On a point of order, a Cheann Comhairle, can you clarify whether it is intended to conclude all Stages of this Bill at 10.30 p.m.?
Financial Resolutions, 1987. - Health (Amendment) Bill, 1987: Second and Subsequent Stages.
That is the position. That was the order arrived at this morning.
I move: "That the Bill be now read a Second Time."
This Bill provides for the amendment of section 56 of the Health Act, 1970 to enable the Minister for Health, with the consent of the Minister for Finance, to impose charges in respect of out-patient services as defined in the 1970 Act.
Before going into the details of this short Bill, I would like, first to state why in my view and in the view of the Government such charges should be imposed. The Members of this House, like the population at large, are more than well aware of the economic restrictions that now face us and the need to prune our expectations in line with what is economically attainable. The figures show that the cost of providing health services over the last number of years has increased quite dramatically. Three or four years ago, it became equally clear that the level of resource available to public services generally and specifically to the health services had to be limited and within that limitation it would be necessary to determine priorities to fund the services within the resources approved. This in general terms was not done. Substantial overruns amounting to £55 million at year end 1986 were incurred and nothing was done by the previous Government to deal with the situation. This has exacerbated an already difficult situation. That leaves us having to fund the health services with that millstone of £55 million around our necks.
There is no getting away from the fact that the resources available for the health sector for the forseeable future will continue to be limited. It is no good pretending or believing there is some untapped source that will release funding into the health services at the level of a decade ago. That is not going to happen. Therefore, in these circumstances the question is, how can the basic components of the health services be kept intact and at the same time live within the funding available?
This country over the last 20 years or more has been blessed with a standard of health care, by and large comparable with the rest of the western European countries. The rate of development, the extent of the services, the range of availability has been quite staggering. Of course, it would be highly desirable that the services in their range and comprehensiveness should continue with the same momentum but this is just not possible.
Like most other European countries we have been hit by an economic recession of major proportions aggravated by the claimant demands for ever-increasing high technology resource and services. No more than even a wealthier European country we cannot meet such demand. This is not a question of ideology or political philosophy. This is a question of fact and how we recover from this recession without permanent damage to the basic infrastructure of our society and services is the essential issue at the moment.
As far as health services are concerned, as I have said it is vital that in this difficult period we ensure that the crucial fabric is preserved. The options open to us, it must be admitted, are difficult. The two basic options are that across the board we slash services indiscriminately or we try to maintain essential services to the most needy and require those who can make an additional contribution to do so. I have no doubt that the latter is the correct course to follow. This is the basis of the Bill before the House. The Bill seeks to impose on certain categories of people a charge for the provision of out-patient services. In line with Government policy, the most vulnerable in society will be exempted from the charges. These are, those who are medical card holders and their dependants, all children who suffer from diseases and disabilities of a permanent or long-term nature and children who require attendance on an out-patient basis in respect of defects which have been noticed at a health examination provided in accordance with the Health Act. They will be the school medical examinations and those held at child welfare clinics.
These exemptions, as the House will see, are provided for in this Bill. In addition, the regulations which are provided for under the Bill will exclude from charges all women in respect of motherhood and infants up to the age of six weeks as already provided for under the 1970 Act. Also persons receiving services for the diagnosis or treatment of certain infectious diseases prescribed under the Health Act, 1947 will be exempted. Finally, the chief executive officers of the health boards will have the normal discretion which is built into the Health Act to exempt people not included in the list of exemptions I have already mentioned, where there would be an obvious case of hardship if the charges were imposed. That is an important provision because people may be worried that they will not be able to meet the demand. In cases of hardship CEOs have permission to waive the out-patient charge.
Therefore, the purpose of the Bill is to require that those people who can afford to pay for out-patient services, and only those people, should be obliged to contribute to maintaining the structures of the health services rather than simply allow those structures to be futher undermined and possibly permanently damaged.
