Dáil Éireann debate -
Wednesday, 1 Mar 1978

Vol. 304 No. 4

Health Contributions (Amendment) Bill, 1978: Second and Subsequent Stages.

Minister for Health (Mr. Haughey)

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

The Health Contributions Act, 1971, established the principle that persons with entitlement to health services should contribute towards the cost of providing them. It was then, and still remains, the intention that, without imposing undue hardship, reasonable contributions should be made towards the cost of the health services by those eligible for them. All medical card holders are exempted from paying the contributions. It was made clear when the 1971 legislation was being introduced that the rates of contribution then proposed, 15p per week or £7 per year, would have to be increased and that at some future date the flat-rate scheme of contributions should be replaced by an income-related scheme. As Deputies are aware, the flat rates have in fact been increased at intervals since 1971.

The sole purpose of the present Bill is to provide for an increase in the present rates of health contributions. As I announced recently, it is the Government's intention to replace the present flat-rate social welfare and health contributions by a fully pay-related scheme.

I would hope to be in a position to formulate proposals based on a report from an inter-departmental working group set up to work out the details of the scheme for Government consideration at an early date. However, I can say to the Deputies, at this stage, that the working group considered that the earliest possible date for the introduction of a pay-related scheme would be April 1979, and accordingly it will be necessary to continue the existing scheme of flat-rate health contributions for a further year.

Contributions are at present payable at the rate of 39p weekly by employees and £18 annually by others. The Bill now before the House provides for an increase in these rates to 50p weekly and £24 annually—these increases to take effect from 1 April 1978.

The explanatory memorandum which has been circulated to Deputies indicates the object of the Bill, defines in some detail the categories of persons who are liable to pay health contributions and outlines the services to which they and their dependants are entitled.

The cost of providing "limited eligibility" services has risen considerably in recent years. Specific "limited eligibility" services are hospital in-patient and specialist out-patient services, maternity and infant care services and the drugs and medicines subsidy scheme. The extent of increases in the cost of hospital and specialist services must be a matter for serious concern and it is a problem to which I will be devoting close attention. There are many factors which influence costs however, such as the inflationary effects of pay and prices. Other factors tend to be forgotten and I think it appropriate that I should mention some of them. They include: the extra demands which have been arising due to increases in population; the need to improve the standard of institutional care for the aged, chronic sick and the handicapped and the provision of homes for the ambulant aged to replace substandard accommodation in county homes; the extra cost arising from advances in medical technology involving more sophisticated techniques and equipment, more specialised staff and greater use of intensive care units; the additional costs arising from increases in the number of accidents; the provision of improved care facilities for infants at risk; the cost of providing services for persons suffering from illnesses caused to some extent by excessive drinking and smoking; increases in the levels of hospital personnel so as to ensure that good standards of service will be available.

The estimated cost of limited eligibility services for 1978 is £265 million, all of which will be borne by the Exchequer. The total yield expected from health contributions in 1978, based on the increased rates provided for in the Bill, is £16.624 million, which is about 6 per cent of the overall cost of providing "limited eligibility" services.

While dealing with the question of health contributions I would like to take this opportunity to clear up some misunderstanding which appears to exist in relation to eligibility for hospital services for non-manual employees. The position is that the present income limit of £3,000 was introduced with effect from 1 July 1976. Any insured person in non-manual employment whose remuneration was within that limit on that date and who was therefore eligible for hospital services, retains his eligibility at least until the beginning of 1979, irrespective of any changes in his income in the meantime. The fact that the £3,000 limit has not been increased does not, therefore, affect his entitlement to services at present and I want to make that clear.

The present system for determining "limited eligibility" is very complex and, indeed, contains many anomalies. However, the introduction of the new pay-related scheme which I referred to earlier should simplify the system considerably and make it far easier for everybody to understand.

I trust that I have explained to the House some of the reasons for the increased rates of contributions proposed and I commend the Bill for approval.

Mr. Boland

I am very surprised the Minister for Health is introducing this measure. This legislation has nothing to do with health; it is purely and simply a taxation measure. It would have been more appropriate to have been introduced by the Minister for Finance and it would have been more honest had it been announced in the course of the budget debate. Unfortunately there was no reference to this proposed increase during the budget speech made by the Minister for Finance when all the "goodies" were being given out.

When you ask people what they thought of a budget they are inclined to say: "I do not know how they are going to do it, but they will get the money out of us some way." This is one of the ways they are going to get it and we might have anticipated when the budget was announced that, as sure as night follows day, this Bill would be introduced. What we might not have anticipated was the size of the increase, the single largest annual percentage increase ever introduced since health contributions began in 1971. This is being introduced by a Government at a time when they are urging people to show moderation, to take steps to control inflation and urging workers, the type of people who will be asked to make this contribution, to accept a moderate wage increase while asking them to pay an increase of 28 per cent in their health contributions, if they pay it by weekly instalments, or an increase of a whopping 33 per cent if they pay annually. Yet these people are being asked to take a wage increase of 8 per cent and to bring inflation down to single figures. The Minister asked this House to acquiesce quietly to a proposed increase of 28 per cent in the health contribution stamp and 33 per cent for self-employed people and farmers who have eligibility.

Mr. Haughey

Well done.

Mr. Boland

We will be back there yet, do not worry about that. I want to remind the Minister of those heady irresponsible days when he was in Opposition when he said whatever came into his mind and whatever he thought would benefit him in the headlines.

On 24 March 1976 speaking on the Health Contributions Bill at columns 265-266 of the Official Report he said:

It is, however, important in dealing with this legislation that we, on this side of the House, direct the attention of the public clearly to precisely what is involved and to explain the nature of these increased charges and the real purpose for which they are intended.

The House and the general public should clearly understand that this increase in charges which the Minister now puts before the House will not go towards improving our health services in any way.

Congratulations; neither will this Bill.

The money which will be raised by this legislation and by these increases will not be used to provide any new services, to improve standards, to provide any extra facilities or to make improvements of any kind in our health services.

Neither will this Bill.

Neither those people who will have to pay these contributions nor anybody else will benefit in the slightest degree in regard to the health services provided for them by this increase in contributions. This is not a health Bill; it is a taxation measure. As such, it should have been included in the budget package of taxes last January. The extra amount these increases will bring in, £1.7 million, has already been taken fully into account in the budget arithmetic. It is important that the House understand that.

It is equally important that the House understands this and it is more important that the House understands that the fellow who said this almost two years ago now has the gall to come here with a similar measure, the only difference being that in this legislation the percentage increases are bigger than they were in the 1976 Bill which he so vehemently opposed. He went on to say:

The amount involved here has been taken credit for as part of the budget revenue. It has already been fully absorbed in meeting the budgetary situation. These moneys will not be available to improve in any way the health services for those who will be called upon to pay them. In fact, this money will be handed over completely to the Exchequer as a budgetary measure. As I said, this is a taxation measure.

Even though the credit for this £1.7 million was taken in the budget, the Minister for Finance in introducing the budget did not mention this increase at all.

At that time Deputy Haughey was apparently shocked by that. He does not appear to be equally shocked at the failure of his colleague to mention this proposed increase in last month's budget. He went on to say:

It was not until the Book of Estimates came out and we saw there the figure for Appropriations-in-Aid of the Health Estimate, £10.2 million, that it was clear that this money which is now being sought by the Minister by way of this legislation, had already been fully credited in the budget arithmetic. That is the way this Government conduct their financial business. They resort to petty deceits.

At least we published the Book of Estimates. If that was not referred to in the budget, when the Book of Estimates was published the Dáil and the public had an opportunity of ascertaining for themselves that an increase was imminent. The present Minister did not even bother to publish the Book of Estimates.

When I rose today I ought to have done no more than say that I would commend the House to columns X to Y of the debate on the Health Contributions Bill, 1976, because if the Minister genuinely believed what he said then, he would not be introducing this Bill today. If the Minister had genuine concern for non-manual workers earning more than £3,000 a year and not covered in any way, and for whom the Minister shed so many bitter tears in 1976, he would have incorporated in this Bill the two amendments which he tabled to a similar measure in 1976. Those amendments were ruled out of order because they would have involved a possible charge on public funds. If the Minister had genuinely believed in those amendments and had wanted them included in that Bill in 1976, why did he not file away those amendments and say: "When I become Minister for Health if I have to introduce another Bill of this kind, I will incorporate these amendments in that Bill?" There is no sign of them today. Of course the situation has changed and Deputy Haughey is no longer spokesman for the Opposition.

