Dáil Éireann debate -
Thursday, 4 May 1972

Vol. 260 No. 11

Adjournment Debate: Hospital Charges.

Mr. Hogan

Deputy L'Estrange and I had a question down on yesterday's Order Paper about the 50 per cent increase in voluntary hospital maintenance charges, an increase of £2 per day. By way of supplementary question I asked the Minister why he did not advert to this substantial increase when his Supplementary Estimate was going through the House some weeks ago so that we could have had an opportunity of discussing fully this involved question. In his reply the Minister told me that he was not responsible for the amount charged by voluntary hospitals to private patients. That was not a reply to my question and, consequently, I am raising the matter here this evening.

This increase of £2 per day came as a shock to everybody. My main bone of contention with the Minister is that he did not deal with this particular problem when he had an opportunity of doing so on the occasion of his Supplementary Estimate being discussed here. He must have known then that some such changes were imminent, although he may not have had the particular figures. It is possible that the matter was under discussion at that time. The gap between costing for treatment in hospitals and hospital charges has been widening in recent years and of an expenditure of £76 million in 1971-72, 70 per cent of that went to hospitals. In 1972-73 our bill was £84 million of which 76 per cent went to hospitals. Therefore, it was obvious to the Minister that the gap was widening and he must have been aware that something would have to be done about it. However, he chose to make no reference to it on the occasion of the Supplementary Estimate going through the House and the news of the increase was burst abruptly on the public a few days ago. The general charge for our non-teaching hospitals has been about £17 per week and in respect of teaching hospitals, the figure has been about £30 per week. These figures are being advanced now to £28 and £44 respectively.

All that information was available to the Minister and he should have taken the House into his confidence. I know that we have only limited resources of money to finance the health services—our Exchequer, rates, returns from voluntary health insurance and from private persons plus a little from the Sweepstakes and, recently, the compulsory hospital insurance which bring in about £5 million per year. As the Minister mentioned, we have a three-tier system. The lower income group constitute 30 per cent of the population, the middle income group, about 60 per cent and the upper income group, the remaining 10 per cent.

Some time ago the Minister introduced a hospitals contributory Bill. This was criticised at the time, but at least we were allowed to discuss it. There is no thanks to the Ministers for that because he had to come before the House in order to get the necessary moneys. I criticised the Bill at the time on the basis that it meant double insurance. Our upper income group constitutes 300,000 persons but there are 350,000 voluntary insurance contributors. Therefore, there is an overlap. I cannot say how many people there are in the middle income group who are now being compelled to insure themselves; I do not know how many people in the middle income group who were covered happily previously by voluntary insurance but from the figures I have given, the number must have been substantial. I made the point at the time that, even allowing some small concessions, in respect of the overlap, there was here a position whereby people who already had free choice of doctor, consultant, specialist or hospital will be compelled to subscribe to compulsory insurance. My point was that when they were already covered by voluntary insurance they should be exempt from compulsory insurance. However, the Minister did not see it that way and an insurance of £7 per year was imposed on 60 per cent of the population.

This particular matter raises a different issue. In this instance we had no opportunity for discussion and the first we knew of the increased charges was by way of an announcement in the newspapers.

I accept that something would have had to be done to bridge the gap to which I have referred, but I object to it being done by the diktat of a Minister for Health who did not allow this House an opportunity of discussing the matter. In a democracy such as this an increased charge of 50 per cent should be discussed here, especially after an increase having been made only two years previously.

I do not know whether the Minister has consulted either the Voluntary Health Insurance Board or the National Health Council on the matter. Perhaps he will let us know when he is replying. I do not know, either, whether he intends to restrict voluntary health activity and coverage. If that is his intention he should say so openly. If it is his long-term objective it would be better if everybody knew of it. On the other side there is the question of the public sector—the question of the local authorities and of the ratepayers. Again, we are left in some ambiguity here. Under this increase in voluntary hospital charges I understand that there will be an extra £4 million coming from the health boards, in other words, from the local authorities, to the voluntary hospitals.

Mr. Coughlan

From the ratepayers.

Mr. Hogan

Yes.

Minister for Health (Mr. Childers)

Those who are eligible for hospital services are covered fully by the grant. There will be no extra charge on the rates or taxes as a result of this increase.

Mr. Hogan

From where is the £4 million extra to come?

Mr. Childers

It has been voted already this year.

Mr. Hogan

The Minister says it will not come from the rates. I appreciate that that may apply to 1971-72 or, even to 1972-73, but is there any guarantee that this will not mean an increased burden on the rates in the years thereafter?

Mr. Childers

The increase of capitation costs is included fully in the budget.

Mr. Coughlan

In this year's budget only.

Mr. Hogan

That is the point I am making and I am asking whether we have any guarantee as to where the money is to come from. The only source that I am aware of, other than the rates or the Exchequer, is the £7 per annum compulsory hospital contribution. Is that to be increased? Will there be a supplementary budget next autumn when these contributors will be told that their payment is being increased to £10 per year? These are the questions to which we want answers. The Minister withheld information from this House which he should have brought forward.

