Dáil Éireann debate -
Wednesday, 9 Mar 1977

Vol. 297 No. 8

Health Contributions (Amendment) Bill, 1977: Second Stage.

Minister for Health (Mr. Corish)

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

The explanatory memorandum which has been circulated to Deputies indicates the object of the Bill, the population groups who are required to pay health contributions and the services to which they are entitled. I do not propose, therefore, to deal again with those aspects in any great detail.

The Bill provides solely for an increase in the present rates of health contributions and this, of course, is a normal annual occurrence. Health contributions are 33p a week at present in the case of insured workers and £15 a year in other cases. The increases proposed in the Bill are 6p a week and £3 a year, with effect from 1st April next. This is an increase of roughly 20 per cent on existing rates.

As Deputies are aware, the House has already agreed today that a Select Committee be appointed to examine, inter alia, alternative ways of financing the health services. In the meantime, it is necessary to continue to avail of the existing financing sources which at present supplement the moneys provided from the Exchequer to meet the overall financial requirements of the health services.

The most significant of these supplementary sources of finance is the health contributions scheme. It is estimated that the revised rates of health contributions proposed in the present Bill will increase receipts from that source by £2.2 million in a full year and, in the current year, will bring in a total of £12.46 million. Compared with a total non-capital health expenditure in 1977 of £316 million, this cannot, perhaps, be regarded as a very large contribution towards the cost of health services, but it represents, nevertheless, a substantial reduction in the amount which would otherwise have to be sought from the Exchequer to finance those services.

Appropriations in aid of the Health Vote for 1977 include an estimated sum of £12.46 million from health contributions. This amount is based on estimates of the additional receipts anticipated from the increase in the present rates of health contributions provided for in this Bill. The proposed increase in the contributions rates is roughly proportionate to the rise in the cost of the limited eligibility services since last year, when the rates of health contributions were last revised. The estimated cost of the limited eligibility services in 1977 is about £220 million, which represents an increase of roughly 20 per cent on the corresponding figure for 1976 of £184 million.

With regard to this expected increased cost of the limited eligibility services, Deputies will be aware that the provision made in this year's Health Estimate is designed to ensure the maintenance of 1976 health services levels during 1977, and that, in addition, a further £10 million of current expenditure has been made available to improve and develop the health services in ways consistent with the Government's job-creation programme. These additional moneys will be used to open new units already completed or due for completion in 1977 and to provide other specific services which will be identified following consultation with health boards and other health agencies.

The additional moneys which I have referred to relate to non-capital expenditure only. As Deputies are aware, I have already issued a statement regarding the health capital programme, for which a total sum of £16 million has been allocated. This allocation will enable me to provide finances for on-going schemes and £6.8 million for new starts on a significant programme of major developments. As indicated in the statement, this capital programme is expected to provide about 700 additional jobs.

Over the next few weeks I expect to be able to announce details of the allocations to be made from the non-capital development moneys and the job-creation element associated with that development. I might add that the same standard of control of expenditure generally which operated during 1976 will, of course, be continued this year, so as to ensure that full value is obtained for the very substantial funds now being provided for the health services.

All these developments will result in a considerable improvement in the level of services which, in the case of persons in the limited eligibility group, they will obtain for a very modest increase in the amount of the health contribution they will be required to pay.

On that score, I should, perhaps, mention a further development in relation to the financing of hospital services which, though not directly related to rates of health contributions, is, nevertheless, becoming a more significant factor in times of high hospital costs. As Deputies are possibly aware, the Exchequer subsidises to a considerable extent the cost of hospital services provided for persons who have no statutory entitlement to them or who, although having such entitlement, decide to make their own arrangements. When persons who have "limited eligibility" for health services are being asked to bear a share of the increase in the cost of hospital services, therefore, it seems only proper that hospital charges in these other cases should be increased also.

I am, therefore, proposing that they be increased by some 30 per cent with effect from 1st April, 1977. The agreement of the Minister for Industry and Commerce to this proposal has been obtained. I have also arranged with the Voluntary Health Insurance Board that persons insured with them will be afforded the opportunity of increasing their cover, where necessary, when the revised charges come into operation.

Deputies will note the revised income limit of £3,000 for "limited eligibility" services which was introduced last year in order to preserve or restore entitlement to health services where the effects of inflation were upsetting the situation. The revision, in effect maintained the limit at its traditional level in real terms. It is not designed to make any change in the proportion of the population which has been traditionally eligible for these services.

When the House was considering the revision of the income limit last year, however, mention was made of certain anomalies in its operation, for example, entitlement limits as between manual and non-manual workers. I accepted that this was a matter to which consideration should be given and I have since appointed a working party, representative of the main interests involved—the medical organisations, the Federation of Employers, the Congress of Trade Unions, the health boards and my Department—to examine the anomalies which arise in the definitions used for "limited eligibility" categories and in the identification of eligible persons, and to consider what action might be possible to remove these anomalies during the period when the income limit will continue to exist. I understand that the preliminary measures necessary to get these various interests involved have now been completed and that the group has recently held its first meeting. I commend the Bill to the House for a Second Reading.

Mr. Haughey

At first sight this would seem to be a rather simple, straightforward and innocuous Bill. It sets out to increase the payments in the form of health contribution to be made by those who have limited eligibility for health services. However, there are a few points I want to make about it to establish that it is of much more importance and significance than it would seem at first sight.

When this increase is made the contribution will have increased by 50 per cent in what is practically a 12-month period. When the increase proposed in this legislation is added to the increase made about this time last year the total increase in the health contribution will be a full 50 per cent. Even for this Government, that is not bad, to increase a contribution from a section of the people of this kind by 50 per cent within 12 months. It is on a par with their performance in other areas.

This increase was foreshadowed by the Minister for Finance in his budget speech and the income which will derive from the increase has already been taken into credit in the budget arithmetic. I quote from the speech of the Minister for Finance when he said:

Accordingly, the Government have decided to defer further action in 1977 on their policy of reducing the Exchequer contribution.

that is the Exchequer contribution to the social welfare fund——

The 1977 social insurance contribution increases will be further reduced because we are removing in April an element which was introduced for one year in 1976 to recoup a shortfall in contribution income. Accordingly, the stamp increase, including an additional 6p for health costs will be about 69p; 42p from the employer and 27p from the employee—that is much less than in 1976.

In fact, the stamp is going up by a full 69p this year, 42p from the employer and 27p from the employee and of course this 6p which is described in this legislation makes its own satisfactory contribution to that increase in the cost of the stamp.

