: I welcome the opportunity of contributing to this debate. I agree fully with the Minister when he says there is urgent need to review the income limit of £3,000 for eligibility for hospital and maternity services.
It is quite unnerving to sit here listening to irresponsible talk about giving carte blanche to the Department of Health to extend the service without making any provision for the cost of such extension. I am not sure if the last speaker was being serious or glib about a very important area of health care here. The present Minister for Health is absolutely concerned about the Departments of Health and Social Welfare, is constantly in touch with the situation on a day-to-day basis. To listen to speakers making such remarks without making positive provision for a bland extension of the health services is quite appalling.
I have always been critical of the manner in which limits are structured, particularly in relation to the health services. This limit of £3,000 is no exception to that criticism. Before discussing the pros and cons of the limit itself it is important to bear in mind that a new set of circumstances will prevail next April when the new scheme of pay-related contributions by workers will be implemented. This will represent a new departure in health care to cover a sector of the community and replacing the present fixed contribution of 50p. We all realise that the present limit of £3,000 is inadequate. We are all in agreement on that but it is a matter of trying to devise, formulate and cost-out a more efficient system. It is more important to be able to operate a higher level of efficiency within the health services and not merely throw out figures and limits merely for the sake of political gain.
It was very interesting to hear the Minister in his speech last evening trace the history of the limit of eligibility from £600 in 1953 to £3,000 in 1976. I was prompted to make some calculations of the purchasing power of the £ in that period. For instance, the purchasing power of the £ in 1953 compared with 1978 represents £5, or five times the amount. Yet in medical terms that is not a realistic assesment at all because medicines, patient requirements, the complexity of the health services, cost of hospitalisation and so on have become far more sophisticated and complex. Indeed the demands on doctors and so on are more immense. Let us say that £1 in 1953 would have purchased an enormous amount of medical aid compared with, say, £5 in 1978. The Minister's approach of trying to relate the amount of contribution to what a person earns is a sensible and constructive one. In passing it is my belief that private medicine and health care should work in harmony with the health services; both must be dove-tailed and operate complementary to each other. There is a place for both services. If you like, there must be the competitive element interacting between the health services and private medicine. It is strictly in the interests of the patient to maintain the highest possible standard of health care.
At this juncture it is important to take a look at the entire percentage of persons covered under the various health services. We have, say, 38 per cent covered by medical cards; 45 per cent would be covered under the limit of £3,000 we are now debating and the remaining 15 to 20 per cent would have no cover themselves at all but could attain cover through the voluntary health insurance scheme or any other private insurance cover available. It is my belief that a free-for-all hospital service would not necessarily lead to efficiency in the running of hospitals. Anyone familiar with the waiting lists in hospitals and the pressures that are occurring would quickly realise that just by extending overnight, as was suggested earlier, the entire service would in no way lead to a more comprehensive or efficient service from the patients' point of view. And this is all that matters. The service in the UK leaves a great deal to be desired from the point of view of the level of efficiency operating in the national health service there.
We have an excellent, harmonious relationship between doctors working in private practice and specialists as well and, indeed, in our public health care also. What is needed here is the highest level of efficiency, constantly monitored by the Department of Health. This particular area of the £3,000 limit is one area being closely scrutinised by the Minister at the moment. The complexity of eligibility also arises. It is not clearly understood by many what they are eligible for. Many people feel when they attain a certain standard of earnings—£3,000 in this case—they cease to have any cover. It may not be widely understood, but it is a fact, that people have this cushioning or buffer period of two years extra cover. It is a carry-over period which protects them. Many people do not realise that. I would suggest that it might be a constructive exercise if the Minister were to mount some publicity campaign informing workers they are entitled to this carry-over period. It is something that is not clearly understood. I know literature has been put out and the book produced by the Department of Social Welfare is excellent. However, a quick reminder to people moving out of the £3,000 upper limit that they are entitled to an extra two years carry-over period would be a good idea. I have run into many cases where people were pleasantly surprised to learn their benefits continued on.
We are talking here about 1.3 million people or roughly 45 per cent of the population covered by this scheme. As I and previous speakers have said, we are unhappy about the level. It is not in present money terms in line with what we would all like it to be. However, let us take the years between 1973 and 1976 during which we had an accumulated inflation of nearly 86 per cent. In the early part of last year inflation was running at close to 18 or 19 per cent. This meant that 100 per cent inflation had occurred in four years. The limit was set in 1974 at £2,250. In 1976 it was increased to £3,000. That rate of increase is slightly less than 30 per cent. Yet, in that space of time, the accumulated inflation rate was running at nearly 60 per cent. There is really no gain, therefore, in finger pointing and saying that the level is now totally out of place. We all realise that. We all realise a more efficient system is needed instead of just striking upper limits of eligibility. It would be more prudent to wait until next year when a new set of levels will prevail, a new pay related structure for health contributions. It would be imprudent to tamper with the present highly complex system. The gain would be minimal and perhaps cause more confusion in an already confused situation.
