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.