It is intended to provided by regulations for a £10 charge for out-patient services but only in respect of the first visit arising in respect of a particular condition. In other words, return visits in respect of that condition will not be liable for the charge. A charge of £10 will also be made in respect of attendance at casualty departments. Virtually everybody with a reasonable knowledge of casualty departments agrees there is considerable misuse of these services. People attend for conditions or with symptoms which could not be described as accident and emergency. A very considerable number of attendances at casualty departments of hospitals are for conditions which could just as appropriately be provided by a general practitioner.
There are, I know many reasons people seek such care at casualty departments particularly in urban areas. Convenience, a comprehensive 24 hour, seven day a week service are major factors. Another factor is that the service is provided free of charge. Is it in the present circumstances unreasonable that people who would be liable for the payment of general practitioners if attending at their surgeries, can receive a like service free of charge in a casualty department which is an expensive location for treating conditions which could be equally well treated in the community? Therefore, a charge of £10 will be imposed with, of course, the exemptions I have already mentioned also applying.
In a situation where it is clear that no additional funding can be expected to come from Exchequer sources, the input of moneys raised through charges on those who could be expected to afford them or to be in a position to insure themselves against them is, I believe, justified.
While not arising from the provisions of the Bill, I should like to take the opportunity of informing the House that I also intend introducing a daily charge for hospital in-patient care. The appropriate regulations in this regard will be made under existing legislation and will provide for a charge of £10 per day subject to a maximum of £100 in any 12 month period. This charge is in respect of the patient's maintenance in hospital. Exemptions, which I mentioned in respect of out-patient charges will also apply in the case of in-patient charges — that is medical card holders and their dependants, maternity patients, certain categories of children, people receiving treatment for infectious diseases. There will also be the hardship clause I referred to in regard to out-patient charges.
The Voluntary Health Insurance Board have been asked to prepare appropriate insurance coverage for the out-patient and in-patient charges which I have outlined this evening with a view to providing cover for those likely to be affected by the charges and to coincide with their introduction. The charges will be introduced when the VHI scheme is available which I hope will be within the next six weeks. I envisage that such schemes will be in place very soon and will be quite attractively priced.
I firmly suggest that the charges I now propose with the exemptions I have outlined are infinitely preferable to charges proposed by the previous Government involving in particular charges for prescriptions for medical card holders, the most vulnerable section of our society. The previous Government intended it to raise £16 million by way of charges to medical card holders on the basis of £1 per item on a prescription up to a limit of £5 per month. If a patient needed ten items that person would have to pay £10 per month. Medical card holders, those on the lowest income in the country, would have to pay that amount of money and, having paid it, could apply to the health boards for a refund of £5 but they would have to wait some time for a refund. We decided we could not impose the penal charges proposed by the previous Government. We also decided to restore the rural dispensing scheme under which doctors in rural areas dispensed the drugs for their patients. The proposal to abolish that scheme was heartless and would have caused undue hardship for many people living in remote rural areas.
Over the last while, there has been considerable discussion about the future directions of the health services. There is virtually universal agreement that in the future the emphasis in health care must be on primary health care especially on disease and illness prevention and health promotion and this is part of the Government's policy. I am absolutely at one with this approach. The large specialised high-technology hospital can no longer be seen as the focus of a health care service. Deputies will be aware that a few months ago, a major document called Health — The Wider Dimensions was published which set down in a broad context the main issues in health and pointed to a framework within which services should be provided in the future. I look forward with considerable interest to the responses to the document which are now being made by a wide range of bodies and organisations. I would hope that through this consultative process and further discussion, a broad health policy can be agreed within which we can then proceed to develop and refine the specific elements of that policy with emphasis on the prevention of illness and health promotion. I believe that it is only by this collaborative approach can real change be brought about and the necessary reorientation of perceptions and approach achieved.
Even though we are going through a period which is very difficult financially this should not cause us to lose sight of the many useful things that can now be done without necessarily adding to expenditure.
For example, in the psychiatric service, the changes which are needed in the service have been clearly spelled out. These changes can bring considerable improvements both to the standard of service which is available to the general community and to the quality of life of the many persons who are now resident in our psychiatric hospitals.