I think that is an erroneous approach by the Government. It is difficult to establish whether it is the Minister for Finance or the Minister for Health who is at fault in this regard. It is validly argued today that one of the major inhibitions in the provision of employment is the cost of the stamp and our party are putting forward a proposal that as a contribution to generating employment the burden of the stamp on trade and industry should be reduced. We have expert economic opinion in support of that proposal. There are economists who argue—they are probably in the majority—that one of the greatest single boosts we could give to the generation of employment would be a reduction in the burden of the stamp. In this regard the Minister for Health is going in exactly the opposite way. He is adding his own 6p to the increase in the cost of the stamp. It seems to me that this is muddled thinking and represents a disoriented approach to the whole problem of employment.

The increases which the Minister proposes in this legislation will bring in £2.2 million in the current year. On the other side of the fence the Minister claims credit for an expenditure of £6.8 million which he says will create 700 additional jobs. Where is the consistency in that approach? On one hand, he is spending Exchequer money to create 700 jobs and at the same time he is putting 6p on to the cost of the stamp to get in £2.2 million which will undoubtedly have a detrimental effect from the point of view of employment. Would it not be very much better if he is providing this additional money of which such great play was made at the time of the budget to assume this £2.2 million into that? Would that not have been a better and more consistent approach?

One would like to know a little more about the 700 additional jobs which the Minister hopes to create by the extra expenditure. What sort of jobs will they be? The Minister was arguing with me recently in the discussion on the motion to set up the Select Committee about what happened in 1976. Whatever else may be said about 1976 there is no doubt that throughout the structure of the health services there was a serious shortage of personnel. There was serious talk of wards in hospitals closing down because of lack of staff. Throughout the health services in the different bodies and institutions these cut-backs and economies were felt in the shortage of personnel. We all know of wards in hospitals in this city that are seriously understaffed, particularly from the nursing point of view. Will these 700 additional jobs be created in that sphere? Shall we have more nurses or will these jobs be of the maintenance or general labouring type? The Minister should have been more forthcoming in that way. In any event it seems to be a convoluted approach to be bringing in this legislation adding 6p to the stamp on the one side and on the other purporting to spend additional money on our health services in the creation of new jobs.

Despite the brave front the Minister puts on it in his speech, the simple fact is that this is another impost on the unfortunate middle class—I am referring to the skilled tradesman, technician, clerical worker, that group of people who have, in some way or other, to meet all their outgoings out of their own resources and who get very little assistance in any shape or form to meet increases in the cost of living. They will be further imposed upon by what the Minister is doing here. It is not just what he is doing in the legislation but this additional thing which he announced in his speech for the first time.

Deputies will be disagreeably surprised to learn that he proposes to increase the cost of hospitalisation by a full 30 per cent. That will be immediately reflected in the premiums of the Voluntary Health Insurance contributors, that section of the community who have no other way of providing for illness requiring hospitalisation than through the Voluntary Health Insurance. About 500,000 people would be in very dire straits were it not for the magnificent and efficient contribution which the Voluntary Health Insurance Board make to our health services.

Here by an unprecedented act, something about which we were not forewarned, the Minister is again increasing the cost of living for this unfortunate section of the community. This approach is reprehensible. I have already outlined that, in my view, increasing the stamp in any shape or form, or for any purpose, is bad from the overall employment point of view. But in this regard there is a grievous error in economic principle by the Government. It is axiomatic that the two basic economic problems which confront us today are unemployment and inflation.

In the Dáil yesterday and again this evening we will be discussing the exorbitant increases in prices by CIE, RTE, ESB, and so on, which the Government are inflicting on the community. A constant, continual procession of price increases faces our unfortunate community through Government action. The Government are, theoretically, committed to the reduction of inflation. We cannot begin to cope with our economic problems, to reduce unemployment, to get economic progress and development until our inflation is under control. Other countries have done that. It should be a basic element in the approach of the Government in all their thinking and planning to do nothing which will contribute to the generation of inflation.

Here we have this positive step by the Government adding to the cost of living, adding a further price increase to a large section of the population. In my view, therefore, the Minister is wrong in principle in bringing forward this proposal. The increase he is proposing in the health contribution is wrong, as is the increase he is proposing in hospital charges which will result in increased voluntary health premiums. It is muddled, convoluted and erroneous thinking on the one hand to be doing these two things and on the other to be purporting to create new jobs by spending additional money on the health services through some as yet undisclosed mechanism. That is my main criticism of this legislation and of what the Minister said when introducing it.

As I said, at first sight it might seem that what he has done is not of any great importance because it is only increasing the health contribution in the case of those who have limited eligibility by 6p a week. That does not seem to be a great deal and the Minister probably hoped there would not be any comment about it. I want to emphasise that it is wrong in principle and represents a seriously muddled approach to our present economic situation by the Government.

Towards the end of his speech the Minister indicated that he had set up a working party to go into this question of the anomalous difference between manual and non-manual workers. I want to avail of this opportunity to emphasise the difficulties that this anomaly causes and the amount of anger it generates among those affected. I want to ask the Minister in particular about a situation which was drawn to my attention where non-manual workers, who were voluntary contributors prior to 31st March, 1974, at which date the limit for insurability was abolished, subsequently became compulsory contributors. I believe such people should be entitled indefinitely to limited eligibility. There is a great deal of confusion about the situation because many of them who are now over the limit of £3,000 per annum are in some cases being denied access to limited eligibility. I do not know if the Minister could have that anomaly dealt with immediately or whether it is something that could be dealt with by the working party but it is causing a great deal of resentment. It is clear from the legalities of the situation that the people I referred to should be entitled to limited eligibility indefinitely, even though they are non-manual and have gone over the £3,000 limit.

I want to direct the Minister's attention to another type of person. There is a fairly sizeable number of people who are, to all intents and purposes, manual workers but because of the very fine distinctions drawn in the administration of these regulations, they are classified as non-manual workers, although very often they are doing exactly the same sort of work as the people beside them who have the benefit of manual classification. A great deal of hardship can arise in the case of the number of these people. I would refer the Minister particularly to the situation where the member of a family has a serious, lasting, long term illness. I am thinking now of cases where the illness would not come within the long term illness scheme. There are many illnesses which are long term and lasting which do not come within that scheme. The family who find themselves in that situation endure very great hardship. They cannot go to the Voluntary Health Insurance Board because they will not be taken on. If they are taken on, it will be only on condition that that particular member of the family is excluded or, if that member is included, the disease will be excluded. The Voluntary Health Insurance Board, with the best will in the world, cannot offer them any assistance. At the same time, because of those rather tortuous decisions about the distinction between manual and non-manual and because they are slightly over £3,000 a year, that family will not qualify for limited eligibility. They are really in a very difficult hardship situation. Something should be done as quickly as possible to deal with this anomaly between manual and non-manual over the £3,000 per annum limit.