This is a democratic assembly. It does not matter about Fine Gael but it does matter about the people in general. It is through this House that information like that should come. An adjournment debate is no substitute for an Estimate debate but this is the only channel available to us in a case like this; it is the only course a person in my position can take in order to get the Minister to explain what he has done and what he intends. The Minister said in his reply:

The additional expenditure involved for the health boards in consequence of the current revision has been provided for in full in the grants payable from the Vote for my Department and the ratepayers will not have to pay any part of the increase.

That, as Deputy Coughlan says, may apply to one particular year only. We appreciate the Minister did try to hold the subvention from the rates in respect of last year, but it applies to only one year.

Mr. Coughlan

We had a precedent for this with the previous Minister for Health, the late Donogh O'Malley, when he remitted the full charge on the rates for one year only.

Mr. Hogan

The Minister should have dealt with this substantial rise, which applies from 1st April, 1972, when he was dealing with the Supplementary Health Estimate here in mid-March. I could not catch all that was said in yesterday's debate but I understand the Minister said that it was not worked out, that he did not understand what was coming. Let us recall that on April 1st, 1970, there was a similar increase in hospital charges. Therefore, when the Minister was carrying his Estimate through in mid-March of this year he must have been aware that hospital charges were becoming a difficulty, that something would have to be done to meet them. Since two years before, on 1st April, 1970, an advance was made, was it not likely a similar advance would be made on 1st April, 1972. However, the Minister did not tell the House that or give any information in his Estimate speech as to what was lying ahead.

I must advert now to the evasive nature of the Minister's reply to this question and his replies generally. This Minister was formerly the Minister for Transport and Power in which capacity he had a number of semi-State bodies under his control. He was well known in the House for his invariable reply to those questions: "The Minister has no function in the matter." This became a hackneyed phrase and was an easy way out for the Minister. I notice that the same trend is appearing in connection with the Minister's present responsibility for regional health bodies in which local authorities have diminished representation and less power. The Minister is again adopting the attitude that it is a matter for the local health authorities. The regional authorities will now be the new semi-State bodies behind which the Minister will shelter.

Mr. Coughlan

We cannot buy a packet of Beecham pills without authority from the Department. The Department are running the health boards, and I am a member of one of them.

Mr. Hogan

I am merely dealing at the moment with the limitations under which we operate here in respect of parliamentary replies from the Minister. The Minister should give the fullest replies here. There should be no attempt at evasion or equivocation. I accept that the Minister must delegate functions and the responsibility to carry out these functions, but he cannot shed the ultimate responsibility. The most important facet of that responsibility is to give the fullest information is to the Dáil, and in reply to parliamentary questions buck-passing and long involved answers are no substitute for a clear statement of affairs.

The Minister has withheld, perhaps not deliberately but certainly in the event withheld, essential information from this House. It reflects badly on this Parliamentary Assembly that the first information that 50,000 people get that they are not fully covered by their insurance, when a few months ago they were quite happy that they were, was an announcement in the papers that the Minister had agreed to an advance in charges. The Voluntary Health Insurance Board did their utmost to provide cover, sending notices to the newspapers informing people that they should reapply if they wanted additional coverage.

This is not a businesslike approach. This is the attitude of a Minister who seems to have forgotten the fundamental concept of good public relations, and who certainly seems to have forgotten his responsibility to this House. I do not enjoy pouring contumely on the head of the Minister. I can assure him there is nothing personal in my attitude. I hope he will appreciate I am merely doing this to defend, as I think he would also like to defend, the operation of democracy in this House.

Mr. Coughlan

We will never get democracy in the Department of Health.

Minister for Health (Mr. Childers)

First of all, I would like to welcome Deputy Hogan as the representative of Fine Gael for Health. I wish he had the position long enough to realise that there are only two other Deputies in this House who have uttered more words of information than me. I defy anybody to deny that my communications with the House—in the form of notes on the Estimates, very prolonged Estimate speeches and, in particular, the two circulars that I sent to Deputies twice indicating the nature of the increased cost in the health services for the coming year, in which I included the increases required for increased capitation rates, the extensive information provided in these documents, together with the answers to a great many questions—constitute an amount of communication which I do not believe could be exceeded by any other Minister in the history of this State, and I say that without fear of contradiction.

To get down to the bones of this matter, the Supplementary Estimate to which Deputy Hogan refers dealt only with the excess expenditure in 1971-72. No prior indication or notice has been given of increases of private patient charges in this House on previous occasions, so I have not established any precedent in regard to this. There are quite a large number of beds in private hospitals that receive no State subsidy whatever, four of them being in Dublin, where the charges are increasing all the time. These increases are inevitable in consequence of the increase in capitation charges and in consequence of the very heavy increase in hospital costs.

Let me say that, naturally, I would undertake a further inquiry into the increase in private hospital charges if I were not aware of the fact that even in spite of these increases there is still an element of subsidisation by the State towards the maintenance in hospital of purely private patients, those who go to the public voluntary hospitals and not to the private hospitals.