The health boards have been very actively involved in drawing up plans and in starting to bring about change. The advisory services of my Department have been strengthened and officers of the Department have begun working in close association with health board teams in selecting changes which are necessary and practicable. I am very pleased with the progress being made by these teams and I am satisfied that they have considerable potential for bringing our psychiatric service up to an acceptable level.
I hope to be able to announce shortly the establishment of an advisory group which will include a representative of the chief executive officers. This group will monitor changes in the psychiatric service and advise my Department on required action.
In the field of mental handicap, the advisory service of my Department has also been strengthened recently. As a result, the Department are becoming more actively involved in guiding changes to a more community-based service in line with modern thinking on the type of service which will be of greatest benefit to mentally handicapped persons and to their families. The mental handicap service is at present being reviewed by my Department in association with the health boards and the voluntary agencies providing the service, with a view to drawing up more definite guidelines on the type of service we are aiming for.
The changes which are required in the psychiatric and mental handicap services do require some capital investment but they do not necessarily add to overall revenue expenditure. We should not lose the opportunity which we now have to improve the quality of these services. This is an area to which some urgency should now be applied. It is inevitable that central to this kind of fundamental rethinking of what should be expected of our health service will be the resources that can realistically be expected over the next few years. It is equally inevitable that those resources will continue to be restricted. I have already indicated that the raising of moneys through the levying of charges on those able to pay is a justifiable approach to take. However, I believe that a more comprehensive assessment of how the health service might be funded is essential. Already I have initiated a study within my Department on the options and alternatives for funding. I expect to receive an interim report on the matter within the next five or six weeks, together with recommendations as to how we should proceed further. Without attempting to prejudice the outcome of this study, I would expect that there would be a particular assessment of the role of insurance systems, especially the role of the Voluntary Health Insurance Board. Since its establishment the VHI has served the country well in providing health insurance for those not otherwise covered by the State-funded services.
Circumstances quite clearly have changed dramatically since its establishment, particularly the significant extension of publicly funded services made available to the whole population. A comprehensive assessment of the role of the VHI has been going on for some time with the co-operation of the board and I look forward to the outcome.
The health services are facing a difficult period. It is consequently incumbent on all to appreciate fully this situation and realise the implications. It means that many ambitions and expectations cannot be met and that the priorities for the country must be identified and agreed. Within the health services my main priority will be to maintain the essential infrastructure of the service and to protect those most in need and at risk. To do this requires the co-operation of all concerned — those managing the services, those providing them and those receiving them. In an effort to achieve this co-operation, I will be commencing tomorrow by meeting with the chairmen and the chief executive officers of the health boards. Clearly there is a difficult time ahead for all health agencies. But I would expect that there be a full appreciation of the seriousness of the situation and that the measures required to maintain essential services will be put in train without delay and with a full concentration of management resources.
Before concluding there is one problem I am satisfied that I will have to tackle as a matter of urgency. During the past three weeks my Cabinet colleagues and I have been preoccupied with the preparation of the budget and I now intend to concentrate on the preparation of an AIDS information programme. In addition I intend to develop further support information and counselling services with the co-operation of the health boards throughout the country. The Dáil will be aware of the fact that since the first case was diagnosed in 1982 there have been 18 cases in all diagnosed, but eight of these cases have occurred in the last nine months.
The Dáil has already been informed of the measures taken by my Department to control the spread of AIDS through blood and blood products, and HIV antibody testing service is now available throughout the country, that the Eastern Health Board held three seminars on AIDS for selected staff from all health boards and that the Health Education Bureau ran a seminar for doctors more recently. The spread of infection continues to be monitored through the AIDS reporting system and from the virus reference laboratory reports on the total number of positive HIV antibody tests.
I intend to build on these developments and in addition to concentrate upon the improvement of the sexually transmitted diseases clinics.
I recommend the Bill to the House.
This week's budget proposals represent one of the most savage attacks on the health services by any Government since the foundation of the State. This Government will go down in history as the first to cut the allocation to the Department of Health. The reduction in the overall health allocation, coupled with a total embargo on recruitment, has dealt a serious body blow to the health service. The allocation has been reduced by £8.6 million, made up of £3.5 million on the capital programme and £5 million on non-capital expenditure. The embargo is biting deeper than our proposals anticipated. Our three-in-one embargo was estimated to yield a saving of £3.4 million, but this Government's embargo is to yield a saving of £14.4 million.