That is only £60 a week. It is not so long ago when we would have considered that was a very good income but it is not very much at the moment. It becomes less and less with every day that passes with the constant savage increases the general public are being subjected to. I want to emphasise that this regulation is causing a great deal of hardship among a fairly wide group of people. I have mentioned two categories and I am sure other Deputies can mention others. I suggest to the Minister that immediate action is necessary here.

We are opposing the passage of this Bill for the reasons I have outlined. We are not opposing it because we regard the increases proposed in this Bill as particularly Draconian. Nobody can argue that 6p a week is a very serious impost; I am not arguing that. I am arguing that this increase, taken with last year's increase, amounts to a total of 50 per cent increase. I am also arguing that the principle is wrong and that the Government at this stage should not be taking any positive action in any area to increase costs, add to the cost of living and add to inflation. The Government should seek to go in the opposite direction in regard to any action they take. If they cannot reduce costs in any area they should be determined not to increase costs as they are doing to hospital charges, as announced by the Minister.

We are also opposing this Bill because it represents an increase in costs for a section of the general public without any increase in benefit. People do not mind paying more if they can see that some new service or benefit will come their way as a result of the increased payment. That is not the case here. The Minister has tried to infer that there will be some vague type of improvement as a result of the extra budgetary expenditure to which he has referred. I cannot see that. This is a simple taxation measure, an increase imposed on this unfortunate section of the community to bring in a miserly £2.2 million into the arithmetic of a budget which has a deficit of £200 million odd anyway. For those reasons we propose to vote against the Bill.

Dr. Byrne

In supporting this Bill it is appropriate to mention in passing the many different aspects of health that can be covered by a Bill of this kind. When one refers specifically to the hospitalisation and possible treatment situation one must say that perhaps the most efficient way of providing this is through health contributions as distinct from private means. This Bill is increasing the amount paid each week. It replaces any possible private financial commitment undertaken by a patient.

There are many aspects which should be considered here. This does not refer completely to the treatment of the person who is acutely ill. It refers to all different aspects of institutional and hospital care in particular from homes for disturbed and handicapped children, Cheshire Homes, voluntary institutions of different kinds, hospitals and geriatric homes throughout the country. It is a very small amount to be asked to give, 6p a week or £3 a year, for the amount of institutional care that is provided in return. One can appreciate what Deputy Haughey said about the increase in the cost of living but I do not think the people have ever considered health as a cost of living factor, particularly when it relates to in-patient care. Although, statistically, it might appear that this represents an increase of 20 per cent on the previous year's contribution it would be facetious for us to attempt to say that it represents a massive increase in the cost of living. If that is the basis for the Opposition statement that they are opposing this Bill it is not a very sound one.

There have been unavoidable increases in the cost of maintaining hospital beds and running the health services before one even considers the medical personnel, drugs and equipment involved. Costs have increased so dramatically in the past decade that the personnel in hospitals are attempting to do projected financial commitment figures for the year ahead. It is no secret that it is an embarrassment to hospital management boards that they are continually in debt and that they have not got an adequate cash flow to keep up with inflation.

Nobody wishes to see any increase in contributions—I am sure the Minister is no exception—but the only alternative is a decrease in the facilities available. If the increase was 6.1p a week perhaps the Minister would be able to provide all the scanners that have been asked for by different hospitals. There could be a great increase in the diagnostic facilities in our hospitals if they each had a scanner machine. It is possibly the greatest breakthrough in medicine this century but we are almost the only country in Europe that has not got one; not that Europe provides any great criterion to go by. We still have not provided our patients, hospitals and diagnosticians with this equipment. I believe it is the Minister's intention to provide this equipment as soon as it is financially feasible.

When we speak of an increase of 6p per week we must consider that if that increase were 6.1p we would have sufficient money for the provision of these machines. That is the kind of money we are talking about. Over the years health legislation and Estimates have become a type of football which is used by politicians, particularly those in the legal profession who seem to have a particular desire to dissect, operate and amputate the health services. This seems to be a fashionable fad with the over-elaborate front bench of the Opposition. I think every legal member of the Fianna Fáil Party who can read or write is on the front bench and the party is unusual in that.

I should like to mention Item No. 5 on the Order Paper, the new committee being set up to examine the health boards.

An Ceann Comhairle

That matter has been disposed of this morning in the House.

Dr. Byrne

The Minister in his statement on this legislation referred to it. I want to say how welcome it is and how important it is that when health contributions are increased the efficacy of spending should be continually examined and monitored to see that the optimum benefit is obtained for all. It is no secret that health boards and health administration have become bureaucratic, over-elaborate and cumbersome and any move to improve efficiency is to be welcomed, otherwise we will have to continue increasing contributions and continue to prop up health administration with a financial type of cotton wool. This would in no way improve the services available to patients.

One might mention in passing that our country is possibly at the top of the league in regard to the number of hospital beds and the number of nurses and medical personnel per head of the population. It is well known that we have more hospital beds, more nurses and doctors per head of population than any other country in the world. One can see in the Arab countries now that money is not the sole criterion for the provision of health services. They are short of personnel and the United States also is short of hospital beds and medical personnel. It is only when one looks at these countries that one can see the tremendous wealth we have here. We can see the tremendous dedication of nursing and para-medical personnel and the unique application and tenacity of consultants in this field.

I was quite disturbed last December when I saw that some nurses going for interview for employment abroad were intimidated. I made representations to the Minister for Labour and in his letter of reply he stated:

While the advertisement in December last was not racialistic as was the case in 1975, the Anti-Apartheid Movement nevertheless objected to it and they got in touch with my office and intimated that it was their intention to place a picket on the hotel during the hours listed for the interviews. I had my officials inform the hotel of the Movement's intentions and might I add of my abhorrence of South Africa's racialist policies. Later the hotel manager 'phoned to say that they had decided to cancel the arrangements for the interviews.

It is abhorrent that any individual or third party group should be allowed to interfere with Government Departments and allowed to interfere with our nursing profession to the extent of the deprivation of interviews. We are going to spend part of the money being raised in health contributions to train nurses to a high level of efficiency and it is abhorrent that when they seek to obtain employment and tend the sick in other countries a third movement can interfere and appear to use the offices of a Government Department. This is a very serious and malignant occurrence in our society. Two wrongs never make a right. In the past Ireland sent many people abroad in differing capacities. Perhaps one of the greatest contributions Ireland makes to other countries today is the provision of highly trained medical personnel. These are humanitarian people of whom we can be very proud.

