Deputies also referred to the very heavy burden of the rates in relation to health services. That is quite true in the towns and the cities. In connection with quite a number of counties, particularly those in the western areas, about 75 per cent of the total health costs are now paid for from central funds, if we include the proportion of agricultural grant attributed to the health expenditure in the county. So that the impact of the rates is heaviest in the towns where it is a far more important element in paying for the health services.

A number of Deputies asked what the people of this country would get in return for the payment of the £5 million a year insurance contributions. I suppose it is absolutely true to say that they will get the benefit of the fact that the volume of services is increasing every year. When the Health Estimate comes before the House I will send to the Deputies a list of extensions to hospitals, of new beds created for various services, of new services provided, and they will find that this, although not as great as I would like it to be, is quite considerable. The people paying the £5 million will be taking advantage of the better theatre equipment in hospitals, the new Sligo hospital, the new St. Vincent's Hospital and the various extensions to other hospitals. They will be able to take advantage of the long-term disability grants for drugs and hospital accommodation for children in all income groups. They will be able to take advantage of the same arrangements for providing drugs for adults who have certain classified, long-term disabilities in all income groups and that service will commence in October.

As the House knows out-patient fees have already been abolished. These people will be able to take advantage of the fact that every year we are gradually and steadily appointing more specialist consultants in various areas. Every year we are gradually providing a more expert out-patient service by specialists who go to various areas in order to examine patients and by means of which we hope to keep people from going to hospital, or whose hospital duration may be less as a result of their being able to avail of out-patient services at an earlier time.

We are gradually providing more short-stay psychiatric units in general hospitals. We have already provided a number and a further six or seven will be provided in the course of the next two or three years. The people who pay for this service will be able to take advantage of the growth of the out-patient psychiatric services all over the country. The numbers who came for out-patient services ten years ago was something like 15,000 compared with 150,000 now. They will be able to take advantage of the new child health service in towns with a population of over 5,000. I am very glad to be able to tell the House that we had a very high percentage response from mothers of babies who offered to have their children examined by the developmental paediatrician, who is a person trained in developmental paediatrics. Some 83 per cent of the total number of children born were the subject of applications for appointment.

The people who pay the £5 million will be paying a contribution towards the inevitable and essential improvement in some of the salary structures in the health service which are a part of the inflationary increases in wages and salaries which took place last year, which are in the nature of well deserved status increases. I am referring to the nursing community. The total cost of providing improvements in salaries and conditions for them in the current financial year is £1,150,000. It was found that because they were not regarded as permanent officers the intern, junior doctors and registrars seem to have lagged behind in receiving the kind of incomes which they merited. Because they were not considered permanent staff the conciliation and arbitration scheme did not apply to them. This was wrong; it was simply an administrative error that they could not be included because they are certainly part of the permanent staff of any hospital even though they move in or out. Certain increases were given to them which placed them at a reasonable level compared with those in Great Britain. The £5 million obviously has to contribute towards those status increases, quite apart from the increases in the nursing staff which will be re-required consequent on the 80-hour fortnight having replaced the 85-hour fortnight and certain other changes which have taken place in the hours performed by junior doctors, interns and registrars, which are still the subject of examination in connection with overtime pay.

There is nothing exceptional in our coming forward with these proposals. Practically every country, including those with far greater wealth than ourselves—even the Swedes who have nearly three times our income per head partly because of the huge capital value of their standing forests and their iron ore—are finding it difficult to raise money for their health and hospital services. It is not true that we are imposing this insurance contribution because the economy is failing or because we are going through a period where the increase in our gross national product is likely to be smaller than it was from 1967 to 1970, which followed equally a period of difficulty from 1965 to 1966. There are countries with booming economies who are still finding it difficult to provide the cost of their health and hospital services.

We are going to make the best effort we can to ensure the greatest possible efficiency in our services while maintaining the right human attitude towards the patients. The regional hospital boards, the resolution for whose appointment will be brought before the House some time between October and January next, will work in co-operation with the work study unit which I am initiating in my Department. We hope to follow the good example of a number of other countries in which some savings in costs have been secured through better methods of management and through better systems by which hospital nurses operate, saving them unnecessary time and walking, and various other changes in methods which we hope, with the consent of the unions concerned, can be effected in the hospitals.