I will admit to Deputy Hogan that it would be much better if we had regular increases in these charges when they are necessary and not to have them jump over periods of two years. I am going to speak to the Minister for Finance about this. As the Deputy knows, we have been slow in increasing capitation charges because there was always the impression that the Hospitals Trust Fund could provide for the deficits on the voluntary hospitals. That day is long past. The Hospitals Trust Fund revenue is about £3 million and all but £1 million of that goes to capital charges and miscellaneous charges and the State, even in this year, and even with the increases in capitation charges, is applying £7.75 million from the Exchequer to supplement the revenue of the now totally deficient Hospitals Trust Fund, so far as hospital deficits are concerned.

I have pointed out on numerous occasions in this House the frightening increase in hospital costs which are occurring both here and in every other country and which are a source of worry and anxiety to every Minister for Health in every civilised country in the world. The reason for the increases lies, first of all, in increases of remuneration, some of which are highly inflationary in character and which I hope will be the subject of careful study by the Employer/Labour Conference in their coming negotiations; some of which are due to the reduction of hours to 40 a week; some of which are due to much merited status pay increases to junior doctor staff and to nurses and to changes in conditions; and some of which are due to costs of materials. A further increase in hospital charges is due to the fact that 2½ per cent to 3½ per cent more people in this and every other civilised state are going for acute medical care in hospitals every year, in spite of all the efforts to provide better out-patient service and to prevent as far as possible any long stay in a hospital through out-patient service clinics.

As I have already indicated to the House, the cost of the salaries and remuneration in the hospitals has gone up 33 per cent in two years. Some of that was, as I have said, in the nature of status pay and some of it I hope will not be repetitive.

I told the House on two separate occasions through the issue of two circulars that, of the increases in hospital and health services this year, in connection with local authorities the increase was £13.5 million and of that £10 million was attributable to increases in remuneration, increase in the cost of materials and increased capitation rates payable to the voluntary hospitals and £3 million was due to an increase in the volume of services which worked out at 4 per cent of the total increase in all health and hospital charges and which I said was a reasonable volume increase which meant that we could make progress in developing a better health and hospital service system. So, the Deputies had on two occasions clear indications of the increased cost attributable to capitation rates and they must have known from that that inevitably hospital charges to private patients would go up.

I might add for the melancholy consideration of the House that the average cost per patient day in the United States for a hospital is £32. God forbid that we should ever reach that extravagant and terrible level.

To speak in detail about those who are covered by voluntary health insurance, there are 350,000 people covered by voluntary health insurance, of whom 233,000 persons will be affected because the reminder, consisting of 117,000, are Health Act patients who who are not required to pay any extra premiums. In other words, those who are in the limited eligibility class who have also taken out voluntary health insurance, who have paid the £7 a year contribution, will not be required to take out additional premiums. So this applies, therefore, to 233,000 persons out of the total population.

I indicated that the net increase for a family of five, after allowing for income tax allowance, was £7 a year and that this is an increase of 25 per cent on the previous payment paid. I worked out for the benefit of the House that the extra charge of £7 a year is equivalent to one gin and tonic every fortnight and I believe can be paid by the vast majority of the group concerned.

We must place the increase in these premiums against the growth of incomes in the State generally in the last two years. The increase in the pay of public servants in the last two years is 25 per cent, equivalent to the increase in the premiums. The total life insurance premiums taken out by this community increased by 25 per cent in a period of two years ended 1970. I have no reason to suppose that that increase could not be generally applicable to the last two years. Retail sales in this country increased by 21 per cent in the two years ended 1971. Total savings increased in the two years ended 1971 in this community by 27 per cent. The gross national product went up 25 per cent in two years. The consumption of drink and tobacco went up from 1968 to 1970 —I have not got later figures—by 29 per cent and reached the staggering total of £140 million in 1970, for three million people. Out of that can come the gin and tonic every fortnight with which to pay this extra £7 premium.

I gave to the House already the effect of the income tax allowances for those with heavy hospital expenditure. I do not think I need repeat it. What it really amounted to was that for a family with an income of £2,000 with three children the tax payable after allowing for very heavy hospital expenses of £600 not otherwise recoverable would be only £9 whereas the tax in 1968-69 would have been £170. Then I also referred to what we do for the higher income group, the long-term disability benefits applicable to certain major disabilities such as epilepsy and mental handicap that went into operation in October; the hardship contributions that can be made under the Health Act for those who are above £1,600 and who find difficulty in paying hospitals bills from whatever resources they have, voluntary health insurance or otherwise. I referred to the numbers of people who retain voluntary social insurance after passing the £1,600 limit, the manual workers who retain their health benefits after passing the £1,600 limit.

An Leas-Cheann Comhairle

Does the Minister appreciate that he has one minute?

Mr. Childers

Now I come to the end and deal with Deputy Hugh Byrne's suggestion that the whole of the extra hospital charges should fall on the Exchequer. Why should they fall on the Exchequer and who would pay for them? Inevitably, the upper income group would have to pay for these extra charges in taxation because they could not be charged either to the middle income group or the lower group. Much the best way of paying for them is through the hardship element which I have described and through increased voluntary insurance payments to the Voluntary Health Insurance Board, which amount to £7 a year.

The Dáil adjourned at 5.20 p.m. until 3 p.m. on Tuesday, 16th May, 1972.