I do not want to digress too much from the contents of the legislation. It is with a degree of satisfaction that we can look at the improvements in health administration which have occurred during the past few years. The setting up of this very powerful committee will, I am sure, bring about further improvements. Recently we saw the unfortunate spectacle in the United Kingdom when McKinsey, who had been paid £25 million or £30 million to advise the Government on the administration of the health services, came back after three years to tell the Government that they had given the wrong advice. In typical bureaucratic fashion they were reemployed to inform the Government about where they had given the wrong advice.

These tendencies can occur in socialist medicine where one takes the human factor out of the health services. Perhaps one of the best things that ever happened in this country is that we never went in for socialist medicine in the way that the United Kingdom did. The United Kingdom possibly helped this country and other countries by showing the drastic mistakes which can occur when one attempts to socialise such a personal thing as the treatment of patients. The Minister has my full support for this legislation. I would ask him once again to be vigilant in regard to the improvements that have occurred and will occur and the facilities, particularly diagnostic facilities, throughout the world in the field of medical technology. Early diagnosis is vitally important and I would emphatically urge the Minister to purchase body and head scanners for the hospitals concerned as soon as possible. I know the Minister appreciates the value of equipment and these scanners represent a most important step forward in diagnosis and subsequent treatment this century. Each day there are people flying over to London to have the benefit of this equipment.

In the general medical services there has been an increase in the population of 38 per cent where holders of medical cards are concerned. Perhaps there is need for close vigilance. I do not believe people deliberately abuse medical cards but there may be some who are inclined to over-use them. The health medication refund system is a very good system but it might be examined because I have a feeling that it would be cheaper to give 90 per cent of the population completely free medicines as against the percentage covered at the moment. I say this because of the administration involved in the scheme. There is no doubt that the refund even in the case of a single prescription often costs more than the actual medicine. We should try to move away from institutionalised medicine and get back to more personal medicine. A great deal of the time of general practitioners is taken up with writing. Today there is more use made of the pen than there is of the stethescope and this is proving most frustrating for medical practitioners. The amount of time spent in actual writing has increased very dramatically over the past few years. The pattern grows more insidious day by day.

There is a list of long-term illnesses which are covered. I would suggest that rheumatism and asthma should be included in this list. The scheme is an excellent one and its success is possibly unparallelled. The framework is already there and the list could easily be extended.

The voluntary health insurance keeps its administration costs down to 8 per cent of gross income. When one compares that with 80 per cent administration cost in the United States and the United Kingdom this is a tremendous achievement and one would wish to see as much encouragement as possible given to the VHI. There could be a sliding scale. Account should be taken of inflation and, if that were done, a certain hardship would be alleviated.

Once again, I congratulate the Minister on this Bill and on his achievements to date.

Mr. Tunney

I do not aim to speak with the same authority or at the same length as the three speakers who preceded me who have in their own right an association at executive and professional spokesmanship level with health services which I do not have. I propose to comment, therefore, on three specific matters or aspects of the health services which I encounter quite often while I operate in my political clinic. One has already been referred to by Deputy Haughey when he spoke about the position of the non-manual worker. In the Finglas area—I think this would apply probably exclusively to men, though I am not too sure but, as yet, the case has not been presented to me by any woman—you have the case of Nicky Lyons or Paddy Murphy who started working in some concern at the age of 16 and served in that concern for the past 40 years. During that time he was practically an insured worker. In his case the situation arose some years ago that in deference to the contribution which he had made to the firm and, more important, because the firm had recognised his declining health, he was put into the non-manual category and employed and paid accordingly. As a result he has gone over the £3,000 limit. His financial position and status in the company has changed but his state of ill-health has not. He finds himself now getting very little award for all the contributions he has made and where other people could go to the VHI when he goes he is told that because of his state of ill-health he is not acceptable. The result is that he finds himself in a situation where, even though he is suffering from a heart condition, for instance, and has been told by his doctor that an aspect of his ailment is that he must not have anxiety, fear or worry, he has hanging over him an increase of 30 per cent in hospitalisation cost.

When we talk about 30 per cent on something small we need not be afraid of it. Nobody fears the imposition of 6p all that much but in the case of the non-manual worker I referred to who knows that a bed in a hospital can cost from £70 to £80 per week he must now pay an extra 30 per cent, bringing the cost for a week in hospital to £100. The national pay agreement gave him 10 per cent of an increase but who will make up the 20 per cent for him? I hope the Minister will be able to tell us that he will direct the working party he has set up to pay attention to the growing body of people who find themselves in the predicament I have outlined. Such people get nothing from the national services, are not acceptable to the VHI but the cost of the service increases by 30 per cent. At the same time they get only a 10 per cent pay increase. The psychological effect of that on such a person must concern the medical profession. The people in question, generally speaking, have just emerged from the stamp paying classes. From that point of view and having regard to the proximity of the Minister to the trade union classes and associations I am confident he will pay regard to their plight.

I should now like to refer to people lower down the age ladder, children in our schools who for the last three or four years have been waiting to avail of orthodontic services from our health boards. Apart from the medical aspects we are all sympathetic towards the child who for one reason or another—perhaps he or she was a thumb-sucker—has teeth disposed in such a way as to cause bother and ambarrassment. That child should qualify for a certain priority in our service but when I questioned the Minister about this I was informed that there was a queue of about 1,000 children in the Eastern Health Board area alone for this service without any hope of the position improving. It is a very expensive service. Children who are entitled to the service at national school are not entitled to it when attending secondary school. Children are leaving national schools at 12 years of age and, in certain circumstances, even though they have been waiting for years to avail of this service, when they reach 14 years of age they do not qualify for it. The parents of many are not in a position to pay for it. The real tragedy is that the service is such that it works wonders on the children so affected and afflicted.

Looking at a budget of this size it is a reflection on everybody in the House that, notwithstanding the fact that a relatively small amount of money would improve the service, so many children must go without it. Having passed from national school it will not be possible for many of them to benefit from that service, one which would make them healthier and more comfortable about themselves. An old Chinese philosopher said on one occasion that we should always be careful not to watch the stars so long and so closely as to disregard what is on the ground or at our feet. I do not think we move around the people enough to see the problems they have. We can talk here about percentages and the achievements of one Government as against another but we tend to lose sight of the fact that that which it is all supposed to be in aid of is not improving in the fashion or manner which we all desire.

Having isolated the orthodontic service, I do not want to give the impression that the normal dental services are anything to boast about. They are equally bad but to some extent the problem there can be corrected at a later date. I have endeavoured to pinpoint the position of children needing orthodontic services.

I wish to refer to the question of the provision of glasses for young people and for old age pensioners. There are waiting lists and delays of up to a year before a person who has been certified as needing glasses can get them. Is this the great health services we are talking about on the local and the national level? Personally it does not matter to me what name we give to any service; I am concerned about what it means for the people. I know of young children and elderly people who have been waiting for glasses for as long as 12 months and others have had to wait for appointments for equally long periods.