A survey is being conducted by the socio-medico research board into the whole of patient work load of every hospital in order to see what further means of co-ordination and integration must be effected in order that the beds we have can be used to the greatest benefit in order to ensure that the average stay in hospital can be reduced and above all that the time taken between the entry of the patient into a hospital, his observation, final diagnoses and treatment can be reduced. All that will be a long-term business which cannot be done overnight but we are beginning to make progress in that direction.

Deputy Browne made a speech which reflected his views as what might be described as a 100 per cent socialist. I am sure that Deputy Browne is absolutely sincere in everything he says but it would be useless for me to discuss his particular philosophy because he is in a very great minority in this House, even in his own party, in his belief in a completely socialist system. Deputy Browne charged me as being someone who expounded the cause of capitalism. I have never done any such thing. I have constantly said through the years in this House that I and my party stood for a blend of private enterprise, co-operation and socialism, using the word "socialism" in its ordinary sense. If I were to list one by one all the socialist-type legislation passed under the aegis of Fianna Fáil in this House involving Government intervention, Government insistence on the redistribution of wealth from the better-off to the less well-off and various types of social measures, it would take me until 11 o'clock tonight. They have been continuous and contrary to what Deputy Browne said there has been no diminution in the rate at which there has been Government intervention in regard to the operation of private enterprise whenever this party consider this to be the right course to adopt. Right from the very beginning without any hesitation or halting this has been done.

I think it is not only necessary for sociological reasons but it is essential because the world is becoming more complex. We are now reaching the position where it is extremely difficult for even private enterprise to continue its own operations without very considerable guidance from the State not only in this country but in all other countries in which they still believe in private enterprise wherever it can be properly administered, wherever it can operate without undue detriment to the people. I want to say that because it is no good Deputy Dr. Browne charging me with being a super capitalist. I assisted, in my position as Minister here, in passing Bill after Bill through this House which were of a Government interventionist nature.

Someone suggested that the insurance system in England paid for the health services to a considerable degree. This is not the case. Only 10 per cent of the huge panoply of the health services in England are defrayed from the insurance contributions made by the people of England. The rest comes entirely from general taxation and is absorbed by the great body of taxes collected from the community in Britain. So let no one suggest that in England, where they adopted the Beveridge scheme, a complete medical service from the cradle to the grave, is associated with insurance. The insurances cover the other types of social welfare, social insurance of one kind or another, social services of various types and only cover to the extent of 10 per cent payment for the health services.

I must also refute the suggestion made by a number of Deputies who in their opening remarks seemed to speak of the 60 per cent of the people of this country who are in the middle income group as the under-privileged of the community. Why did Deputies use that statement that the middle income group were the under-privileged of the community? It is true that we are not a very wealthy nation. We are the least well-off of the more wealthy nations, about 18th out of 153 nations according to the United Nations. We just at this moment have an income which is above those of the less well developed white countries and our income is growing steadily as the incomes of other countries grow. That being the case and when one observes the very high consumption of foodstuffs in this country, the consumption of calories, as compared with other countries and when one observes the report of medical officers in relation to malnutrition and the very low figure found recorded in this country, to speak of the middle income group as under-privileged seems to me to be a hopelessly exaggerated statement. There are people who live on extremely frugal incomes, who are very near the poverty line, at the lower end of the lower income group. We are constantly doing our best to assist those people by increasing the social services and by developing more industries. We have still a certain problem to solve in that region but no one who is honest can really describe the middle income group as the under-privileged group in the community. I could not possibly accept that.

Deputy Dr. Browne asked whether the general practitioner service would be made available to the middle income group. I have already indicated that that will not be the case. They will not be included.