The increases here are quite considerable. In the case of those who pay weekly, the contributions are being increased from 39p to 50p, an increase of 28 per cent, the single largest annual increase since the Health Contributions Act was introduced in 1971. The Minister should not be shaking his head. He may come back with his vast economic experience and begin quoting at me, but I can work out simple percentages. This is the single largest percentage increase since the first Bill was introduced in 1971.

Mr. Haughey

There was an increase of 71 per cent in 1975.

Mr. Boland

The contributions were increased from 26p to 33p in 1975, an increase of less than 27 per cent. There was an increase last year from 33p to 39p, which is 18 per cent, and that was bitterly opposed by the Minister at the time. Incidentally, each of those increases was in years of high world inflation, when this country was bedevilled by inflationary trends which were outside our control. Yet, when inflation has come down to 13 per cent and when the aspiration of the Government is to bring it down to single figures, when the Minister for Finance, the Minister for economic promises, has been exhorting the people to exercise moderation in their pay, the Minister for Health blandly turns around and tells the people they should bear an increase of more than 28 per cent.

Mr. Haughey

Does the Deputy not agree that the increase in 1975 was from £7 to £12?

Mr. Boland

First of all, I am talking about the increase in the rate of the weekly stamp. That increase was 73 per cent, from 15p to 26p, but that was in a period of four years, from 1971 to 1975. The increase was from £7 in 1971 to £12 in 1975. The increase was from £12 in 1975 to £15 in 1976, an increase of 25 per cent; and from £15 to £18 in 1977, an increase of 20 per cent. It is now proposed to bring it from £18 to £24, an increase of 33 per cent. Congratulations to the Minister, who has broken the record once again. This is the single largest percentage increase ever and it comes at a time when inflation is going down. The Minister's contribution will help inflation to go up again.

From that point of view, all I can say is that whatever chance there was of having the wage agreement accepted and ratified, this sort of action does not help especially at a time when not only have this party been calling consistently for the inclusion of the non-manual worker earning more than £3,000 a year in the eligibility services—hospital in-patient treatment, specialist out-patient treatment and certain other services—but the ICTU have been calling vehemently and loudly for it, and the ITGWU, the single largest component in the congress, the union who if the agreement is not ratified will be one of the main contributory factors to that, have been calling consistently on the Minister to include the non-manual workers earning in excess of £3,000 a year. Does the Minister think that either body will be pleased with this information at a time when they are being asked to urge their members to agree to a wage increase of 8 per cent? It will not be taken lightly by the social partners. It is a retrograde thing, particularly in view of the Minister's commitments and his statements in Opposition. After the promises made by the Minister and his aspirations to be remembered as an outstanding Minister for Health, all of us assumed there would be major changes this year in the range of people covered, in their income limits, and that there would not have been increases out of line with the projected rate of inflation and the terms of the national wage agreement.

This is especially upsetting when one realises that not one extra service will be provided for this money, not one extra person will be given hospital treatment or specialist out-patient treatment or maternity or infant care or assistance towards the drugs scheme. All that will happen is that those already in benefit will be asked to pay more than their fair share in view of the projected wage increases and the projected figures for inflation.

In a vague sort of way the Minister referred to the difficulties of defining who is and is not a manual worker. I do not accept the suggestions being made that legislation to achieve this is so complex that it would be impossible to prepare a Bill to define who is and who is not a manual worker. For that reason you get all those anomalies which define a bus driver as a manual worker but the conductor as non-manual, or the other way around. That sort of anomaly could be resolved very quickly. It is not fair and it is not acceptable that the Minister should say that the people who have been studying it found it baffling, that we had called in experts from England and that it baffled them too. All the Minister has to do is to draw up a simple piece of legislation defining afresh who is a manual worker and who is a non-manual worker and saying that that supercedes all existing definitions. That would solve the problem straight away.

For a short time the Minister was a member of a local authority and he knows that the simplest way to clear up difficulties about title to land is to make a CPO-that clears the board and gives a fresh title to the land, clearing up all the troubles and the controversies of the years. The same thing can apply in the case of manual and non-manual workers. Then, the troubles being faced by non-manual workers who have been earning more than £3,000 per annum and who have had to pay for all the health services will be abated.

In 1976 when the Minister was in Opposition he suggested that it was unconstitutional to distinguish between a manual and a non-manual worker and he said that the amendments he was entering at that time would have the effect of preventing the Minister of the day from distinguishing between a manual and a non-manual worker, thus forcing him to extend the health cover to all persons irrespective of their occupation up to whatever income limit obtained at the time. The amendments were ruled out of order on the grounds that they might constitute a charge on the Exchequer and, consequently, could be introduced only by the Minister. The person who introduced the amendments is now the Minister.

Today he told us something slightly different from what he has been telling us up to now. He said the working group considered that the earliest possible date for the introduction of a pay-related scheme would be April 1979. Up to this we were promised categorically that the scheme would be introduced in April 1979. When the Minister was urged to remove the anomaly in relation to the non-manual worker he said it would go in April 1979 in any event and that very few people were affected. He told us it was not worth changing until April 1979. I believe it is worth changing and there is now serious doubt as a result of the Minister's speech today as to whether the scheme will come into operation on the date mentioned.

He should state clearly whether he will give the House and the public an assurance that the scheme will come into operation at the beginning of April next year. Otherwise people will not know where they stand. It is only fair that they should be given a date towards which they can work. The situation is particularly unfair on the group who are outside insurance cover, the non-manual workers earning more than £3,000 per year. In reply to questions I raised sometime ago the Minister refused point-blank to consider including them for the interim because he said they would be entitled to make contributions from April 1979. Now he tells us that perhaps they will be able to make contributions from that time. It is only fair that the people and this House should have a clear indication as to whether eligibility will extend from that date.

When reading debates of previous years I noticed that some of the Minister's colleagues took the opportunity when discussing this matter of turning it virtually into an Estimates debate on the Department. I do not propose to do that but I assume the Minister will indicate that we will have an opportunity in the near future of discussing the Estimates for the Department of Health. On that assumption I do not think it right to delay the House in extending the debate on this Bill into a general Estimates debate. This is not really a health Bill but is a taxation measure.

I hope the Minister will deal with the following points. First, why was this increase not announced in the budget? Secondly, why is this the single largest annual increase imposed since the Health Contributions Act was introduced in 1971? Thirdly, even at this late stage why has the Minister not considered including the non-manual worker who earns in excess of £3,000 a year and who is now deprived of eligibility for any of these services? Finally, and perhaps most tellingly of all, why has the Minister not included the two amendments he introduced in 1976? They would have debarred the Minister of the day from distinguishing between manual and non-manual workers. Why has he not reintroduced those amendments which he was precluded from discussing as an Opposition spokesman but which he would be entitled to enter as Minister? Why did he not do this if he genuinely believed in them? Why does he not introduce a simple measure defining what is and what is not a manual worker, thus clearing up the grey area that exists? This would bring much relief to many people who are bedevilled at the moment as to whether they qualify. It would also take considerable worry from the officials of the Department of Health and officials in the health services. They have a dreadful task in trying to define whether a person is eligible.

This is simply a taxation measure and in view of the fact that it was not introduced or referred to in the course of the budget speech it cannot be accepted by us in Opposition. I conclude by repeating the words of the Minister on 24 March 1976 when he said: "That is the way this Government conduct their financial business. They resort to petty deceit." By their own words you shall know them.

Dr. O'Connell

The Minister is following in the footsteps of his predecessors in bringing in this legislation as a separate measure since the original Bill was introduced in October 1971. If I remember rightly it was introduced as a separate measure on each occasion.

Mr. Boland

It was announced in last year's budget.

Dr. O'Connell

I know that the Minister's predecessor brought it in as a separate item because I remember speaking on the matter. It may have happened in 1975-I am not quite sure. However, I do not want to delay the House unnecessarily.

There is provision in the Bill for the considerable increase of 30 per cent—20 per cent in the case of those who pay weekly and 30 per cent for those who pay yearly. There are two aspects that must be mentioned. Yes, it gives entitlements but the entitlements are on paper. At the moment there are enormously long waiting lists for out-patient services. Those who are entitled to receive such services in the hospitals are not able to avail of them. I wonder if we are taking money from them under false pretences? I can say without fear of contradiction that there are waiting lists of six months for some essential services. If we are talking about providing good health services for our people we should not tolerate a situation where people have to wait for six months even for normal diagnostic out-patient services. It is a terrible indictment of our health services that such a situation exists.