If one asks a question one is told by the Minister that there is a scarcity of professional people in this area. We are told that advertisements have been issued but that it is not possible to get suitably qualified people. That is the excuse that is often given in respect of dentists and orthodontists. If that is the position the Minister should consult with the universities and tell them he is not happy with the situation. He should tell them that arrangements must be made for a flow of graduates to satisfy the home needs.

In passing, I wish to point out that I am a member of the council of the Kevin Street College of Technology and we have there what is regarded as a very high-class course in ophthalmics. The standard of entrance is the same as that required for university. We have students there who spend four years studying ophthalmics only but as yet they have not been accepted by our health boards. I do not understand why this is so. I can understand if people in that area may be concerned about their own position. However, where there is an admission by all concerned that we have not the professional people to service the demand the Minister should look at the situation. Irrespective of who is vexed or pleased he should concern himself with the recruitment of suitably qualified people.

I was anxious to pinpoint those three matters and I hope by avoiding any suggestion of what any one Government did or did not do in the matter of provision of services I may have been able to help the Minister to appreciate my sincerity in making my case. I have looked forward to the opportunity of referring to the three aspects of the medical services about which I am not happy. I could continue at much greater length talking about other aspects but my philosophy is that if there are 100 things to be done, while there is no hope of doing all of them together if we succeed in satisfying three at least we are on the road to partial success.

Mr. Halligan

I should like to make my contribution to the debate in the spirit indicated by Deputy Tunney which has been commendable and helpful. Perhaps we might lay down a new economic law in relation to health, namely, that health is an area where demand increases in accordance with supply rather than the other way around. There is absolutely no limit to the supply in terms of problems.

Deputy Tunney raised matters in two areas which jogged my memory and which indicate the extent to which we have progressed and for which all Governments may be credited. He referred to the situation with regard to spectacles. I wear glasses. It was a long time before I discovered I needed them and when it was found out at school that they were necessary my father had to pay for them. The fact that there is a queue for glasses, even though it may be long, indicates the extent we have come in that direction. That the queue is there is something to be regretted but we should be slightly proud of the fact that at least people can get into a queue.

Mr. Callanan

Perhaps the Deputy would speak a little louder. The amplification is very bad.

Mr. Halligan

Deputy Tunney's contribution with regard to orthodontic treatment was valuable and worth while. I had a problem in that regard and I had to wait to go to work in England before I could get treatment. However, I am making these points as a slight contribution to what is a much wider and broader problem. Deputy Haughey postioned it correctly in his own contribution when he referred to this Bill in the context of budgetary policy and I cannot disagree with that. I agree completely with that approach. This is an ancillary to the budget, just as certain measures announced yesterday and also in the Minister's speech must be seen in the context of overall budgetary policy. While the amount to be raised this year might be regarded as nugatory, it must be seen in the context of the overall deficit which is of the order of £200 million for this year. As the year goes on it may work out to be much less but there is also the possibility that it may be much more. For that reason any Deputy must take into account the fact that measures that are designed to bring down the deficit, no matter how unpalatable they may be for the individual concerned, must be considered as welcome in the over-all economic context.

I say without any element of party point-scoring that this time last year the Opposition were asking for a decrease in the budget deficits. The burden of the argument put forward this morning would lead to an increase in the budget deficit. There is a little inconsistency there; perhaps it is unintentional but it exists. As I understand the main spokesman for the Opposition, he makes the point that the opposition to the Bill will lie on the principle that even though the 6p is in itself small it must be taken in the context of the other increases which are in fact a tax on labour and for that reason will lead to a diminution in employment prospects for the coming year. On the basis of expert advice they say reductions in social welfare contributions will lead to greater employment, but presumably the expert advice therefore also advises that increases in social welfare contributions will lead to a diminution in employment and that is the reason why it is being opposed.

That is an interesting argument, but I do not think there is much empirical evidence to justify it. Very often one gets into areas of economics like this where one runs on a lot of a priori assumptions which do not have much empirical justification. I think the case could legitimately be made that there are economies where there are far greater and far higher imposts on employers in respect of labour with much higher labour contents and with much smaller unemployment figures. There should be empirical evidence to justify the argument being put forward. In respect of both employer and employee contributions, we are away behind the European average contributions in economies which have far higher standards of living than ours and which also have been spectacularly successful compared to us in dealing with the problem of unemployment.

The Bill has to be seen in the context of a general inflationary situation. I do not think any Government, particularly in an election year, wants to inflict—Deputy Haughey used that verb—price increases on the public. However, it is untrue to say that other countries have got their inflation under control and that this Bill is a consequence of a situation where inflation has not been controlled. One has only to look across the water to the United Kingdom to see an economy in a situation where both high levels of unemployment and of inflation coexist and where the prospects are that there will be an upward surge in inflation over the latter half of the coming year. While it is true that one or two countries have been spectacular in reducing the rate of inflation, one does not refer too often to the medicine which is prescribed for reducing the rate of inflation, medicine which I would have no hesitation in saying would be unacceptable to the Irish people.

For example, The Irish Times recently contained an article showing that the Swiss economy had got the rate of inflation down to 1 per cent, and therefore a Bill of this nature would have been unnecessary. The article also said, however, that unemployment in Switzerland had risen from a nil figure to 30,000 and that those 30,000 people had no social welfare services to help them through that unemployment period. It did not mention that some 300,000 so-called guest workers had been permanently sent home from that economy. That is a way of dealing with inflation, to cut real levels of income or to cut the level of employment provided you can export those who will be unemployed. If you cannot do that then you are confronted with the situation with which we are confronted here, that is to say, a society that is not prepared to accept certain levels of unemployment——

Mr. Haughey

How did sacking 300,000 bring down inflation?

Mr. Halligan

They are not prepared to accept certain levels of unemployment and at the same time they continue to demand, legitimately, the services to which they have become accustomed, and not only to demand that but to demand increases and improvements in those services.

There is a problem here which runs right to the very heart of the democratic system. There are tensions here which will be very difficult for any Government to handle. The fact that we agreed earlier without division to establish a committee is in itself an indication that many Deputies recognise that there are tensions which transcend party differences because of the strains which have been put upon the democratic system in answering the demands which people are putting upon it. Quite clearly there is a limitation to what the democratic system can supply by way of services, of which the health service is a central social component. I think we recognise that here in this House. It is the reason many of us have the desire to take the matter of health out of straightforward party politics.