The public health charge of £10 per day for non-medical card patients in public wards, together with out-patients' charges, are a savage attack on the most vulnerable sector of the community. The public ward charges affect people who are most vulnerable, those without a medical card and those who cannot afford VHI cover. The typical people who will be affected are local authority workers, general operatives in the health services and other persons on minimum wages. It is tragic that the Minister has decided to impose extra charges to fund the health services rather than attacking the many inefficiencies and defects in the services themselves. The Minister cannot justify the charges by the introduction of a hardship clause, as he has tried to do tonight.
The budget has been a savage attack on families who are most vulnerable. Let us look at a family with a mortgage who are affected by the new hospital charges. If they do not have VHI already they will be forced into joining a scheme which, from the figures I got today, will cost a minimum of £100 per annum. The reduction of mortgage interest relief could cost up to £200 per annum and the extra one-quarter per cent health contribution, which we dealt with earlier will amount to an increase of £43 per annum. The increase in the ceiling will cost that family a further £150 per annum. As a result of these proposals the family could find themselves facing an extra bill of £10 per week.
The introduction of public ward charges is designed to bring in £6 million this year but it is anti-social and shortsighted. The previous Government proposed certain prescription charges estimated to save £13.5 million. The Minister knows that £3.5 million of that was coming from the charges themselves and the remainder from a cutback in the use of drugs and visits to doctors for prescriptions. That was a far-seeing proposal because we all know that every house has an excess of drugs in its cupboards. It was designed to cut back on the over-use of drugs, with which the Minister could not argue. The announcement in the budget is an attack on sick people and many families will now be unable to afford to be ill.
We abstained on the vote regarding increases in health contributions but I am now giving a firm indication that when proposals come before the House to introduce charges for in-patients we will be opposing them. I am clearly signalling my party's intention to vote against such regulations. Fianna Fáil went into an election with a slogan that they were defending the sick, the handicapped and the elderly but this budget has done quite the opposite. The Social Welfare Bill was published today but the promise of social welfare payments from 1 July is a hollow one when we see that it will be 24 July before they are implemented, almost a full month after the date set by the Government. It is another con job.
Public health expenditure for 1987 will be over £1,100 million. This spending is divided into six separate health programmes including the community protection programme, under which approximately £22 million will be spent on health education, food hygiene inspections and prevention of infectious diseases. The other programmes are the community health service and the community welfare service. The community health service have a budget of almost £176 million and the community welfare service have a budget of approximately £106 million. The psychiatric services have a budget of £176 million, services for the handicapped amount to £136 million and the general hospitals services spend over £700 million, that is, the service with which we are dealing tonight. It is obvious from these figures that over half of the money for the public health programme is spent on hospital services. In other words, the general hospital service absorbs the largest proportion of the total health budget and we must ask ourselves if we are getting value for money. We should be looking at that area instead of imposing extra charges. If the Minister did nothing else over the next couple of months he should examine value for money in the health service.
We should examine in detail the performance of the general hospital services programme before any extra charges are imposed on the public. The sum of £1,100 million which is spent on health is paid for by the public and it would now seem that we are once again asking the public to put their hands in their pocket to fund the hospital services programme. There is a grave responsibility on everybody here to ensure that value for money is obtained on behalf of the general public. We should examine the programme in detail and eliminate inefficiencies and wastage in all areas.
One of the main areas where substantial savings could be made is in the capital programme in which there is a substantial cut this year. My own experience in the health area to date has been very limited but I did have a brief opportunity to study a number of areas in relation to health through my membership of the Committee on Public Expenditure. During my time on that committee we examined two specific instances of cost overruns relating to the development of Tralee and Beaumont hospitals. During the period we investigated the cost overruns, the committee heard suggestions about the abuse of tender procedures in relation to some of the sub-contracts. It was found that substantial additional works were added to the original brief after the contract stage. This was in direct contravention of the regulations set out for capital projects by the Department of Health and the Department of Finance. Costs for these additional works amounted to close on £2 million. In that project, the final cost was originally budgeted for £7.6 million but Tralee hospital cost over £25 million. The Department argued that the original budget was too low and maintained that the final cost was still reasonable in relation to the cost per hospital bed. However, the fact remains that the approval was originally given on the basis of the budgeted amount and the final cost was an entirely different amount. The episode in regard to Tralee hospital indicates that there is very poor public expenditure control and management and it highlights the potential abuse of budget approval procedures.