Appointments for such simple procedures as X-rays can take months to arrange and when there is a question of malignancy there could be a rampant spread of cancer before the patient even has the X-ray. This situation cannot be glossed over lightly. In the Eye and Ear Hospital there are waiting lists of more than six months for people who need glasses and for old people who have had cataracts and for whom glasses have been prescribed. They have to wait for a year in many cases. This is an inhuman approach towards people who deserve the minimum for which they are paying, namely, an appointment to have glasses. I tried unsuccessfully to get an appointment last October for a man. It could only be arranged for next May, some eight months after making the appointment. I would ask the Minister to see if his Department could investigate the situation. Perhaps they could monitor the cases to see how the consultants could be assisted by registrars. If back-up services were available to consultants the backlog could be cleared. It is causing considerable hardship and jeopardising the health of our community. In theory they are getting a service but not in practice. The same applies to hospital beds. This entitles people to free hospitalisation, but the number of people not able to get beds who should be getting them demands immediate investigation. There is not enough co-operation from the voluntary hospitals with the Medico-Social Research Board in the in-patient inquiry scheme. These voluntary hospitals are paid out of public funds and they should be prepared to co-operate to provide this service and enable the Medico-Social Research Board to give information to the Minister as to the average length of stay for a patient in hospital. This is the kind of information which the Minister and his Department need so that they can evaluate the situation, and this demands immediate attention.

We will have to examine seriously the question of X-ray departments and laboratories in our hospitals working on a shift basis so that we can eliminate the backlog in different diagnostic services. If a patient is admitted on a Friday there is terrible expense, and it is an indictment of our system that investigation into his case cannot commence until the following Monday or Tuesday. I have been hammering at this for many years but all my pleas have been in vain and ignored. We pay a lot of money for our X-ray equipment and from the way it is being used at the moment it becomes obsolete long before its true use expires. It is wrong that equipment costing so much should be available only from 9 a.m. until 5 p.m. We must talk seriously with those involved in this work with a view to introducing shift work to make this service available on a 24-hour basis. This would eliminate waiting lists for these services and make life much easier for the Minister and his Department. He could then say that he is getting proper value for the money, and those who pay health contributions would be getting the service to which they are entitled. I am not blaming the Minister for the situation which he has inherited, but I ask him to look at this aspect of it. A lot could be achieved because there is a limit to what you can put into health and better use of the services would help enormously.

I would like to consider who is entitled to the services. We have got to define who is a manual worker. This is the biggest problem that has arisen since the question of eligibility for hospitalisation arose. There is a serious number of anomalies in our present free hospitalisation scheme and eligibility for it, and we are not going to solve the problem simply by remedying one anomaly after the other. There are people who are barely outside the £3,000 limit and therefore are denied free hospitalisation, and this is causing severe hardship. If the Minister were to endeavour merely to rectify the amomalies that exist at the moment he would be bogged down in the work of this Department and he would never be able to formulate policy. As he remedied or rectified one anomaly another would be created. Therefore, the answer is not in the correction of anomalies but to have a proper health service along the lines of a pay-related health contribution scheme which the Minister has mentioned, but we can have it only in the context of bringing the extra 15 per cent into free hospitalisation. I have considered this from every angle and I find that is the only answer. If the Minister approaches it in any other way he is going to create problems for himself. He will have to look at this aspect, however reluctantly and make such a scheme available. A lot of people are suffering hardship in the existing situation, and voluntary health insurance is not the answer.

I once said that the 15 per centthe wealthy-could provide for themselves. In theory that is so but in practice there are many people who are not manual workers within the limited definition of that term. Is a foreman a manual worker? Is a technician a manual worker? I met a group of technicians with the Eastern Health Board who had come in as manual workers and paid social welfare contributions, and it was decided recently that they were not manual workers within the meaning of this term. I have a question down to the Minister asking him to define manual workers. Bus drivers are manual workers. Are bus conductors? Are shop assistants manual workers? Some say they are not. Butchers are manual workers. Railway station ticket checkers are manual workers, but those doing a similar job in a cinema may not be. The confusion and the problems created here are enormous and we may spend our time in the next few years defining what a manual worker is. If a technician gets promotion to senior technician does he become a manual worker? This problem has arisen over and over again. We could end up not helping our health services or furthering the cause of the medical services because we would be bogged down in trying to define this term. The Minister would have to make a swift and definite decision on this and say that this Department would be wasting time, effort and money in trying to define who is not a manual worker.

The answer is to provide free hospitalisation for all. If the Minister were to make a decision on this and have consultations with the medical profession on the basis of working out a method of payment to the consultants in such a free hospitalisation scheme that would be satisfactory to them, I believe he would get full co-operation. The medical profession are not there to thwart the Minister, and one of his headaches would be over. He has inherited something that is going to cause him a lot of headaches and I do not envy him his problems at the moment. I would like to see him make a decision fast, because many people are suffering severe hardship and getting mounting bills from hospitals which are causing a lot of problems for them. People who were eligible a couple of years ago for free hospitalisation find now that they have to pay bills amounting to £300, £400 or £500. I heard the other day of a £320 bill for maternity. That is a lot of money to pay for hospitalisation and for the obstetrician's attendance. Many people in the civil service at a certain level are not able to pay their hospitalisation costs. This happens in the public service and in the various trades where people are not classified as manual workers. I ask the Minister earnestly to make a decision on this class and to introduce a pay-related scheme. I believe everyone will be willing to co-operate in this and we would get a proper service.

The Minister spoke at the turning of the sod at Beaumont. I did not like his quotation from Thomas More of the 16th century as it was not quite apt. Our aim is to keep people out of hospitals. Thomas More said that the hospital is a place to be when you are ill. I would not quite agree.

Mr. Haughey

I quoted mutatis mutandis.

Dr. O'Connell

The Minister did not convey that in his speech. I remember a consultant saying to me that he wanted to take a patient of mine in for a rest in hospital until he checked his blood pressure. It is an expensive rest at £200 a week. It is a lot to pay for a bed in a hospital. We could easily give him a rest in a hotel.

Mr. Haughey

I made that point in my speech.

Dr. O'Connell

Yes, I saw that, but I thought the quotation was not apt. It was apt in Thomas More's time but at today's high cost I think not. It was a good quotation to keep. I was pleased with it. I would say that there will not be over-utilisation of beds. We have this Health Education Bureau, and with a real effort we will get people educated in the proper use of the health service. We have to educate doctors too. If we can get out-patient services streamlined so that there is a proper use made of X-ray equipment and laboratories then there will be no need to keep people in hospital or, if they have to be detained, no need to keep them too long. People should be able to attend at five o'clock in the evening for investigation and it should be possible to discharge them the following day at noon. I have known that to be done.

Now, I do not want to make any distinction between town and country, but farmers are not paying their contributions. The last time I asked a question about this I was astonished at the reply. Has the Minister up-to-date figures now? The urban worker pays weekly because the contribution is deducted at source. The amount owed by the farming community was quite considerable two years ago. Has there been an improvement in its collection?

Another matter that requires examination is the drug subsidy. The idea is excellent in theory but the practice is not always satisfactory because there can be quite a lapse of time between the time a claim is made and the health board makes a refund. I do not think officials are operating the scheme in the way we intended it should be operated. Over a certain amount a refund will be made. That is not quite correct. If a person gets a prescription on the 18th or 20th of a month he will not get a full refund because the health board argue that that must carry into the following month. It is a small point but it causes considerable hardship. Rigid decisions like this are unfair. Would the Minister have a look at this? Hardship can be caused where people have actually to borrow money to pay for drugs. The health board should be a little more flexible.

Will the working party go into the anomalies and make a decision on them? Will there be a common contract for doctors to replace the pool system? Will it be a common contract under the present scheme of 85 per cent eligibility or will it be a common contract negotiated with the doctors for a free hospitalisation scheme? Will we have this pay-related scheme in the context of 85 per cent or 100 per cent eligibility? I would appreciate it if the Minister would give us some information about this.

If we ask questions about the disbursement of public funds in regard to, say, a site-we vote the moneysare we entitled to get answers? I asked a question about the Beaumont site——

An Leas-Cheann Comhairle

That hardly arises on this Bill.

Dr. O'Connell

That could be argued.

An Leas-Cheann Comhairle

It could not possibly arise.

Dr. O'Connell

People are paying for the site. We should have a little more local government and there should be no bar on that kind of information. We vote the funds and we should know the cost.

An Leas-Cheann Comhairle

There are several other ways of getting that information.

Dr. O'Hanlon

I support the Bill. The health contribution scheme was introduced in 1971. I believe those who subscribe to limited eligibility get very good value. There are problems certainly in relation to delays, waiting lists and so on but, by and large, very good value is given in our hospitals. Patients get very good value through both the in-patient and out-patient services. It is a comprehensive service. They get free maternity and infant care service outside the hospital and they get a subsidy for drugs.