The Bill has been brought about probably by four different factors. Inflation is certainly one of them. Another matter was referred to in Motion No. 5, something which will cause us increasing problems in the future, that is, the matter of demographic growth. Deputy Byrne referred to the huge increase in the child population. We again have had verification of this population evolution in the paper delivered last week by someone from the Central Statistics Office showing that we are in the middle of an unprecedented population growth, which at this moment is placing great strains on the health service.

There is also the issue of the complexity of medical technology, which simply means it costs more to provide the same range of services than five, ten or even 20 years aog. There is, too, the problem to which Deputy Byrne referred of over-bureaucratisation, which is something I am very glad to see will be the subject of all-party scrutiny in this House, and perhaps it might be as a result of the examination of the health services by this committee that future Ministers for Health, from whatever side of the political divide they may come, will not have to ask, even at a time of high inflation, if such exists, for increases of this order, and that this House will be able to see to it that there is greater efficiency and effectiveness. I believe there has been over-bureaucratisation in the health service, perhaps born out of an era where the belief was that bigger is ever better. I do not think that bigger is ever better, and we are going into an era now where we will hold to the reverse principle.

There are certain key questions which this Bill and the debate generally raise and which I do not think can be answered or should be answered in the context of the debate. Perhaps they could be dealt with in the calmer atmosphere of the committee. Deputy Haughey at one stage mentioned ideological floundering. It is not a bad thing to flounder there occasionally so that we may pose for ourselves fundamental questions: should there be free health services and for all?

Mr. Haughey

Can there be?

Mr. Halligan

Or can there be? Exactly. If there should be—and there cannot be due to economic conditions —what sort of means test should be employed to determine who is eligible and who is not eligible? Separating the eligible from the non-eligible always involves an element of injustice and inequity. Deputy Tunney was quite right in bringing forward to the House a number of such instances. We are all confronted with these every day of the week, and who is to say to a person: "I am sorry. The limit of eligibility ends there and you are just beyond it."? What are the principles upon which we must determine where the element of eligibility ends? The Deputy is perfectly right in saying it is a cause of great social concern and tension, not only in individual cases of genuine hardship but, for example, in respect of eligibility for the general medical services, particularly for persons who are paying taxes and who see others enjoying services for which they themselves are not eligible.

An arbitrary figure beyond which the percentage of the population encompassed by this service cannot go has been laid down. I do not know what the justification is for that percentage. I am not aware of any philosophical exposition in regard to it but I think everyone here will realise that to exceed it would lead to a situation where the service itself would be put in question. These are questions that we must ask ourselves in the context of this Bill and, hopefully also, in the calmer atmosphere of the all-party committee.

The Bill raises the question of how the health services should be financed. Should they be financed totally by way of taxation or by way of insurance or by a combination of both? The answer to this question would depend on one's ideological attitudes towards society. How are we to deal with the problem of people who are sick? Do we say that free health is a matter of right or do we say that it is something for which the individual must provide in which case it would be a matter of insurance or of relying on one's resources? Alternatively, do we say that society has an obligation towards certain categories only?

This Bill is a short-term response. In saying that I do not intend criticism but what we have is a hotchpotch system that has been created on an ad hoc basis. We have dealt with problems as they have arisen but we have not tackled this area in a systematic way. For that reason, while the Bill can be regarded as a short-term response we can today welcome what was done before. I refer to the establishment of the working party to examine various anomalies in the health service. I welcome in particular the announcement by the Minister telling us that there has been established a working party to examine the anomalies that arise in regard to the definitions used in respect of eligibility. There are times when one would need to be a medieval philosopher to justify the various divisions that exist between manual and non-manual workers. These distinctions are a reflection of the ad hoc approach which governs our society's attitude to the development of the health service.

In the meantime, as some Deputies have said, we must continue to improve the range of the health services within the limits of available moneys. The great task of the party as individual political entities and of this House as a reflection of the people's will is to identify areas of greatest need and then to ask ourselves whether we can provide the resources with which to deal with the situation. I agree totally with Deputy Byrne when, speaking in the context of long-term illnesses, he advocated the inclusion of asthma.

As a medical practitioner, he made the point that there is much difficulty in regard to definition in so far as this condition is concerned but of all the illnesses to which we must pay attention, asthma must loom very near the top in terms of people who experience this real problem and which very often is the cause of much distress particularly in respect of children when the families are not eligible for medical cards. Adding this illness to the list would bring about great social good. Therefore, I urge the Minister to have asthma included at the earliest moment possible.

I agree, too, with Deputy Tunney when he says that the lacuna in the age groups for eligibility in respect of children must be closed off as quickly as possible. It is ludicrous that a child is eligible while at primary school but becomes ineligible on leaving that level and going on to second-level education. There is an unintentional gap there which nobody wished to create there which has arisen out of the very nature of the system we are trying to operate. I trust that the Minister will give his early consideration to this question. Perhaps we could make a substantial and significant improvement by providing that all children under a certain age, irrespective of the incomes of their parents, were entitled to free medical service. Perhaps we might specify all children under school-going age without that provision being taken in the context of the general medical service.

A society which has a large number of children and which places the family very high in terms of respect as a social unit must try also to protect and sustain particularly the younger members of the family. To fail in this regard is to engage in a contradiction. I am sure that all parties here would support a move to provide that all children under a certain age level be entitled to free medical services.

Deputy Byrne made a valuable point in respect of examining the possibility of free medicine being an alternative approach to the current system of refunding on drugs. He made the point that, perhaps, the administration cost of the current system might be put towards financing free medicine for about 90 per cent of the population. This debate has resulted in that valuable point being made. It is something we had not thought of before. On first hearing it sounds very attractive. Perhaps it is a financial possibility.

It goes without saying that the availability of more money does not necessarily mean better medical treatment. All of us have voiced concern in regard to the efficiency and the efficacy of the health services. We are all determined on means of ensuring that in the future there will be greater efficiency in this area. The message should go out from this House that as the body responsible for voting moneys, there is an air of anxiety, of questioning and of doubt as to whether we are achieving the best value for moneys expended on the health service. I trust that this, too, will be a matter to which the all-party committee will give attention.

Mr. Leonard

The Minister has told us that this provision is to allow for increases in present rates of health contributions and that this is a normal annual occurrence. During the past few years the health contribution has been increased from £7 to £18. Having regard to this increase, we must examine the level of the services in order to ascertain whether they are improving or deteriorating. Those of us who are members of health boards have been hearing continuously for a number of years past of efforts to maintain the level of previous years having regard to budgetary restraints.