In the case of Beaumont hospital, the original tender was £16.77 million based on a measurement contract but this figure was exceeded by £6.4 million. My impression of that project was that it was rushed through using the plans for Cork hospital as a basis for tenders and making design adjustments as construction proceeded. Again, this was in direct conflict with the procedures laid down by the Department of Health hospital planning office and was definitely not prudent capital project management.
Substantial savings could be made in these areas by eliminating deficiencies in the overall management and control of the capital project and the two examples I gave justify that statement. An in-depth analysis must be carried out as to why the running costs of a hospital on an annual basis is now coming close to half its total capital cost. Investigations must take place in relation to the system of heating, cleaning and maintenance of hospitals. Priority must be given to reducing running and maintenance costs at design and subsequent stages.
During my time on the Committee on Public Expenditure, I learned that the planning office of the Department of Health is adequate but that the management and boards of the voluntary hospitals and health boards were the clients in almost all hospital building projects. They can and do make decisions which dramatically affect the cost of hospital building programmes. These changes ultimately are charged to the Department of Health and, of course, eventually are paid for by the taxpayer. There must be tighter management control of all new capital projects in order to eliminate wastage and to reduce overspending. There is need for a clear development plan for the health services and each year's capital allocation should be part of a planned development. This development plan must take into consideration the existing private health facilities as part of the national network. We must avoid duplication at all times. Now is the time for a clearly set out development plan for the health services for the next decade indicating the total capital cost in today's terms. We must ensure that the existing hospital services are made more effective and that the health service as a whole becomes much more community centred. I go along with Deputy Higgins' contribution earlier tonight that we are long overdue a comprehensive plan for the health services.
I could talk at length about the cost of catering and housekeeping in our health services and hospitals——
I am afraid you could not.
I think I could just——
There is a tradition that a certain latitude is given to a spokesman ordinarily, but bearing in mind the constraints of time that exist this evening and——
This is Second Stage.
——the time limits, everything must be finished by 10.30 p.m. I am just advising you on this. There are other people present who wish to contribute. I hope that you will not go into matters of great detail or administration, all of which can be raised ordinarily on an Estimate.
If he told us whether he was supporting the charges it would be of considerable help.
I said it already.
I am sorry to interrupt you, but all stages must be completed by 10.30 p.m.
I would like to refer to the computerisation programme. The strengthening of the embargo will affect seriously the computerisation programme within the health service which has been developed to bring about more efficiency in that service. I would like the Minister to take that into consideration.
I would like to deal in detail with the question of the consultants and their role within the health services. It is very relevant and I will be surprised if you do not leave me some latitude in this.
The Deputy will appreciate that it is not relevant at all, and except, as I said, in so far as traditionally latitude has been given to the spokesperson, I remind you that there are representatives of three other parties all of whom I presume are anxious to make a contribution and if we allow you to stray too far, then apart from the fact that it is not entirely correct, you are preventing other people who might have a direct comment to make on what is before us. Therefore, I ask you not to stray too far.
I got to my feet at 7.30 p.m. and with three or four interruptions from you. I have been on my feet for 20 minutes. The Minister introduced the in-patient charges which are not relevant and I am making the point now that instead of imposing charges we should be looking at savings. I am putting that argument forward and I think I am quite justified in doing so.
You are not, but we will tolerate a little more of it.