Deputy Boland mentioned that the subscription is larger now. On 1 October 1974 it was £7. In 1975 it was £12, which is over a 70 per cent increase, and in that year there was an increase from 1 January 1975 of £3.75.

One of the problems that arise is in relation to collection. Not all farmers have subscribed to the limited eligibility fund. In my own area on 30 September 1977 only 35 per cent had subscribed and there was over £90,000 outstanding. In many cases these people wait until they have to go into hospital and then, as every public representative knows, they make representations to get into the limited eligibility scheme. Sometimes they do not get in and then they are faced with a very large bill. More encouragement should be given to induce people to join the scheme. It is a scheme which gives very good value.

Another delay occurs in relation to money collected by the Revenue Commissioners. Sometimes patients have to go into hospital while they are actually awaiting a reply from the Revenue Commissioners and they feel they are not getting good value. Those who are in the VHI and also entitled to limited eligibility feel they should not have to subscribe to limited eligibility because they are not getting good value. They are wrong in this because they actually get very good value. They have a lower rate of premium to pay to the VHI. They also have the advantage of the maternity scheme outside of hospital and the advantage of out-patient services and they have the benefit of the drug subsidy scheme.

Another problem arises in relation to the contribution year. It is different from the date of payment and this can cause a problem. For instance, those who paid in October last will be eligible for a further payment from 1 April. Perhaps it might be possible to bring the date of the payment of the subscription and the commencement of the subscription year into line.

With regard to the manual and non-manual worker this is something the Minister inherited from his predecessor who was unable to find a solution. I have no doubt the present Minister will find a solution. In the case of those with over £3,000 a year CEOs have discretion and, if there is hardship, these people can be brought into limited eligibility. I do not think anybody is suffering on that account.

Mr. F. O'Brien

What concerns me most on this Bill is the very steep increase in the charge on people least able to afford it. They are now being asked to pay £26 a year. When it is a question of health it is disgraceful to impose this very severe charge on the less well-off in our society. We hear a lot of pious talk about concern for health. Surely if our concern for health is so great this charge could have been foregone and sought elsewhere, or is this the first move towards having budgetary adjustments every other week going through this House? That might appear to be the way moneys will be raised in order to pay for the abolition of charges on other services. I believe the health of this nation is more important. To come into this House seeking additional moneys on that account when car tax has been withdrawn——

An Leas-Cheann Comhairle

Deputy, please do not get on to budgetary matters. This is a very limited Bill and car tax certainly does not arise on it.

Mr. F. O'Brien

I am making a comparison. It is a question of raising an additional £3 million. Why was it not raised in other ways? That is what I am questioning. This additional charge should not have been imposed. It illustrates the attitude of the Government towards the less well off in our society. There is nothing in this Bill for them except that they must pay for the people who have received benefits under the budget. That is the point I am making.

Another important point is that people who thought they were covered under the Health Acts are being penalised when they go to hospital because of this anomalous categorisation of manual and non-manual workers. I would ask the Minister to investigate this serious anomaly. People who genuinely thought they were covered when they go into hospital and find out that they are not could, with hospital charges at their present levels, be beggared in a short period of time. The question arises of who determines whether a man is to be categorised as a manual or non-manual worker. I know of an instance in which an employer-not prompted by the fact that an employee was being levied with a charge-had him categorised as a manual worker but the relevant health board said: no, he is a non-manual worker and consequently must pay.

This situation must be examined immediately. People cannot wait until April 1979 for some new scheme to bear the burden. It must be introduced without delay even if it entails introducing a Supplementary Estimate to meet any additional charge that may be incurred. It behoves the Minister to introduce this because genuine hardship is being inflicted, nobody can deny that. I know of cases, as does every other Deputy in this House. There is the example of people who invested their money at a very high interest rate in a particular bank, and when it fell by the wayside the tab was picked up for them by the Government. There is no comparison between the two situations; a person's health is far more important.

The Minister must examine this situation. If he does not, he will not be living up to the image he projects of being concerned about the health of the nation. I have no doubt but that he is so concerned. However, if he is, he must accept responsibility in this matter. It is ridiculous to categorise people as manual and non-manual workers. It is wrong and is dividing people. Deputy O'Connell posed the question: is a barman a manual or non-manual worker? Take another example. Is the man who was promoted last week from the shop floor to be a foreman to be regarded as a manual or non-manual worker? I think he remains manual, but how will he be regarded by the relevant authorities? As far as I can ascertain it is done on a cheese-paring basis, and a matter such as health should not be handled in that way. Rather it should be done with full consideration for the people in question, ensuring that they have the best services available to them and will not be denied them because they are not covered, not through any fault of their own but because they were under the impression they were covered.

There is the question of the overall increases involved in hospitalisation. I suppose this accounts for individual charges constantly increasing. I question whether we are getting value. We hear a lot of talk about major hospital development. As far as I can foresee, henceforth the bigger the hospital the bigger will be the bill per week per patient. Therefore one is tempted to ask: why should we rationalise? It does not make economic sense. Perhaps it makes medical sense, but I doubt it. This will place a large burden on the State, on health charges generally. Existing structures will be closed down. In my constituency, unfortunately, it will mean the closure of a number of hospitals which at present serve a deprived community. The bill is ever increasing. When it rises it is felt we can impose an extra 10p or 20p on the unfortunate people to be burdened with this payment. That is the easy way out.

We must examine the whole question of health expenditure. What is the grand total taking into account VHI, a person's contributions and those of the State and ask ourselves are we getting value for money. I do not think we are. I could not quantify it but I believe that what we are paying for health is astronomical and is not giving a fair return. During this year we should ensure that we are getting the best value for the money being spent. We owe it to the taxpayers to ensure that their money is being spent to give the best possible services. I doubt very much that the Government are concerned with that. It is so much easier to come in here with a Health Contributions (Amendment) Bill and levy people. That will not solve the problem. We should be looking at our costings, not with a view to downgrading services, but a view to ensuring that money spent is well spent. This is a very important aspect and I would ask the Minister to look at it.

In relation to the question of medical cards, there may be abuses and we may be losing money, I do not know. We should look at the thresholds and at people with long-term illnesses. Families in which there are chronic illnesses, such as children with asthma, should be covered under the medical card. In the long-term this might save hospitalisation and consequently might save the additional expenditure we are looking for under the Health Contributions (Amendment) Bill. We should examine all aspects of health expenditure, how the money is to be raised and how it is to be spent.

I strongly oppose this measure brought here today because it introduces a further levy on the people who can least afford it. The present trend of the Government seems to be that for some reason or other they penalise the people who cannot pay. Maybe they have not as many votes as the people who can afford to pay. I would ask the Minister to reconsider this measure and to consult with the Minister for Finance in whose budget there was no hint that there would be an increase in this health contribution. Why did the Minister for Finance not take responsibility for it in his budget speech? Why did he not make this announcement? Was that not the popular thing to do in the window-dressing effort the Minister was trying to put over? The Minister for Health is doing the dirty work for the Minister for Finance in coming in here looking for money. That is the subtlety of this package that the Government are trying to put over. They put forward a glossy package and now we are paying in other ways. The subsidies are coming off this, that and the other and this is another hidden charge that people will have to pay. The people were not informed in the manifesto that they would have to pay additional money for health services. They were only told about the "goodies" they would get. Let us be honest, and let us stop the political gimmickry; let us tell the people exactly where the money must be raised to pay for the removal of the car tax and to make life easier for the people who have it easy already.

I am disappointed in this Bill. I have voiced my criticism against this savage increase on the less well off in our society. I am surprised that the Minister for Health should come in here to try to sell this to us. It has to be rejected.

Mr. M.P. Murphy

I do not share the surprise of the previous speakers at the introduction of this measure. It was evident that the Government would have to introduce a number of measures to bring in additional funds, taking into account that in the current year we have borrowed £821 million, more than half of which is for current expenditure. Having succeeded in becoming the Government by the gimmickry of the election manifesto and in throwing away money that had been coming into the Exchequer over the years, the Government must seek additional funds. The sum of £3 million to be raised by this measure is very modest as a percentage of the total health expenditure. I will not quibble at the increases. Everybody knows that services must be paid for, and having regard to the inflationary trend at present and having regard to health and hospital charges, 11p per week is not an exorbitant demand, neither is £24 an exorbitant demand for cover for those farmers and others who qualify under the health contribution scheme.

The question of what value we get for the money was posed by Deputy O'Brien in the course of his speech. I know that a Minister for Health has an exceptionally difficult job no matter who he is or what his qualifications may be. All along the line the Minister is confronted with organised groups capable of exerting a great deal of pressure to get what they think is their entitlement without taking into account other groups of citizens. This seems to be the pattern at present. There are such groups within the health services.