Are we actually doing that? Is that good enough? When one examines the waiting lists for dental, ophthalmic and all other treatments one would think that we would have to do better. To maintain them at that level is not sufficient. Deputy Tunney dealt in detail with the problems regarding secondary school children. This is a growing problem, where we have a vacuum between the ages of 12 and 13 and the age of 16, when they qualify for a medical card. Children's health can be seriously affected during those formative years. Many people are waiting for orthopaedic treatment. Some of them have to wait for years. Their condition is deteriorating so that, when they are eventually called for treatment, their joints are crippled. A great effort should be made to remedy this situation because many of those people are suffering severe pain.

The Minister mentioned the increasing number of people who are qualifying for medical cards. Because of reviews that are being carried out at present by the health boards I doubt if that will be the trend in 1977. I believe there will be a reduced number of medical card holders. Reviews that were carried out a number of years ago in rural areas related to poor law valuation. They are now related to farm income. Most if not all of the assistance officers who are assessing means are assesing farm incomes very highly. People come to us daily telling us that their cards have been recalled following a review. This can create severe hardship. There are cases of young married couples with families whose children require continuous medical attention, but they do not qualify for medical cards. The health boards should be fairly liberal in their allocation of medical cards in respect of these children. It would eliminate a lot of hardship.

The stamp has been increased by 6p per week. It looks very small, but the total cost of the stamp has a serious effect on job creation. This is a real problem. The health boards should also devote more attention to the provision of home help. This service could be expanded to good effect. It could be used to curtail the institutionalisation of old people. Many old people could remain at home if they had sufficient home help. In relation to the curtailment of services I brought to the Minister's attention last January the need for the provision of a welfare home in Monaghan, where we have a large number of geriatric patients. The three institutions that we have at present—St. Mary's and two private institutions—are not adequate to cover the demand. I had hoped that the Minister in his capital allocation would have given consideration to this proposal. I am sorry that the Minister did not do so, because there is a real need here for a welfare home.

In our health board's recent budgetary review for the year we had a list of job creations. The Minister mentioned today that there would be in the region of 700 jobs. I doubt very much if that number will be created. The Minister will be getting communications from local bodies and probably from the health board in relation to the hospital at Monaghan. They need more nurses, laboratory assistants and x-ray attendants. They also need an additional surgeon, an additional gynaecologist and an additional anaesthetist.

Asthma is a big problem, especially in relation to children. Many people believe that it is very hard to get a definition of it, whether it is a long-term disease or a short-term disease. There are many types. Attention should be paid to it.

Mr. C. Murphy

This legislation must be seen in the context of previous legislation of a similar type. There seems to be a continuing escalation of costs without an adequate return of services for these costs. Previous speakers have indicated that on 1st January, 1975, contributions were in the range of 26p a week or £12 per annum; on 1st April, 1976, these were raised to 33p a week or £15 per annum. In March, 1977, we had a further increase to 39p a week or £18 per annum. This was simply a device to collect money, a further system of taxation.

I am glad to hear the Minister making reference to this working party but I would refer him to his speech of last year when he spoke of having set up an interdepartmental committee consisting of people from the Departments of Health and Social Welfare to examine the financing of the health services. At column 264 of Volume 289 of the Official Report for 24th March, 1976 he said: "I expect that they will be in a position to submit their report by the summer." That was the summer of 1976. Could I inquire whether this report has been presented as yet, whether it is available? Perhaps the Minister will say that it was an omission on my part that I failed to see this report coming before the House or missed its circulation. I hope the Minister will refer to this.

If we speak in terms of increased costs, surely people in return have the right to expect further services. After all, if one pays more one can anticipate receiving more, but what extra services will there be? I can see as I saw last year only queues and further waiting lists. At this point I would like to pay tribute to the dedication of the medical personnel in my constituency who are working in many cases in substandard circumstances and conditions, providing the services to the best of their ability. I am sure this is the case in various other areas throughout the country. That surely must make one think of what can be done in this field if they were not hampered. I hope the Minister will make extra capital available for proper facilities.

In view of the fact that the Minister has not decided to raise the upper limit this year, has he given a great deal of thought to the number of people who will become ineligible for services because they have gone over the limit? Last year when he was raising the limit he said that one of the reasons for doing so was that if he did not a huge number of people— I forget the exact number—would become ineligible. I wonder as a result of the limit not being increased how many will become ineligible. Further hardship will be created for these people and for their dependants.

Could I, through the Ceann Comhairle, ask the Minister if by failing to raise the limit at this stage, he is not creating an anomaly which he would hope that this working party that he has mentioned will have to resolve? Is there a double edge to this? I regret that many of the anomalies that were mentioned last year in this debate apparently have not been resolved some 12 months later. We have the promise of a working party and I suppose they have had one meeting. I would like to know when the meeting was. Was it very recently? I hope it was not simply an inaugural meeting just to fulfil a commitment to this Bill. I do not think the Minister would have that in any case, but I hope he will clarify the position.

Last year I spoke of difficulties that people were experiencing after they had made a payment of £15, and now £18, to the Revenue Commissioners for limited eligibility and in return they obtained a receipt from the Revenue Commissioners. Many people seemed to think that this receipt was some form of certificate of eligibility for the following 12 months, and on being hospitalised many of them were to discover that their income went above the limit, and so a difficulty was created. The Eastern Health Board, dealt very favourably as far as they could with the cases I brought before them, but there is difficulty there which could be resolved if medical cover for a person and his dependants could be the same as the life of the receipt from the Revenue Commissioners, that is for the 12-month period. I hope the Minister will refer back to that.

Regarding geriatrics, we have a fairly good service in some areas for the ambulant aged. The welfare homes provide excellent service and they seem to be working at a very low cost or economic factor, but what of the non-ambulant citizens for whom there is no place in a welfare home, who must, possibly because of the inability of their kinsfolk to look after them, end up in some form of private home or hospital? In respect of this I would like to speak about the level of services available to the health boards in a purely financial vein. I gather that these people would be somehow classified as coming under section 54 of the Health Act, 1970 which deals with in-patient services at choice of patient and so on. I quote:

A person entitled to avail himself of in-patient services under section 52 or the parent of a child entitled to allow the child to avail himself of such services may, if the person or parent so desires, instead of accepting services made available by the health board, arrange for the like services being provided for the person or the child in any hospital or home approved of by the Minister for the purposes of this section, and where a person or parent so arranges, the health board shall, in accordance with regulations made by the Minister with the consent of the Minister for Finance, make in respect of the services so provided the prescribed payment.

In many cases the senile aged and the non-ambulant aged come within this category, and this section indicates that people may have a choice of venue. However, we know that beds for long-stay geriatrics are simply not there, and therefore there is no choice except between individual homes that are approved by both the Department of Health and the relevant health board under different regulations. The sections refers to the prescribed payment. Would the Minister let me know what the prescribed payment is? What is the maximum subvention the Eastern Health Board may make for the maintenance of a long stay patient in this category? I believe it is something in the region of £15 per week. People who are providing this service, this form of home, are claiming—and I believe they have a very valid claim—that a subvention of £15 per week is not nearly adequate. I wonder if those people are being overlooked within section 54 and somehow being grouped together as section 51 patients.