I also want to mention again the whole problem of payment for drugs by the middle income group. That also has to be remembered in connection with what is available for the £5 million. Those in the full eligibility class, the lower income group, will get their drugs free through the retail chemists or in some rural areas direct from the doctor. A scheme will be introduced on the 1st October and will provide free drugs for all people with certain long-term conditions including epilepsy, phenylketonuria, cystic fibrosis, spina bifida, haemophilia and diabetes which is already covered by a free scheme. Then a scheme will be introduced at a later date which will provide a subsidy towards the medicine bills of the middle income group families when their monthly spending on medicine exceeds a specified sum. I want to be honest with the House. I am not able to tell the House when this scheme will be introduced. It will be introduced as soon as I can. Of course, the figure of monthly drug expenditure above which there will be a subvention I am unable to state. I will do my best in regard to this but I think that I have generally and reasonably kept my promises as Minister in various Departments and it may be taken for granted that this is an integral part of the scheme for the middle income group which will be introduced as soon as possible.

Dr. Browne

Is that for long term illnesses or for any illness at all?

Mr. Childers

Any illness. As the House knows, we voted £200,000 this year towards hardship cases in relation to drugs for the middle income group which matches a similar amount that has been raised by the rating authorities, that is, something in the neighbourhood of £350,000 to £400,000 is now already spent to help people in the middle income group who have real difficulty in paying for their drugs. It is spent on a very pragmatic basis. There are no specified rules for it and I have not heard any great complaints about how it is being spent. I gather it would not be sufficient to meet the very heavy cost of drugs as they gradually mount in cost in the next few years. Hence the section in the Health Act, 1970 which makes it possible to make a specific kind of contribution. I would say without fear of contradiction that that provision of £200,000 is assisting many people who otherwise would find it very hard to pay for drugs.

Mr. T.J. Fitzpatrick

(Cavan): The troops must not be in yet.

Mr. Childers

I have quite a lot to say on this subject. Deputy O'Connell seemed to imply that in some way we could tax the richer section of the community a great deal more in order to provide the extra cost of the health services. This is a subject which is largely debated during Budget time but I have already indicated, and nobody has contradicted me yet, that the number of persons earning very, very large salaries in this country is extremely small, the number of persons even earning £3,000 and over and who are subject to tax and surtax is not large. If a person earning, for example, £7,000, who is married without children pays £2,468 in income tax and surtax we in Fianna Fáil regard that as a reasonable contribution towards paying for other people's health service. If he earns £5,000 and is married without children I think the tax and surtax amounts to £1,300. Then we have the very high rate of death duties that have just been increased. I do not believe it would be possible to tax the very wealthy group in the community much more than we do at present.

The Taoiseach told the House about two years ago that if no one in this country was ever allowed to earn more than £5,000 a year the result in tax and surtax would only be a few million brought into the Exchequer and that the result would equally be that those who were very highly paid as extremely effective executives and professional people would tend to leave the country. If we allowed nobody to have more than £5,000 the differential between the £5,000 and the income of the lowest paid worker would be far less than it is even in Communist Russia and Czechoslovakia. So, this concept that there is a huge wealthy community to be milked with huge taxation in order to get us over the difficulty of finding the money for more expensive health services is not acceptable.

Another argument which one could use—and this was rather suggested by Deputy Browne—is that not enough taxation is collected. He also suggested that the upper income group found medical costs very high in any event. We collect between 30 and 32 per cent of the value of gross national product in taxes and in rates. This is a respectably high figure. It is higher in some countries with enormous defence commitments. It varies between 28, 35 and 40 per cent in the developed countries of the world. Contrary to what might be imagined, with one or two exceptions, it can be said that the more wealthy the country, the higher the amount of taxation and rates as a proportion of GNP. The figure of 32 per cent at least places us in the respectable category of a country that takes a great deal in taxes and rates in order to provide social services and all the other necessary State services. At least no one can say that we are taxing too little those who are better off in comparison with other countries. There may be variations here and there. That again relates to the fact that the level of taxation and rates is so high, particularly that of rates, that the introduction of an insurance contribution seems to me to be a reasonable proposition under the circumstances.

If Deputies say that this new insurance contribution is another example of patchwork in collecting money—I think I have already dealt with this but I will put it in another way—I know of no country in Europe where changes in taxation and in rates of insurance contribution could be called anything but cumulative patchwork followed sometimes by some co-ordination or by looking at some particular tax structure and examining it very carefully and eliminating anomalies in it. It is true to say that, in the whole of Europe, the whole development in methods of collecting money for services has been in the nature of, as I described it, a cumulative modification of taxation systems of a patchwork character. If Deputies accuse me of patchwork I am at least in good company with a number of very respectable democracies who consider themselves as having first class administrations.