Parliament gave authority to the chief executive officers of the health boards which I thought should have been retained by the Minister of the day. Health executive officers have too much authority. When people vote in an election, the primary objective is to elect a Government. The person selected as Minister for Health should have a great deal of power so far as the health services are concerned. That power was very much eroded when the health boards were established. It rests with the executives when it should rest with the man answerable to Parliament and to the nation. It is futile to question the Minister on many aspects of the health services because he has to say they are functions of the health boards and he is powerless.

Small as this sum may be relative to the total health bill, we are entitled to ask what will happen to this £3 million of the £16.624 million which will be raised through health contributions. I was interested in a statement made by the Minister for Finance in his financial statement in the House on 1 February. He stated positively that 2,400 additional jobs will be provided to enable the health services to function more smoothly and more efficiently. What kind of jobs has the Minister in mind? I am sure the Minister for Health reported to the Minister for Finance and the Cabinet——

Mr. Haughey

Right across the board from consultants to hall porters.

An Leas-Cheann Comhairle

I am afraid we are broadening the scope of this very limited Bill.

Mr. M.P. Murphy

In the White Paper it is stated that these adjustments will increase receipts from health contributions by £3 million, bringing the total yield to £16.624 million and receipts from health contributions are appropriated in aid of the Vote for Health. It is relevant for us to inquire about the use to be made of this money for which the House is being asked to vote approval today.

As an ordinary layman I am reasonably conversant with the health services. I cannot see how 2,400 jobs are necessary from the Department down to the district hospitals and the local community welfare officers section. The health boards are overloaded with administrative staff, if anything.

An Leas-Cheann Comhairle

That would be a matter for the general Estimate.

Mr. M.P. Murphy

We are asked to give approval to a Bill introduced by the Minister to provide for additional contributions totalling £3 million for health services. I am entitled to ask how that money will be expended. It is as simple as that.

An Leas-Cheann Comhairle

The Deputy may not go into detail on the running and staffing of hospitals until the debate on the general Health Estimate.

Mr. M.P. Murphy

I want to ask the Minister about these 2,400 jobs. The employment of senior consultants would be justified.

Mr. Haughey

They are included.

Mr. M.P. Murphy

The number there would be insignificant.

Mr. Haughey

Public health nurses.

Mr. M.P. Murphy

We could do with more staff in the orthopaedic hospitals, orthopaedic surgeons, and so on. Of course, 100 of such people employed around the country would be a great many. Possibly there are not more than 100 available. What about the other 2,300? I know the Minister will be as helpful as any other Minister. I want him to consider the people who will pay these contributions and see that they get value for their money.

Deputy O'Connell mentioned a waiting period of six months before some patients can get treatment. People needing treatment in the orthopaedic hospital in Cork could have to wait as long as three years. Some people have had to wait more than three years. Because of lack of accommodation they were unable to get admission. The numbers on the waiting list from Counties Cork and Kerry are exceptionally large. If I thought some of this money would provide additional staffing or additional accommodation for such patients, I would be very pleased.

Old people who need ophthalmic treatment, whether they pay this contribution or whether they are in the medical card group, find it very difficult to get such treatment. There are waiting periods of long duration. I do not want to labour this point, but it seems terribly peculiar to me that we should be providing jobs which are unnecessary to my mind. I should like to see everybody in Ireland employed. We would all like to see employment provided, but if that employment is non-productive, and if this money could be better utilised in some other direction, it should be expended in that other direction and utilised to provide better services.

The cost of maintaining patients in hospitals is astronomical. It has gone up and up even in district hospitals where the average cost per patient is more than £70 per week. All the small hospitals are finding it difficult to deal with applications for beds. Our district and cottage hospitals accommodate mainly old people waiting for their end but should this be the case? I have a lot of experience of hospitals and have contact with many elderly people who are confined there. In my opinion, most of those patients would prefer, in spite of any incapacities and in spite of their old age, to be at home. In most cases the reason they cannot be catered for at home is that the allowances paid for caring for them at home are completely inadequate.

An Leas-Cheann Comhairle

Those matters should be raised on the general Estimate; they do not come under this Bill.

Mr. M.P. Murphy

I was anxious to draw the Minister's attention to that point. There is a big difference between a person in the 70 to 80 age group who enjoys reasonably good health, is mobile, can smoke his pipe and go out and have a few drinks——

Mr. Boland

The Minister will not allow people to do any of those things. He will not allow people to smoke or have drinks.

Mr. Haughey

In moderation.

Mr. M.P. Murphy

——and those who are confined and must be given constant care. If the home help allowance was increased and extended, those people could be kept at home.

An Leas-Cheann Comhairle

That is a genuine point but it is not relevant to the Bill. The Deputy is broadening the scope of the debate and I cannot allow that.

Mr. M.P. Murphy

Those people should be cared for at home so that the cost to the State would be reduced and the hospitals available for people in need of other types of treatment. The money we are voting in this Bill is going into the general Health Estimate and for that reason we are entitled to inquire how it will be expended. I am anxious to know what the Minister intends to do about people who are considered borderline cases as far as a means test is concerned. I accept that because health services are so costly at present it is financially impossible to extend them very much but those borderline cases must be catered for. The situation here is peculiar. If we compare the income of a general practitioner with that of the Head of our Government, the Taoiseach, we find that in most cases the income from public funds of a practitioner living in a small town or village is greater than that of the Taoiseach. The records prove that. When we have that type of system operating health services are bound to be costly. I expect that most of the £3 million being voted today will go towards paying doctors' fees.

There is something peculiar about the fee per service. In theory the scheme may be a good one. It looks well but I wonder if it is efficient in practice. Are our hospital waiting rooms cluttered with people who are not necessarily in need of medical attention but are there by virtue of the fact that they must be paid for by the State? I accept that to a large extent the Minister is powerless in this regard but it is surprising that in a country where conditions are reasonably good so many people have to avail of periodic visits to medical practitioners. When I was young it was unusual for people to go to a doctor. In fact, if one heard of a person visiting a doctor one came to the conclusion that that person was thinking of moving out. Certainly, there was no question of going to a doctor if one had a running nose or a cough, but that is the position now. In my view that is encouraged by some of our general practitioners. It is costing the State a lot of money. When we come to debate the general Estimate I hope the Minister will tell the House the number of visits made to general practitioners by medical card holders.

An Leas-Cheann Comhairle

The Deputy is making his speech in advance of the general Estimate. The fact that £3 million is mentioned in the Bill does not give any Deputy the opportunity to go fully into the general Estimate. A general Estimate will be introduced later, I hope, and then the Deputy will have the opportunity he now seeks.

Mr. Boland

We also hope it will be introduced. Can the Minister say when it will be introduced?

An Leas-Cheann Comhairle

Deputy Murphy is in possession.

Mr. M.P. Murphy

I am anxious to know the situation in relation to borderline cases. I refer to those who must go to the VHI or must make a case to the local CEO. I am particularly interested in those people suffering from long-term illnesses. Some people are handicapped from birth and they find it difficult to get cover. In the case of children under 16 years suffering from long-term illnesses they cannot get cover from the VHI with the result that they are nobody's baby. More attention should be given to our handicapped people and those suffering from long-term illnesses, irrespective of family income. Those people should be given free medical services. Most of us have had to make representations on behalf of such people. The scope of the measure covering the provision of drugs for certain illnesses should be extended. For instance, those suffering from asthmatic ailments are not included. That is wrong. We should help that small group of people who need such attention.

We must have measures like this to bring in money to the Exchequer. After all, Fianna Fáil bought their way into power. They were so generous before the election in what they were promising. I recall, too, what the Minister present had to say about fisheries then but I shall not talk about that now.

An Leas-Cheann Comhairle

Surely not.

Mr. M.P. Murphy

The increases proposed are fair and reasonable. A sum of £24 per year is not an excessive contribution in terms of the type of services that are provided and having regard to the cost of these services and to the people providing the services. They are loud enough where charges are involved. Perhaps this increase of 11p per week should have been included in the budget proposals but I expect that the Minister for Finance had no wish to spoil his nice budget by announcing increases and, consequently, left this increase to his close friend, the Minister for Health and Social Welfare, to announce.

Mr. B. Desmond

The financing of our national health services is likely to become a major political issue in the next three or four years. Regardless of how adept the Minister for Health may be in terms of public relations and even allowing for his having virtually an unpaid public relations officer at the moment in the person of the health affairs correspondent of the Irish Independent, he will need to be much more adept when the real political crunch comes in a matter of a year or two.