Where health is concerned rigid income levels of eligibility are not always the answer. Hardship cases are accommodated under the health services. This is a good thing. I would prefer to see a sliding scale of benefit and contribution. Health is not just a black and white issue in which you can fix a certain level. This is what was done in the past. There are many shades of grey and there is a big area for examination here. I have every confidence that the Minister and his Department are actively engaged in endeavouring to structure out the best formula whereby persons who fall into this category will benefit to the maximum degree.
Here, perhaps, we should take a look at the highly efficient working of the Voluntary Health Insurance Board. Maybe there is some area here that could be copied by the Department of Health. Perhaps it would be possible to allow workers to invest in whatever scale of eligibility they want with, of course, a minimum level. Maybe it would be possible to give them the option of buying extra benefit, if they wish to do so, provided they invest through their employment structure in a minimum level and their employers are given the option of investing more to give their employees that extra benefit if they desire it.
The Voluntary Health Insurance Board is an excellent body. It has served the community in a very desirable manner since its inception. Perhaps there is a case to examine the giving of a flexible system of coverage to workers. Everyone realises that people are at their most vulnerable when they are ill in hospital. They certainly do not want to be burdened by large hospital bills, by worry and the anxiety of trying to cost out of their budget how they will meet these bills. The Minister is aware of this. He has made many statements to the effect that he is engaged in a very critical overhaul and examination of the level of cover that people can be given within the health services. But money cannot just be printed and lashed out just for the sake of doing something. It does not follow that by providing money you will solve a problem. You have to get to the root cause of the problem and correct it at the root and then by all means spend the extra money.
The Minister has made it clear that he is not satisfied with the criteria of eligibility. Over the years anomalies have developed in the system, the principal one being the distinction between manual and non-manual workers. It is all very well to say in 1978 that there should be no distinction between manual and non-manual workers, but this is discrimination and so on. But 20 years ago, or less, manual workers had to be protected within the health service. This is a carry-over from that time. The Minister is aware of this. Perhaps it is an unfortunate distinction that has been made through the years; nobody likes it but there was a time when it had to be made. We might be excused for saying now that it is a reflection of the advantages gained by manual workers in rates of pay and conditions generally. This is a good thing but we must approach it constructively and not try to be divisive or create an attitude which does not necessarily exist among workers. There were days when manual workers were badly paid and had poor security and were not getting a fair share of the cake. This is why the distinction was made.
It is unfortunate that it has given rise to an anomaly in eligibility for health services but seeing it in the broader context it could be regarded as the price of progress and a very good thing in a sense. Perhaps the Minister could consider the advisability of a survey to try to quantify the percentage of manual and non-manual workers, possibly through the Revenue. If that information could be gathered it would be invaluable to his Department.
The rate of inflation over the past few years has resulted in money losing value. The rules of limited eligibility are such that they provide protection against large-scale loss of eligibility in times of declining money value. The Minister has made a clear statement and because of its importance and the misunderstanding that seems to have persisted in this debate it is necessary to underline it. All insured workers who were eligible because their earnings came within the £3,000 limit when it was introduced in July 1976 are still eligible and will retain eligibility at least until the beginning of 1979. It does not matter what was the source of the increase in their income. That is a factual statement of the position. This might be criticised in the system of limited eligibility. For example, if through some good fortune a worker whose pay is within the limit receives a massive increase in pay which puts him into the wealthy class, he retains his eligibility. This carry-over period is most important.
One benefit of this carry-over entitlement period is that it gives time to study how the system operates, its defects and the changes that can be made. The Minister has assured us that this is being done. He has highlighted some of the defects and indicated his intention of remedying them so far as is reasonably possible. He has accepted that the £3,000 limit is now out of date and urgently needs review. For reasons I have given I do not feel it is absolutely necessary that this should be done immediately. Hasty action now could cause more problems in the long term. Therefore the Minister's amendment to the motion is sensible and worthy of support.
Deputy Collins last night and Deputy Desmond this evening said that the carry-over provision applies only if the increase in income is due to the national wage agreement. The Minister clarified this position briefly but it is important to refer to it again. Any worker whose pay was within the £3,000 limit in July 1976 was eligible then and retains eligibility until the beginning of 1979 irrespective of the source of the increase. Wage agreement considerations do not apply here. Even a change of employment would not matter, or if the extra money was earned from two jobs, he would still retain eligibility. The misunderstanding might have arisen due to a provision made in 1976 which related to payments under the national wage agreement. Under that specific provision a person whose remuneration went from less than £2,250 to more than £3,000 between April 1974 and July 1976 by virtue of pay awards under the national wage agreement was allowed to retain eligibility for one year in addition to the normal carry-over entitlement period. That provision was designed to meet a special situation which obtained then and affected only a limited number of people and was of limited duration. It did not affect the normal carry-over period. This may have caused the confusion. The carry-over period protects workers for its duration and this is the important point.
Deputy O'Connell produced estimates of what it would cost to extend free hospital service to the entire community. He estimated it would cost £12.5 million. I do not think that takes into account the cost of hospital maintenance for persons who are now ineligible. It is costed only for those who are eligible.