I would like to mention the terms of employment of medical consultants in the health sector which were referred to earlier by Deputy Higgins. The annual payroll cost to the Exchequer of the employment of these consultants is about £40 million. My worry is that the terms of employment in relation to these consultants reduce the Department's ability to run the hospital system efficiently. It is costing over £700 million. The other major question is whether the terms of the contract give the consultants an incentive to develop — or overdevelop in many cases — private practice which in turn affects the quality of service for the public health patients and puts pressure on these patients to seek extra treatment through the private health care system. My opinion is that the common contract is a disaster. It does not pinpoint clearly the real role and the responsibility of consultants. It excludes specifically monitoring of the private practice arrangements which occur in our hospitals and which are funded by moneys from the taxpayer. The contract and the rules of eligibility for patient care provide an incentive for the use of hospital facilities by the consultants and the development of private consultant practice and as a result have put a heavy financial burden on the State.
There was a recommendation from the working party who set up the terms of this contract that the contract be reviewed completely after five years. This review was due last year but to date no review has taken place.
Who was in Government last year?
It did not take place, it is relevant now and I ask the Minister to give some indication as to whether he would enter into negotiations with the IMO immediately on this issue. As I am sure Deputy Desmond will confirm later, attempts were made by us to enter into negotiation but the IMO resisted. I am asking now that the Minister pursue the matter with all the power he has.
In deference to you, a Leas-Cheann Comhairle, I will shorten my remarks. The most serious point of contention is the consultants' unrestricted right to practice. The common contract provides the consultant with the unrestricted right to develop a service of private practice. There is a potential conflict of interest for consultants in relation to admissions to hospital in accordance with medical needs and patients eligible for public health service require to go private as a result. The use of public facilities by consultants for the purpose of private practice can be seriously abused and the greater potential earnings from private practice can divert the time of the consultant from public commitments. That is taking place. This week during the radiographers' strike certain serious allegations were made to me, but in the sensitive time that we are going through now that can be left for another day.
The consultants must be brought into line with the arrangements operating in Britain. In the British system consultants are obliged to submit certified audited accounts of their earnings and they are restricted to earning 10 per cent of the public income. Even the most conservative estimates in this country would put the consultants' earnings from private practice at least at ten times that. Unfortunately, there is no arrangement to monitor the level of private practice consultants in our hospitals and there is a grave possibility of conflict of interest. There is an urgent need at the moment for a strategic plan for hospital services and overall health care. The FitzGerald report of 1968 outlined a radical plan for hospital reorganisation and the plan of 1975 set up various proposals which were derived from that report. It is vital that such a plan be developed immediately to ensure that public expenditure is controlled in an organised manner. I ask the Minister to indicate tonight whether such a plan is in the pipeline or if he has any views on the matter.
Prevention is cheaper than cure and I ask the Minister to take a greater initiative in relation to disease prevention and to step up his programmes in relation to the abuse of alcohol and the abuse of diet.
I will finish in this limited debate by asking the Minister to let us have a comprehensive policy paper on the health services at the earliest possible opportunity. Only through a planned approach to the health service can we alleviate and possibly overcome the problems that affect us all.
Is the Deputy supporting the £10,000 charge?
If the Deputy was here at the start he would have heard me tell him that.
You are supporting it?
We are opposing the introduction of in-patient charges because we feel they are totally unnecessary and I hope other parties will do likewise.
The Bill is not about in-patient charges; it is about out-patient charges.
Ba mhaith liom, ar dtús, comhghairdeas a dhéanamh leis an Aire as ucht an post Rialtais atá bainte amach aige. Tá súil agam go mbainfidh sé tairbhe as agus go dtiocfaidh feabhas ar an gcóras sláinte fhad is a bhíonn sé sa phost sin.
I have no intention of making an Estimate type of speech as Deputy Allen did earlier. I merely want to deal with the specific that is contained in the Bill before the House. That is, as the Minister stated, to introduce legislation to provide that by regulation a charge for out-patient services can be made. In the Minister's speech he indicated some of the contents of the proposed regulation. He stated that the charge he proposes to introduce by regulation is one of £10 for the first visit arising out of a particular condition. All we have at this stage is the Minister's statement of intent. We do not have the regulation under which the Minister will do this.