Section 51 provides:

In this Part "in-patient services" means institutional services provided for persons while maintained in a hospital, convalescent home or home for persons suffering from physical or mental disability or in accommodation ancillary thereto.

Am I interpreting this section and the category of patient correctly when I say they are short-stay patients and that their stay may be for a duration of six weeks or 12 weeks? I gather the Minister is allowing the Eastern Health Board to increase the subvention for this type of patient. Has the Minister agreed to increase the subvention for the services provided for the type of person who comes within the ambit of section 54 of the Health Act, 1970? It is vital that this should be done. There is a little confusion about it. I hesitate to say it is deliberate. The health board are coming in for a certain amount of blame. I do not think that is right in this case. The section clearly states that the health board shall, in accordance with regulations made by the Minister with the consent of the Minister for Finance, make a payment. There is also the famous section 31.

Has the Minister obtained the consent of the Minister for Finance to increase this subvention? Has he approached the Minister for Finance and expressed the need for an increase in this subvention? If a health board in this case can subvent to a maximum of £15 or, by squeezing a little extra, to a maximum of £20, the old age pensioner who has a GMS card retains a small portion of his pension for sundries, the little knick-knacks such a person would require. He does not require many but he might want a certain number of cigarettes—I suppose I should not say that at the moment but this type of person is usually old and cigarettes are probably the only consolation he has if he is non-ambulant—or some chocolate, or a magazine, or something of that nature, and the balance of his pension is paid in conjunction with the subvention from the health board which must be sanctioned by the Minister with the approval of the Minister for Finance. In many cases this makes a grand total of £25, £24, £22 or even £19, but I gather never greater than £28 a week.

I know I am dwelling on this subject for a long time and I sincerely hope the Minister will come back on it. It is an area which is very much in the news at the moment, an area in which there seems to be a great need. In my own district, in south County Dublin and in County Wicklow district there is a severe shortage of beds for long-stay geriatric patients and people are being accommodated in private hospitals and private nursing homes. Let us consider what would be a realistic subvention. Is £28 per week —and this is possibly the maximum figure drawn from those two sources— an adequate figure for a 24-hour, seven-day TLC, tender loving care, service? When one relates it to costs of weekly stays in hospitals or even in welfare homes, one finds it is very difficult to do it for that figure.

In many cases people who operate essential services are trying to maintain patients on as little as £18 or £19 per week. I do not think that is possible. We should show a greater appreciation of their efforts and we should utilise the present system to the full. In dealing with this situation the Minister may say a son or a daughter may contribute a certain amount and then it becomes a three-way contribution. From inquiries I have made— and I met representatives of these homes very recently—very often the only relatives these aged people have might be nieces or nephews who have their own commitments. A great deal of clarification is required.

This Bill speaks in terms of services. Here is a vital service for the aged. It would appear to be the policy that, when people are no longer able to cope and provide for themselves, provided they are in reasonable health and that they are ambulant, a place will be found for them in a welfare home. Indeed, these welfare homes are magnificent. They are a wonderful idea. They allow people freedom. They can express their own individuality. They do not suffer from loneliness as do many of our aged people who live alone. They have company, comfort, warmth, heat. I hope we will see more welfare homes in other centres.

In Wicklow we look forward to the opening, possibly next month, of a welfare home in Arklow. We may be considered lucky to have one in Bray and another in Arklow. I hope we will have a third because we have many aged people in the county, many of whom are living in very remote areas, areas of very difficult terrain. Even if it were only for the winter months I would hope that these people could be offered accommodation and warmth which would build them up over the lean and most difficult period of the year for them. I have dealt with this matter at greater length than I had intended but I hope the Minister will also deal with it at length and spell out precisely what his Department will do or permit health boards to do on behalf of these aged people. I know that the Minister is very concerned knowing that this case was brought to his notice before by people representing the Private Nursing Homes Association. He said then that he would examine the position and do what he could. I hope that when replying to this debate he will be able to give an adequate answer stating how he will do so.

I want to speak now of the hardships experienced by many people to whom previous speakers referred. Only yesterday I met six young men working with CIE at the Broadstone Depot and who were formerly insured. They then received promotion which meant they were classified as non-manual. They now find they are over the upper limit and see that they have little or no cover. Cover will perhaps remain—is it for 18 months?—after they go over the limit. They see coworkers, possibly with a similar type of income, but in a different classification who, because they are termed manual workers, remain covered by the health contribution. This is a difficult position for the six workers mentioned. They are lucky in that they know about it in advance; somebody has interpreted the system for them and shown them their position but this does not meet their needs.

Later today I hope to be able to put a representative of this group in contact with the Minister's Department so that they can state their worries that they are no longer entitled to hospital in-patient and out-patient services. This is not because their income has become sufficient to enable them to provide these services for themselves, their wives and families but because of reclassification. If £3,000 is to be the figure, I would ask the Minister why he does not propose to raise this upper limit and I ask him to indicate the number of people who will be ineligible because of the limit not being raised. It seems to be a system under which one month you are in and the next month you are out. In that context I welcome the working party that has been set up. I wish it success and I hope it will reach early and satisfactory conclusions. The system seems to be piecemeal in some respects at present and it is extremely difficult for people to decide unless they are dealing with it on a regular basis who should be termed manual and who should be non-manual and it makes such a difference from the point of view of eligibility for health services.

I had another case very recently of a man employed as a counter-hand in a hardware store and he also does a good deal of outdoor work. He fills up the dockets, goes out and locates the material and helps to load it on to a truck for delivery to the customer. Should he be classified as manual or non-manual? Where does the distinction lie? Is it too legalistic? Is there any breakdown in respect of the proportion of a person's time spent on manual and non-manual work? I asked this person how he saw himself and he replied that he was a certain amount of both. Is he another person who is caught up in the complexity of the system?

It is vital that this matter should be cleared up as to who is manual and who is non-manual. It is not sufficient to await the findings of the working party; the difficulty could be resolved earlier. The Minister is aware that certain anomalies exist and I exhort him to try to rectify them even before the findings of the working party emerge. Why wait if there is hardship for people at present if it can be identified and rectified by a stroke of the pen, of if it is not as simple as that, by a short regulation? This side of the House would welcome a provision that would help people involved in a situation not of their own making or choice and who are concerned to know what their exact position is.

Business suspended at 1.30 p.m. and resumed at 2.30 p.m.