Dr. Browne

It is the Minister's social services we are calling patchwork.

Mr. Childers

I am not in a position to give Deputy Browne the list of increases in social services over the past ten years and the net increase over and above the cost of living, but we made a very big contribution in that regard. Deputy Hogan suggested that levying these contributions might have the effect of encouraging people not to go to a doctor but to wait until they had to go to hospital because they would get the hospital service free. I have challenged Deputies to give me really succinct, specific evidence that in the middle income group there are a noticeable number of people who do not go to their doctor because they do not want to pay the charge and who wait until it is very late and then have to go to hospital. I have not been able to get any evidence of this. If anybody can give me any evidence of it I should like to hear it.

In all the various social surveys that are made from time to time by social workers who go around the country exploring social evils of one kind or another, I have not been able to get any evidence of this. My reply to Deputy Hogan is that we are developing out-patient clinics all over the country. The out-patient services have been developed. We are trying to discover disabilities in children at an earlier age. We hope to reduce the time taken for observation in out-patient clinics when the patient has to go into hospital. This will take some time and it will take a good deal of examination of one kind or another.

Mr. Hogan

On a point of explanation, I think the Minister misunderstood me. I did not say exactly what he has said. I said that if a patient outside——

An Leas-Cheann Comhairle

The Deputy is making a statement.

Mr. T.J. Fitzpatrick

(Cavan): He is helping the Minister.

Mr. Hogan

——had to pay for a service and the institutional service was free, there would be a tendency for him to opt to go into the institution rather than remain under the care of the outside practitioner.

Mr. Childers

Both Deputy Browne and Deputy O'Higgins suggested that the contributory scheme in this Bill is being brought in only because of our application to enter the European Economic Community. There is no requirement in the EEC which would oblige us to bring in a scheme of this kind. This point is really irrelevant to the debate. There is no comprehensive health insurance scheme in the EEC countries. In each there is a complex of schemes covering specific groups. I do not really need to read to the House the list of the health schemes in the European Economic Community because they are extremely complex. In fact, their actual definition of terms and words is slightly different from ours, but the House may take it for granted that we are not obliged to introduce a specific health insurance scheme as part of the conditions of our entry into the EEC.

Deputy Tully asked whether, once a person had paid a contribution as a member of the middle income group, the limited eligibility group, he would be able to apply for a medical card if he felt that circumstances so warranted. The answer is that the person can apply for a medical card having paid the contribution, but the contribution could hardly be refunded. It would be regarded as a new situation. He would have an income which would have declined to the point that he was regarded as being in the medical card full eligibility group.

A number of Deputies asked about the method of payment. We are examining all this. When we reach Committee Stage, if a number of Deputies in all parties really press me to provide cards with insurance stamps for the use of the farming community, and if they recommend that this might be one of the best ways by which the self-employed community could save the money for this very modest contribution, I, in turn, will press upon the officers of my Department and on those concerned in the Revenue Commission to adopt the principle. Even though the amount is very small, saving money like this is an excellent principle: saving it gradually through the accumulation of stamps. I should also like to see it apply more than it does to rates.

Of course everybody is complaining about the level of rates. The other day I was reading one of the White Papers issued after an examination of the rating position. It is about five years out of date now in terms of statistics. It stated that a person who had to pay £65 in rates in the year paid the same amount if he smoked 20 cigarettes every day, or if he drove a medium sized motor car 10,000 miles, the tax on petrol would amount to £65 in the year, and that it was the impact of the two moieties in a solid cash demand that created some of the objections to paying rates. I am not talking about those people in the community whose incomes have not increased to the same degree as have rates; I am talking about other people in the community. The psychological elements in the impact of taxation and rates can be overcome by way of insurance stamps and I hope it will be possible to do this.