The Progressive Democrats support the principle that those who can afford to pay should be asked to do so. That is just a broad statement of principle. It in no way implies general agreement with everything the Government might propose in the line of introducing charges for any particular service, in this case a health service. We will at all times retain the right to examine very carefully what is contained in the regulation and to adjudicate in each individual case as to whether we felt it would operate fairly and that it would not have any injustices built into it. We are not absolutely happy with the Bill as presented. The level of charges which the Minister is speaking about may in some cases be reasonable but in other cases it may not be reasonable. He stated that the chief executive officers of the health boards will have the right to exercise their discretion in cases of hardship. We have not seen the regulations under which that would operate.
We will propose an amendment to the Health (Amendment) Bill, 1987, which is before us when we come to Committee Stage. Because of the short period available for this debate I want to indicate to the Minister at this stage what the main intent of our amendment will be. It states:
In page 3, between lines 8 and 9, to insert the following:
(d) Every regulation made by the Minister under this section or under section 53 of this Act shall be laid before the Dáil as soon as may be after it is made, but, unless within the next subsequent 21 days on which the Dáil has set after the regulation is laid before it, a resolution confirming the regulation has been passed by the Dáil, the regulation shall stand annulled but without prejudice to the validity of anything done thereunder.
We are very anxious that the Minister accept that amendment. We recognise that under the Health Act there is a provision whereby any regulation made by the Minister to introduce these charges could be challenged by a Member of the House but if that Member of the House is in the Opposition benches his opportunity to do so is very restricted. In a major change in health policy the House should have full opportunity to discuss the content of the regulation which is introducing the new change. The only satisfactory way in which the House can have that opportunity is under the proposed amendment from my party. I ask the Minister to indicate at an early stage whether he will accept this amendment which places the onus upon him to bring the regulation to the House and requires the House to debate it and to decide whether it is for or against the proposed regulation. Only in that way can the House satisfactorily express its wishes in regard to the content of whatever regulation the Minister makes.
I am a long time in the House and I have heard sincere Ministers state that such-and-such shall only happen if you accept this Bill. The Minister will recognise that experience has shown that either Ministers at a later date change their minds or their successors avail of legislation. If this Bill goes through in the form it is in, he, at a later stage, or some other person as Minister could introduce draconian charges for in-patient and out-patient services — my amendment covers both. It would be entirely unsatisfactory if the House did not have an opportunity to debate it fully and decide whether it supported it and gave its authority to the introduction of the health regulations. As the House has made an agreement that this Bill shall pass at 10.30 p.m. and that the only amendment to be accepted is an amendment from the Minister, I recognise that by indicating now the type of amendment we want it will be necessary for the Minister to indicate whether or not he will accept the amendment and put his name to it. I can assure him that if we get that indication from him we will then be in a position to support the Bill. I make that very clear to him and ask him to be specific on that issue in his reply.
It was indicated that only amendments from the Minister could be accepted, that was providing for a situation where there would not be any other amendments, but now that we have other amendments that falls.
If we get the opportunity we will put that amendment to the House. There is also the difficulty of the time limit which means that we may not reach Committee Stage at all depending on how many more speakers wish to contribute. I do not want to use up too much time and deprive others from contributing. Having reserved our position on what the proposed regulations might be and wishing to have an opportunity to debate the regulation at a later stage when we see its full content, in principle we have no objection to the idea of charges. We are not indicating that we will support charges in all cases. They would have to be examined very carefully.
In this instance where the Minister is taking upon himself the authority to impose a charge for out-patient care we are very concerned at the practicalities of this and with how it will work. I understand there have been previous attempts to apply charges for medical services in out-patient departments and casualty departments and these have not been successful. The charge has been uncollectable. It would be remiss of the House to introduce legislation which would bring the House into disrepute in introducing some form of charge which experience had shown previously was impossible to enforce. On behalf of my party I ask the Minister tonight to spell out in great detail how exactly these charges are to operate. The Minister for Finance informed the House yesterday of a very strict embargo on staff employment. It is clear that there will be no new staff allowed to administer these charges. We are quite well aware, from contacts with those in the medical profession, and from previous experience, that they have refused to handle cash at out-patient and casualty departments. If the medical or paramedical staff are not prepared to collect the money and issue the receipts it falls to the administrative staff of the health boards to do so but they are not being allowed any additional staff. It is difficult to see how the Minister will staff this system, bearing in mind that these departments operate on a 24 hour a day basis.