This is the first instalment in regard to the critical situation that the country is about to face in relation to the financing of the health services. No amount of public relations work or of liaison with special correspondents can cloak the fact that the Cabinet have not provided and obviously do not intend providing the kind of money that will be needed if we are to have a universal and comprehensive national health service. Regardless of whether sex or something else is given up at the Ard-Fheis next year in lieu of smoking this year, these side contortions cannot get us away from the fact that as of today some tens of thousands of insured workers both in the public and the private sectors are sliding out of limited eligibility benefit.

We are serving notice on the Minister of our intention to oppose the Bill. The situation is serious. There is enough trouble in respect of the postal services but one of the causes of the considerable and growing dissatisfaction within the Post Office is the huge number of employees there who are no longer eligible for limited eligibility. In this area the Minister has failed totally but his predecessor was not successful in this regard either. There has been failure to extend general eligibility throughout the country. The achieving of a universal extension in this regard would mean the abolition of the outdated £3,000 income limit. It was a simple matter for the Minister to have included in the explanatory memorandum a note to the effect that an eligible person who exceeds the remuneration limit retains eligibility for the balance of the contribution year in relation to persons involved in the national pay agreement, 1976.

In relation to that agreement the only increases that are conceded as retaining eligibility are basic increases. Thousands of civil servants have in the meantime got incremental increases which have put them beyond the £3,000 limit while thousands of Post Office employees and of workers in private industry have also gone way beyond the eligibility limit and, consequently, lose entitlement to the health services. This serious situation has been brought to the Minister's attention recently by a number of organisations. In December last representatives of the ICTU met the Minister and told him that they were totally dissatisfied with the situation regarding eligibility. In January they made a submission to the Minister but so far they have not heard from him as to what action he intends taking to rectify the situation. It is an issue on which the previous Government were defeated.

While allowing for the exceptionally competent Minister that we have in the Minister for Health and Social Welfare and having regard to his capacity to bring about great change, he is scared stiff of the political confrontation that he will have to face with the medical profession, particularly with some consultants, if we are to have a general extension of eligibility. During his eight months in office the Minister has appreciated the implications of what is involved but has said nothing. Apparently he has no intention of doing anything on this question apart from the setting up of another glorious Department of Health working party. But we have had many working parties in relation to the health services. Indeed, I remember as a young trade union official appearing before a former Minister for Health, Mr. MacEntee, who threw us out and told us there was no question of a general extension of eligibility. That was 15 or 20 years ago. Let us take a simple example of the situation and consider the case, say, of a barman in the Minister's pub——

Mr. Haughey

Is the Deputy referring to my pub?

Mr. B. Desmond

Perhaps my imagination is getting the better of me but, then, I may not be all that inaccurate. Can we not envisage a situation in which the Minister would have supplies taken by helicopter to his island?

Mr. Haughey

I assure the Deputy that I have not got a pub.

Mr. B. Desmond

Let us take the case of a barman. He is classified as a non-manual worker and, consequently, does not qualify for eligibility to health services. Another example is that of a working foreman with Bord na Móna who undertakes hard manual work but who is regarded also as being in the non-manual category for the purposes of eligibility. Is it not a crazy system that a man driving a train from Dublin to Cork is regarded as a non-manual worker while a porter on the train is in the manual category? The Minister knows that the system is mad but it is mad because the medical profession, notably the IMA and many consultants, say "You will not extend eligibility. We want our segment from which we shall cream the surfaces of our incomes." Deputy Corish as Minister tried to do something about this but failed. He should not have failed but that was the situation. In his efforts he got very little assistance from Fianna Fáil.

I am appalled that there is so little general debate on this Bill. During the past 12 months there has been a dramatic decline in the number of persons retaining eligibility for health services. Obviously there will be another Health Contributions Bill at the beginning of next year but that will be long before there will be any question of pay-related health contributions. These contributions would have the most horrific implications for many people because the health services are funded from Central Exchequer funds. Now we are to have a situation in which, for instance, I will be expected to pay 2 or 3 per cent of my salary towards the health services and Fianna Fáil in the next budget will undertake to wipe out £60 million or £70 million from Exchequer expenditure. The Minister is proposing to introduce pay-related contributions for social welfare and health services and I challenge him to deny that.

I am not very worried about the 50p a week or the £24 a year. As the Minister knows, half the farmers and self-employed people do not pay this £24 anyway. They wait until the health boards go berserk and until they are half dead from illness before they pay the £24. It is the ordinary insured worker who has to pay 50p. It is not a fantastic imposition but it constitutes a contribution of £16 million from employees. I know what is in the minds of the Minister and the Department. They will introduce a percentage of salary contribution for the health services and hundreds of millions of pounds will be lopped off the Exchequer contribution of the budget and dumped on the backs of PAYE contributors. With due respect to the Minister, I do not think he has the political clout to take on the farmers and self-employed and make them contribute a pay-related sum. He could hardly collect it from them; it is difficult enough to collect income tax from the self-employed without imposing a health contribution on a percentage basis.

The financing of the health services will become a major political issue. Giving up smoking at the Ard-Fheis or giving up black and white television licences in the next election will not cloak the overall issue.

Mr. Boland

Colour licences, at least.

Mr. B. Desmond

The Coalition will be giving colour television licences. That is our secret.

An Leas-Cheann Comhairle

We should get back to the Bill and leave the colour television to the people who are dealing with it. Colour television does not arise on this Bill.

Mr. Haughey

I think Deputies are confused about the free telephones for old people.

An Leas-Cheann Comhairle

That does not arise on the Bill either. Deputy Desmond should get back to the Bill.

Mr. B. Desmond

The Minister received some months ago a comprehensive submission from the ICTU on this issue. He has not replied to the ICTU. This is an important issue. Many people who work in the post office tell me that they are no longer eligible for health services and they want to know what the Minister will do about it. There is enough frustration in the post office at the moment without adding to it. It will not be good enough for the Minister to say that he intends to replace the present flat-rate social welfare and health contribution by a fully related scheme. That is not good enough. It is not a question of methods of contribution; it is a question of eligibility.

I would refer the Minister to one of the most spurious arguments which has ever emanated from this country. It is the argument that if there is extended eligibility people earning over £3,000 a year will flood into the hospitals and avail of all types of health services. One would imagine that there would be a rapid increase in the birth rate; that is implied by those who are opposed to the extension of general eligibility. One would imagine that the expenditure on drugs and medicine subsidies would automatically rocket. I submit that the Minister should examine carefully the excellent report of the NESC which blew that myth sky high. It is a myth which is perpetrated by people with a vested interest who do not want any extension of eligibility. The Minister should accept this report.

Mr. Haughey

Which report?

Mr. B. Desmond

There are a number of comments made by the NESC in relation to the extension of the health services and the Minister knows that this report refutes the proposition that a general extension of the health services will automatically give rise to a massive increase in State expenditure. Nobody wants to go into hospital unless he must do so. Nobody will breed families of 16 children overnight if there is a general extension of the maternity services. We will not swallow millions of pounds worth of extra drugs. This is the implication. It is implied that such an extension would cost too much and that people would go berserk. The NESC report has exploded that myth and the Minister knows that, notwithstanding the increase in costs which is a matter of serious concern, the problem is capable of being tackled and dealt with.

I have felt strongly over the years about the blatant antediluvian class discriminatory structure built into the eligibility question within the health services. How can any Minister for Health come into this House, as all his predecessors have done, and say that one has to be a manual worker in order to be eligible? The definition of a manual worker is so bad that the chief executive of a health board is almost driven out of his mind trying to decide whether a worker belongs in the category of manual or non-manual worker. They cannot possibly work on a coherent basis in the provision of health services. Secondly, there is the category of non-manual employees whose rate of remuneration is £3,000 or less. I remember having a "barney" with the Minister in relation to those earning less than £50 a week. On reflection I possibly over-estimated in regard to some of my strictures. I would point out to the Minister that since that discussion new figures have been produced in relation to average male adult earnings in the transportable goods industry and these earnings have again risen. The average male adult industrial worker earns about £75 a week. Another 8 per cent has been added in the construction industry from 1 January and this is to be provided from 1 March on the private side. We are then talking about average earnings of about £85 a week by the end of the year. Another £100 may be added to that to cover the 2 per cent productivity provision in the national pay agreement and the limit of £3,000 will be derisory.

My twin brother is a post office technician and his earnings are well above £3,000, with the result that he is "clobbered" as regards eligibility. I happen to be a voluntary contributor and have kept up my contributions through the years since I went over the limit. I am now in this unique category of non-manual employees whose rate of remuneration is over £3,000 and who are voluntary contributors under the Social Welfare Act of 1974.