A Deputy asked whether we could increase the limit for the limited eligibility group beyond £1,600. The answer is "no". Here again there can be a hardship element in relation to those people in the very upper income group but as the House is aware we are not changing the system whereby someone in the upper income group who may find the cost of medical services or hospital treatment absolutely enormous can get a contribution from the health authority. One Deputy suggested that the £1,600 limit was not sufficient. This figure is reasonably fair when compared with the period during which there was a limit of £800. If we start with the new limit of £1,600 and compare it with the £1,200 limit we would have to admit that the figure should be more than £1,600 but all I can say is that we have done the best we can in raising it to £1,600, as is to be the case in respect of social welfare contributions.

Deputy Donegan complained, as did other Deputies, about the cost of general practitioner services and drugs for those not covered by medical cards. In 1966 a household budget inquiry showed that the average medical expenses in a family which included some children were about £16 per year. Allowing for increased fees and costs since then, the figure is now probably between £20 and £25 a year. I would not consider this as being a grossly excessive amount in respect of a middle income group family. The House may disagree with me on this but I honestly think that total average expenditure of this amount on general practitioner services and drugs is not excessive and if it is compared with the consumption of tobacco and alcohol and with entertainment costs by the same group of people, no one can say that we are imposing a crushing insurance contribution by asking this group to pay, initially, 15p per week towards hospital services.

Deputy Fitzpatrick suggested that this was merely another form of tax and asked if, by the imposition of this tax, I hoped to relieve the rates. We do hope, in later years, to relieve the rates by the use of this insurance contribution method and of course while relieving rates we would also be relieving taxes of one kind or another. I cannot predict what the insurance element will be in future years in the payment of health services. I can only indicate that we intend charging 15p per week and, in the case of self-employed persons, £7 per year for this year. It would be impossible for me to foretell what the level would be in later years.

Deputy Tully made an incorrect statement about the estimated yield of these contributions. He said it is £3 million when in fact it is £5 million and the figure of £5 million relates now to a full year. We expect to earn £2 million in the present year.

Some Deputies referred to the cost of collecting these insurance contributions. The cost will not be noticeable in connection with the social welfare group of people because it will only be a matter of putting on a stamp and we reckon that the cost will be between 8 and 10 per cent in respect of the farming group and the self-employed but it is estimated that they will provide only about £700,000 in a full year out of the total of £5 million. Therefore, no one can say that the cost of collection will be excessive.

I want to be fair to Deputy O'Higgins in his references to the Fine Gael scheme as it was devised originally. Fine Gael claim that, ten years ago, they put forward a viable scheme, based on the then existing services, for comprehensive services which involved the State paying one-third of the contribution and the employer and employee each paying one-third, amounting to 1s 6d per week. The main point about this scheme was that it assumed static costs and we have never been able to persuade those in Fine Gael who were sponsoring that scheme that there was no provision in it for increases in the cost of existing services. In fact, the increase in expenditure from the time of the 1s 6d per week scheme as proposed by Fine Gael has been £57 million. This annuls the significance of any insurance scheme proposed a very long time ago. The kind of contributions envisaged then would have done little to solve the real and growing problems of health finance. Without imposing very substantial and probably intolerable increases in the rates of contributions the scheme would quickly have become insolvent.

Dr. Byrne

The Minister must know that that scheme made provision for a complete general practitioner service.

Mr. Childers

I am about to deal with that.

Mr. T.J. Fitzpatrick

(Cavan): Did the Minister say that 15p per week or £7 per year will remain static?

Mr. Childers

We will have to examine that. I do not believe it will remain static. It is bound to increase but I cannot commit myself because this question has to be studied. A version of the Fine Gael scheme was published in 1969 in a document entitled Winning Through to a Just Society. If a scheme on the lines advocated by Fine Gael was in operation this year, the total health expenditure instead of being £76 million would be between £95 million and £100 million. That would include the general practitioner service for the middle income group and also a free dental service. It is clear that the contributions as advocated, much the same as in the Bill, could not meet this additional cost and relieve the rates and keep the Exchequer commitments within bounds. That is the position. If, for example, one reckons that there are about one million people gainfully occupied, one would reckon that a general practitioner service would cost about 45p a week. This would be 15p each from the Government, the employer and the employee. Presumably it would be 30p from the farmer and the self-employed person. It would not cover any hospital services but would simply be an imposition on top of the present budget of £77 million. I do not think this is a practical scheme but I am willing to admit that with the introduction of any insurance scheme great care and vigilance must be exercised. We must do our best to estimate how fairly it operates and how far the insurance contributions can be increased on a pay-related basis.