I am now in this group of unique people who are voluntary contributors and have eligibility. If I did not have that eligibility I would have been crucified in the last few years with continuing illness in my family, particularly of one of my children. I appreciate the benefits of this. I know many public servants, members of the Garda Síochána, members of the security forces who are no longer eligible for the health services. It is not enough to talk about the famous carry over the Minister has spoken about. If a member of the Garda Síochána, for instance, got a straight increase under the national pay agreement that is included in the carry over. If a fortnight later he gets an incremental increase that is not included. You can get your basic increase, add on your incremental, you are over the maximum and you are out.

There was the 10 per cent relativity increase in salaries given in addition to the national pay agreement. That 10 per cent relativity increase in the public service puts several thousand public servants out of eligibility under the health services. The situation will become much more serious. The Labour Party are, therefore, opposing this Bill. It is totally inadequate. I have been a member of the Social and Health Questions Committee of the Council of Europe for the past five years. I have visited almost all the west European countries. I had the opportunity afforded to me by being a member of this House and being an Irish delegate of visiting the health departments of approximately ten different countries. When I show them what we have as a so-called enlightened democratic country with a reasonable standard of living they regard our health services as being based on class discrimination, income discrimination and on professional discrimination of the worst kind. When I say that I am not being anti-IMA or anti-consultant. I am simply saying that there are people in the country who are earning a very good living from their work in the health services. I do not see why an ordinary public servant, a clerical officer with an income of £3,100, should, after a few years, go out of eligibility under the health services. When the Minister goes around the country he will find that this will be a major political issue in the next 12 months.

I am very concerned about what I call the social expenditure priorities of a number of members of the Cabinet. I regard the Fianna Fáil Party as moving sharply to the right at Cabinet level.

An Leas-Cheann Comhairle

Surely that does not arise on this Bill?

Mr. B. Desmond

It arises on it.

An Leas-Cheann Comhairle

The Deputy is broadening the scope very much.

Mr. B. Desmond

One has only to read the implications in the Government's White Paper on Social and National Development, whereby the Minister for Health is now saying that we can have all the services we like but we will pay for them as employees and they will slap on a pay-related contribution for the health services. I am afraid he will have a big political battle on his hands. He will need far more than the health affairs correspondent of the Irish Independent to rescue him from some unfavourable publicity in that regard. The Minister has to look sharply at his policy. He has got to tell the Department of Finance that he will not wear the strictures which were put around his neck like a halter by the Minister in his budget and he will not be able to run out after the next budget and say: “A great coup for Deputy Haughey, 10 per cent increase in social welfare, he really did well at the Cabinet table.” There would be a halo around Deputy Cluskey's head at that stage because he could get that at the drop of a hat in an October review.

The Minister should have a second look at this Bill. I am gravely concerned about its contents. The Irish Congress of Trade Unions are horrified at the lack of action by the Minister. Every trade union in the country, whether it is the Garda Representative Body, the Post Office Workers Union, the Civil Service and Higher Executive Officers' Association, the Civil Service Clerical Officers' Association or any other public service union in the country, are at the moment arming themselves to let go at the Minister on the question of general eligibility. He has dodged the issue and there is no way in which he can ride out the storm gathering this year. Thousands of workers in the public and private sectors are going out of eligibility for the health services.

Mr. Haughey

That is rubbish.

Mr. B. Desmond

It is not rubbish and the Minister knows it. He has done a very clever PR campaign in the last few months and tried to cod people. I ask all workers in the country: "Have a look at your PAYE certificate, ring up your health board, check with your local health authority, ring the Department of Health and you will be told that you are no longer eligible, you have run out of your two years or 18 months." The Minister knows well what I am talking about.

Mr. Haughey

Nobody can run out. Everybody goes on to the start of 1979 at least.

Mr. B. Desmond

That is not true and the Minister knows that. If he rings up Mr. Peter Cassells, the health expert of the ICTU, the assistant general secretary of the ICTU or talks to the secretary of his Department he will realise that what he is saying is not true. As of last week, as of this week, people who had exhausted their 18 months or two years are now gone out of eligibility. The people the Minister is talking about are a small group of people who got certain increases of a basic nature under the last pay agreement. There are massive changes coming this year. I ask the Minister to have a look at the situation because I am most concerned about it. The country deserves much better. The Minister is capable of much better and he knows perfectly well that all he has got to do is say to the medical profession: "There will be a general health service in this country and we will have to work out the finances of it."

Mr. Haughey

Like the Coalition did.

An Leas-Cheann Comhairle

The Minister will have an opportunity of replying.

Mr. B. Desmond

We could have brought it in if we got any co-operation at all, even in the worst economic climate the country ever faced.

Mr. Haughey

The Coalition ran away from it.

Mr. B. Desmond

We did not. We were blackmailed into not having it. The Minister has an opportunity of facing up to that in a good economic climate without the rocketing costs of medicine. He can bring it in if he has the political will to do so. I look forward to him showing that political courage.

Minister for Health (Mr. Haughey)

There is one point made by Deputy Fergus O'Brien which I would like to deal with first. He said that this was a savage increase inflicted on the less well off sector of the community. Even allowing for the hyperbole which we all indulge in from time to time in the course of debating in the House that is an unacceptable statement of the position. In fact, on one aspect of it Deputy Michael Pat Murphy put the thing in perspective when he said that those increases are reasonable having regard to the changing situation. Of course, they are not inflicted on the less well off section of the community. I am not saying that those who will have to pay these increases are well off but they certainly are not the least well off.

Mr. Boland

The Minister did describe smaller increases as savage in 1976.

An Leas-Cheann Comhairle

The Minister is in possession. Deputy Boland was not interrupted.

Mr. Boland

I was.

Mr. Haughey

The point I was endeavouring to make is that these increases are not paid by the poorer section of the community, those who have medical cards. As most Deputies know, anybody with a medical card is entitled to full eligibility free of charge. Deputy Boland sought to make a point that this is the largest single percentage increase ever made. As I said by interjection, it is not. In 1975 the Coalition introduced a 71 per cent increase, raising the annual rate of contribution from £7 to £12. Deputy Boland asked about an Estimate debate. I hope we shall have a debate on the Estimate early in the year. It is impossible to have it now before the Easter Recess but I should like to ensure that we will have a debate on the main Estimate.

Deputy Boland and others spoke about the introduction of the pay-related scheme. There is no reason to query my intention to bring in the pay-related scheme on 1 April 1979; what I said was that the working party has indicated that there is no way, administratively, in which it can be brought in before that. On the basis of their report, which I shall have any day now, I will be formulating proposals to the Government which I hope will ensure that a fully pay-related scheme is introduced on 1 April 1979. That will do away with much of the criticism levelled today against this system operating at present. None of us regards it as satisfactory; I still think about it as I did in Opposition, that there are anomalies in it, that some of the classifications between manual and non-manual are ridiculous, but Deputies opposite have no right to criticise me about these things because they prevailed when the Coalition were in office during the full period of that Government and they did nothing about them. It is hypocritical on their part suddenly to find these things so obnoxious and unacceptable when they tolerated them for their whole period of office. I intend to do something about them.

Mr. Boland

When?

Mr. Haughey

I hope to do something about them.

Mr. B. Desmond

You are eight months in office now.

Mr. Haughey

The introduction of the pay-related scheme will give us an opportunity of endeavouring to deal with the whole matter in a comprehensive way.

Mr. Boland

You cannot live on the Coalition back forever.

Mr. Haughey

If Deputy Boland continues to interrupt I shall cease trying to answer the points made.

An Leas-Cheann Comhairle

I shall keep order. Deputy Boland will not interrupt.

Mr. Boland

Fair enough, but I did not object when the Minister interrupted me.

Mr. Haughey

Deputy Dr. O'Connell, as usual, made some valid and constructive points. He said that one of the real criticisms that can be made of this measure is that people are paying for limited eligibility services but because of delays, blockages and snarlups in the system people are not getting these services to which they are entitled. I recognise that, and in an attempt to deal with one aspect of it, the out-patients' department side of it, I have set up a group to go into that matter and see what improvements can be made. I invite Deputy Dr. O'Connell, because I think he knows more about this than most of us, to give evidence to that group, submit his views to them on the difficulties he sees and on how improvements could be made.

I think Deputy O'Connell also asked about the situation in regard to farmers paying contributions. Approximately 82,000 farmers are registered with the health boards as being liable to pay health contributions. In 1977 the collection rate for those farmers was about 70 per cent overall. Certainly, there is an unsatisfactory situation there. I think everybody recognises that the health boards have difficulty in administering that aspect of the scheme effectively.