Deputy Donegan said that only those in the lower ranks of the middle income group can ask to be treated as hardship cases. This is not so. Anyone outside the lower income group can ask, on hardship grounds, to be given free or reduced cost services to which he is not otherwise entitled.

Deputy O'Higgins said that the Bill would provide £5 million to cover the cost of £700,000 hospital expenses for the middle income group. The charge of 50p per day is not related to the economic cost of providing a hospital service. The cost of maintaining a patient for a week in a teaching general hospital can be as high as £80. This is due to the specialised nature of services, to examination by teams of consultants, to the use of expensive equipment and the other modern devices of medicine today. As I have already indicated, no country has been able to produce a perfect scheme of contributions to cover the very heavy hospital expenses. I hope we never reach the American level of hospital expense. I was reading recently that there are some beds in American hospitals that cost £70 per day—not £80 per week. I hope we escape that frightening escalation of cost.

A number of Deputies asked me about the standards for the medical card group. I shall bring them before the Dáil and I think Members will be reasonably satisfied with them. I am sorry to disappoint Deputy Fitzpatrick, but we must continue with the method of calculating medical card standards for the farming community by assessment of their agricultural incomes. As the Deputy knows, this is being done throughout the country in connection with non-contributory social assistance payments and in connection with other services. Although I can see the objection by farmers to this assessment and although it is being changed in connection with the limit of valuation for social welfare payments in the summer months, nevertheless when we are going to have a standard basis of income limits provided by this House for the medical card group, it would be anomalous to make use of the valuation system if the valuations differ in their economic content so much from one part of the country to the other. We shall adopt the principle of relating the agricultural income of the farmers with the income stated for the non-farming community. This seems reasonably fair.

Deputy Donegan asked why we did not change the £60 valuation limit for the limited eligibility group. Estimates of farm incomes prepared on the basis of management surveys sometimes are questionable. Nevertheless a survey was carried out by An Foras Talúntais on a sample of farms in a variety of regions. No attempt was made in these summations to relate the results to valuation. If one wants to make a rough guess, the total valuation of agricultural land is £6.9 million; total family farm income, including home consumption at farm gate prices, was £178 million in 1970. On this basis the average income for £1 valuation was £26. I hope Deputies understand the method of that calculation. Using this ratio, a table can be prepared showing what might be regarded as the approximate average income in the range of valuations from £20 to £60. On that basis—which is a rough calculation—land with a valuation of £60 would yield an average income of £1,560. I hope it is not just a coincidence that it works out this way because the business of applying an average income per £1 valuation is dangerous. Nevertheless, for what value that statement has, I give it to the House. In this way it can be seen that the £60 valuation corresponds to some degree with the £1,600 upper limit in the case of the social welfare class of people.

Deputy Barry seemed to imply that the health boards would not be effective. The Deputy will admit that he must give them some chance to operate before he condemns the concept of the eight regional health boards. They are new small parliaments, created recently. They began only a few months ago and in many cases the final officers have not been appointed. In many instances the officers will have to be trained in their work with the help of our consultants and officers of my Department. They must examine the content of the health services and the health board area; they must initiate a system which has been well devised by the consultants for indicating performance to the health board members; they will give financial reports; they must set out priorities for improvements in the service based on whatever general indications I can give them. It would be reasonable to say that the health boards will have proved themselves, or not proved themselves, not before at least three or four years. They must develop the whole concept of the regional examination of health services which involves not only the centralisation, co-ordination and integration but the better handling and administration of a variety of decentralised services. It would be unfair to condemn the health boards at so early a stage in their development.