Deputy O'Connell also asked about the cost of the Beaumont site. I recognise that there is a difficulty there. I think traditional practice in this House is that where a private interest is concerned the details of a transaction are not disclosed. That is a broader matter than could be dealt with in the context of this legislation. I think it is absolutely legitimate for the Deputy to raise the matter but all I can say is that the site we got at Beaumont is first-class value. It is a splendid site, ideal for building, very suitably located and, in my view, we got it at very reasonable cost. I have already expressed my thanks to the sisters of the order concerned for their co-operation in making it available to us.

On the general question of hospitalisation, we shall have to concentrate increasingly on trying to keep people out of hospitals. I said this on the occasion of the Beaumont ceremony, that modern hospitals are so expensive, so complex and so full of sophisticated equipment that they must be reserved for those who really need them. By building up geriatric homes, welfare homes, outpatients' departments and local community services we must try to ensure that more and more of our medical services are administered outside these very expensive modern hospitals and that hospital beds will be reserved for those who really need them. If we can do that, a great deal of the complaint voiced here today will be dealt with and we can ensure that people who really need sophisticated, intensive hospital care will be able to get it as it is needed without the annoying delays which cause the suffering and hardship to which many Deputies referred.

What I said last year in Opposition is true. This is not really a health measure; it is only such in so far as it helps to pay the cost of the health services. This is something arising out of the budget, part of the general financing of the whole of the public services for 1978. It is included in the budgetary arithmetic. It is not really a taxation measure; it is more specifically related to the provision of service than is normal taxation, but to an extent it may legitimately be called a taxation measure. I do not deny that it is part of the budget, part of the arithmetic whereby the Government and the Minister for Finance in particular make arrangements to discharge the debt for the year. I should like to make one or two points about it. In the context of the cost of the health services it is minimal. The cost of the limited eligibility services this year, as I pointed out elsewhere, will be £265 million.

The total cost of providing the limited eligibility portion of our health services this year will be £265 million. That works out at approximately £380 per person. In other words, if all those who get limited eligibility services were to pay for them in full they would pay £380 a year. All we are asking here is that people pay 50p per week or £24 a year. It is important to mention those figures in order to put the health contributions in their proper perspective. These people are making a very minimal contribution to the cost of the limited eligibility services we are providing. As Deputy M.P. Murphy pointed out it could not be regarded as anything but reasonable and fair and in line with increasing costs generally.

Deputy M.P. Murphy asked about jobs. The Chair sought to restrain him from widening the debate but perhaps I might say that as far as the 2,400 extra jobs we are providing in the health services in 1978 are concerned, an overwhelmingly high proportion of them will go to improving services— they will be consultants, doctors, nurses, public health nurses or people of that sort. Some of those jobs will undoubtedly go to things which cannot be immediately and directly related to an improvement in the services, such as repairs and renewals of premises and so on. As I said, the majority of these extra jobs will go towards improving the services for the people who will be asked to pay these increased amounts stipulated in this legislation.

I do not think there were any other points of significance raised in this debate. Again I want to put the broad proposition to the House in favour of the legislation that these increases are reasonable. If you are to look at them strictly in economic terms the amount which people pay for these limited eligibility services is small and the contributions represent good value in present-day terms. As I said, the total cost of the limited eligibility service is £265 million and overall the contributions which these health contributions make to that figure is £16 million or 6.27 per cent. In that context they cannot be regarded as unfair or unreasonable.

I want to repeat that it is the intention to bring in a pay related social welfare and health contribution. I am astonished at Deputy B. Desmond's apparent opposition to a pay-related scheme.

Mr. B. Desmond

For social welfare, yes.

Mr. Haughey

I thought the whole concept of a pay-related scheme to cover health and social welfare was unanimously and widely welcomed, sought after and pressed for by the trade union movement.

Mr. B. Desmond

Not the health services, as the Minister knows well.

Mr. Haughey

Perhaps Deputy B. Desmond knows more about the area than I do, but I do not think he does.

Mr. Boland

In view of the fact that on a similar measure last year and the year before this Minister is recorded in the course of the then Minister's summing up as having interrupted 17 times in 1976 and seven times last year——

An Leas-Cheann Comhairle

I am sorry Deputy but——

Mr. Boland

In view of his thinskinned attitude now may I be permitted to remind him of several questions I raised and which were not answered? I asked if the amendments he tabled——

An Leas-Cheann Comhairle

The Minister has concluded at this stage and we cannot continue the debate.

Mr. Boland

I am entitled to ask a question.

An Leas-Cheann Comhairle

I was not in the Chair last year and I have no responsibility for what happened.

Mr. Boland

I am entitled to ask questions.

An Leas-Cheann Comhairle

You may ask one brief question.

Mr. Boland

I asked a very important question and the Minister did not reply to it. Why has he not introduced the amendments he introduced when in opposition in 1976 into this Bill which would have removed the distinction between manual and non-manual workers within the income limits? Why has he not made any reference to my request to introduce new definitions for what are manual and non-manual categories which would remove all the anomalies and difficulties which Deputies have been complaining about all morning?

Mr. Haughey

I have already said that it is my hope that the vast proportion of existing complaints in this area will be dealt with in the context of the introduction on 1 April 1979 of the new scheme to which I have already adverted several times.

Question put.

The Dáil divided: Tá, 68; Níl, 45.

Tá

• Ahern, Bertie.
• Ahern, Kitt.
• Allen, Lorcan.
• Andrews, David.
• Andrews, Niall.
• Aylward, Liam.
• Barrett, Sylvester.
• Brady, Gerard.
• Brosnan, Seán.
• Browne, Seán.
• Burke, Raphael P.
• Callanan, John.
• Cogan, Barry.
• Colley, George.
• Collins, Gerard.
• Conaghan, Hugh.
• Connolly, Gerard.
• Cowen, Bernard.
• Crinion, Brendan.
• Cronin, Gerry.
• Kenneally, William.
• Killeen, Tim.
• Killilea, Mark.
• Lalor, Patrick J.
• Lemass, Eileen.
• Lenihan, Brian.
• Leonard, Jimmy.
• Leonard, Tom.
• Leyden, Terry.
• Lynch, Jack.
• McCreevy, Charlie.
• McEllistrim, Thomas.
• MacSharry, Ray.
• Meaney, Tom.
• Molloy, Robert.
• Daly, Brendan.
• Davern, Noel.
• de Valera, Vivion.
• Doherty, Seán.
• Fahey, Jackie.
• Farrell, Joe.
• Faulkner, Pádraig.
• Filgate, Eddie.
• Fitzgerald, Gene.
• Fitzpatrick, Tom
• (Dublin South-Central).
• Fitzsimons, James N.
• Flynn, Pádraig.
• Fox, Christopher J.
• Gallagher, Denis.
• Gallagher, James.
• Geoghegan-Quinn, Máire.
• Haughey, Charles J.
• Hussey, Thomas.
• Keegan, Seán.
• Moore, Seán.
• Morley, P.J.
• Murphy, Ciarán P.
• Noonan, Michael.
• O'Connor, Timothy C.
• O'Donoghue, Martin.
• O'Hanlon, Rory.
• O'Leary, John.
• Reynolds, Albert.
• Tunney, Jim.
• Walsh, Joe.
• Walsh, Seán.
• Woods, Michael J.
• Wyse, Pearse.

Níl

• Barry, Peter.
• Begley, Michael.
• Bermingham, Joseph.
• Boland, John.
• Bruton, John.
• Burke, Joan.
• Clinton, Mark.
• Cluskey, Frank.
• Collins, Edward.
• Conlan, John F.
• Corish, Brendan.
• Cosgrave, Liam.
• Cosgrave, Michael J.
• Creed, Donal.
• Crotty, Kieran.
• D'Arcy, Michael J.
• Desmond, Barry.
• Desmond, Eileen.
• Donnellan, John F.
• Gilhawley, Eugene.
• Griffin, Brendan.
• Horgan, John.
• Keating, Michael.
• Kelly, John.
• Kenny, Enda.
• Kerrigan, Pat.
• L'Estrange, Gerry.
• Lipper, Mick.
• McMahon, Larry.
• Mitchell, Jim.
• Murphy, Michael P.
• O'Brien, Fergus.
• O'Brien, William.
• O'Connell, John.
• O'Keeffe, Jim.
• O'Toole, Paddy.
• Pattison, Séamus.
• Quinn, Ruairi.
• Ryan, John J.
• Spring, Dan.
• Taylor, Frank.
• Timmins, Godfrey.
• Treacy, Seán.
• Tully, James.
• White, James.

Tellers: Tá, Deputies P. Lalor and C. Murphy; Níl, Deputies Creed and B. Desmond.

Question declared carried.

Agreed to take remaining Stages today.

Bill put through Committee, reported without amendment and passed.

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