When Deputy O'Higgins was explaining his reason for putting into operation the Fianna Fáil Health Act of 1953, I was surprised that he seemed to think it was a dreadful Act in many ways. He was not able to convince the public about it. He was not able to convince the electorate because Fianna Fáil were returned to office in 1957 and, ever since then, there has been criticism by the Fine Gael Party of the division of the community into three groups for the purpose of devising methods of payment for health services. Policy documents have been issued by both the Labour Party and the Fine Gael Party as to other methods of ensuring payment for health services and providing services to the public at large. As I have already said, nobody has given me any evidence to show that the limited eligibility group suffer medically as a result of having to pay general practitioner bills. With the policies we are devising to help with the payment of drugs it is very unlikely that anybody will suffer in future.

So far as the medical card group is concerned, as the House knows, I hope the Medical Association and the Medical Union will agree to the proposals I have made in connection with the choice of doctor principle. If I am to believe the medical magazines my amended proposals will be approved and the choice of doctor system will start to operate on 1st April, 1972, and we should then be ending the old-fashioned dispensary system. This will have some effect on certain people who have never yet secured medical cards and who have always paid a private doctor. There may be a change there. Other people will obviously leave the full eligibility group because of rising incomes and wages.

Mr. O'Higgins

That is a good thing and I commend the Minister.

Mr. Childers

This does not solve the problem entirely in regard to doctors in rural areas. Deputy Donegan suggested people in rural areas were not getting the kind of service they deserve because of the difficulty of finding local doctors. The problem of general practitioners is acute not only here but in other countries as well. I am promoting an advisory committee to examine the whole position of the general practitioner service. We have had a considerable number of commissions of inquiry into various aspects of the health services. We have none in operation at the moment except the temporary committee on drug abuse. It would be a good thing, I think, to have this whole matter of general practitioner service thoroughly examined by a committee, with very wide terms of reference, including postgraduate training, apprenticeship training, refresher courses and the problem of finding general practitioners to operate in the west, as well as the problem of group practice, et cetera. I hope this committee when they function will have some useful recommendations to make so that those in the middle income group who feel the medical service is inadequate because of a lack of an adequate number of doctors will have every cause for satisfaction.

I have examined exhaustively all the observations made from the Opposition benches. I should like to thank Deputy Burke, Deputy Healy and Deputy Carter for their helpful contributions. I agree with them. I do not believe sensible people will object to paying 15p per week to finance health services. I do not think that could be regarded as an excessive contribution. I do not think it will be hurtful even to those at the lower income end of the limited eligibility group. Much as I would have liked to begin the scheme on a pay related basis that is not administratively possible. However, I think this is a very reasonable contribution. We will be watching its effect and examining how we will find the money for what will be inevitably increased costs of health services as time goes on.

The cost of psychiatric services will increase. Ten or 15 years hence the cost of these services will be much higher than it is now in relation to the cost of the ordinary acute care hospital services. The cost of the mental health services is bound to increase if we are to deal with the problem of the large numbers of young persons who are having their first entry into mental hospitals. This surprising fact was illustrated by the medical and social research board in their recent study. It came as a shock to many of us because, when one goes into a mental hospital, one does not get the impression of youthfulness. However, the registers were examined with great care and the facts were confirmed by the officers of my Department. This applied not only in rural areas where inter-breeding might account for a certain level of mental illness, but it also applied in urban areas. We will have to have some kind of priorities.

Mr. Tully

That is a shocking statement for the Minister to make.

Mr. Childers

What statement?

Mr. Tully

That people living in rural areas might develop mental illness because of inter-breeding.

Mr. Childers

I am talking of 100 years ago when cousins tended to marry simply because they lived in close association.

Mr. Tully

Not more than in any other place.

Mr. Childers

I am not insulting anybody and the Deputy knows this has taken place.

Mr. Tully

No, I do not.

Mr. Childers

It may not have taken place in the Deputy's constituency but in mountainous areas in every country, where there were no roads or poor roads, the tendency was towards marriage between second, third and fourth cousins and that led to recessional genes operating changing the personality and characteristics of the people. Everybody knows that.

Mr. Tully

I do not and I do not accept it.

Mr. Childers

We will have to have more psychiatric clinics, the aim being to reduce as far as possible the number of young people requiring institutional treatment. I thank the House for the way in which Deputies have discussed the Bill. I was interested in the fact that two Fine Gael Deputies welcomed the Bill. Others seemed to criticise it very strongly.

Mr. Tully

To keep the record straight: the Minister replied to two questions I asked him and he misquoted both of them. The figure of £3 million that I gave him I got from the Minister for Finance. It was in the Budget Statement and it was repeated in reply to a question I put to the Minister for Finance. In the second case I asked the Minister if someone is paying 15p a week and gets a medical card does he have to go on paying?

Mr. Childers

No, but I do not think we can reimburse him.

Mr. Tully

Nobody asked that. I will be interested to see how that works because it will be difficult to change it.

Question put.

The Dáil divided: Tá, 62; Níl, 49.

Tá

• Aiken, Frank.
• Allen, Lorcan.
• Andrews, David.
• Boylan, Terence.
• Brady, Philip A.
• Brennan, Joseph.
• Brennan, Paudge.
• Brosnan, Seán.
• Browne, Patrick.
• Browne, Seán.
• Burke, Patrick J.
• Carter, Frank.
• Carty, Michael.
• Childers, Erskine.
• Colley, George.
• Collins, Gerard.
• Connolly, Gerard C.
• Cowen, Bernard.
• Cronin, Jerry.
• Crowley, Flor.
• Cunningham, Liam.
• Davern, Noel.
• Delap, Patrick.
• de Valera, Vivion.
• Dowling, Joe.
• Fahey, Jackie.
• Faulkner, Pádraig.
• Fitzpatrick, Tom (Dublin Central).
• Flanagan, Seán.
• Foley, Desmond.
• Forde, Paddy.
• French, Seán.
• Gallagher, James.
• Geoghegan, John.
• Gibbons, James.
• Gogan, Richard P.
• Haughey, Charles.
• Healy, Augustine A.
• Herbert, Michael.
• Hillery, Patrick J.
• Hilliard, Michael.
• Hussey, Thomas.
• Kenneally, William.
• Kitt, Michael F.
• Lalor, Patrick J.
• Lenihan, Brian.
• Lynch, Celia.
• Lynch, John.
• McEllistrim, Thomas.
• Molloy, Robert.
• Moore, Seán.
• Moran, Michael.
• Noonan, Michael.
• O'Connor, Timothy.
• O'Kennedy, Michael.
• O'Malley, Des.
• Power, Patrick.
• Sherwin, Seán.
• Smith, Michael.
• Smith, Patrick.
• Timmons, Eugene.
• Wyse, Pearse.

Níl

• Barry, Peter.
• Barry, Richard.
• Begley, Michael.
• Belton, Luke.
• Browne, Noel.
• Bruton, John.
• Cooney, Patrick M.
• Corish, Brendan.
• Cosgrave, Liam.
• Cott, Gerard.
• Coughlan, Stephen.
• Crotty, Kieran.
• Desmond, Barry.
• Dockrell, Henry P.
• Dockrell, Maurice E.
• Donegan, Patrick S.
• Donnellan, John.
• Dunne, Thomas.
• Enright, Thomas W.
• Finn, Martin.
• Fitzpatrick, Tom (Cavan).
• Fox, Billy.
• Harte, Patrick D.
• Jones, Denis F.
• Kavanagh, Liam.
• Burke, Joan.
• Burke, Liam.
• Byrne, Hugh.
• Clinton, Mark A.
• Conlan, John F.
• Coogan, Fintan.
• Kenny, Henry.
• Lynch, Gerard.
• McLaughlin, Joseph.
• McMahon, Lawrence.
• Malone, Patrick.
• O'Connell, John F.
• O'Donnell, Tom.
• O'Donovan, John.
• O'Hara, Thomas.
• O'Higgins, Thomas F.
• O'Leary, Michael.
• O'Reilly, Paddy.
• O'Sullivan, John L.
• Pattison, Séamus.
• Taylor, Francis.
• Thornley, David.
• Timmins, Godfrey.
• Tully, James.

Tellers:—Tá: Deputies Andrews and S. Browne; Níl: Deputies Begley and Kavanagh.

Question declared carried.

An Ceann Comhairle

Next Stage?

Mr. Childers

Next Wednesday.

Committee Stage ordered for Wednesday, 7th July, 1971.