Has any estimate been made by the Department of the cost of administering the collection of this £10 charge for the first visit or, indeed, of the £10 charge per day if one is unfortunate enough to be admitted to a hospital? Where will the staff come from? According to yesterday's statement no new recruitment will be allowed. We know how pressed the health services are at present. It would be helpful if the Minister could give some indication of how the staff were appointed on the previous occasion to collect the lesser charge. People coming into a casualty department are not thinking of having to pay for the service. Many come in in an emergency capacity and do not have the cash on them at the time. Many do not carry their medical cards when they arrive at the out-patients' department. How will the staff establish whether a person is a medical card holder?
If the person cannot pay at that point, will bills be sent, at 28p a stamp? We know that in the past health boards issued letter after letter demanding payment of small amounts of money which were never paid. Unpaid small bills were then sent to solicitors who sought to collect them and charged their own 10 per cent collection fee and we had a whole new bureaucracy with expense being added to the system, to collect a very small sum of money. One rightly must put the question — is the Minister really satisfied that the introduction of this charge will prove beneficial to the health services, will bring in a substantial sum of money? Can he give an assurance that he is not creating another expensive bureaucracy which will use up most of the resources he hopes to obtain from the introduction of such a charge? How are the staff at the outpatients' departments expected to establish liability? People can give false medical card numbers, false names and false addresses. The staff in the health boards in the different regions have not taken very kindly to this form of charge in the past. Can the Minister confirm that he is satisfied that what he is proposing now will be viable and workable?
My amendment refers to the in-patient charges also. The Minister has indicated that under section 53 of the Act he can apply in-patient charges merely by introducing a regulation which we say should be presented by him to the Dáil for ratification. He says the charge of £10 per day will go only to a maximum of £100 per annum — I do not know if that refers to the individual or the family. How can money be collected from somebody who just cannot afford to pay? The Minister must be well aware of families who are just short of qualifying for a medical card, or of people of very low means who, if they or a member of their family become ill and are in hospital for, say, ten days will not be able to pay the sum of £100 required. Tens of thousands of families just do not have the money to pay a charge of that kind. We would be very concerned about the application of such a charge.
We would be very reluctant to give our support to the charges at that level until we see exactly how they will be applied. Will there be a staging of the cost? What hardship clauses will apply? On the surface, as the Minister has presented it, it seems very clear that families who we recognise will just not be able to afford to do so will be expected to pay up to £100. Again, the Government are introducing a measure which will not operate. They are bringing the whole system into disrepute, going through the whole wasteful procedure of a bureaucracy trying to collect uncollectable money with all the additional cost involved in that. That raises the question as to whether the whole exercise is worth the amount of money that will be brought in.
We question the whole area of the cost of administration and of the hardship caused to families expected to pay this charge. We are not at all happy that such a charge should be introduced at such a level for people whose income is not sufficient to qualify them for a medical card, many of whom are not in a position to pay VHI. Those are the very defenceless families. Those are the PAYE people who are most vulnerable to our taxation system. They are caught into every type of tax levy and income tax system operated by the State. These people in the main are the hard core of the body of workers of this country. We wonder if the Minister is wise in the terms in which he proposes to introduce such regulations. We would reserve our position on the regulations until we see their exact content and what measures the Minister is taking to ensure that there will be no hardship and no attempt to impose a charge on families who would be in difficulty seeking to meet it.
It is a little unsatisfactory at this stage. We will not give carte blanche to a Bill which allows the Minister the freedom to make regulations which he would not be obliged to bring before this House for ratification. I hope the Minister clearly understands the position of my party in this matter and that he will indicate very clearly in his reply whether he will accept our amendments. That will very much determine our attitude to the Bill in general.
The Minister rather disingenuously stated that the introduction of the particular charges was not a question of ideology or political philosophy. That is a rather interesting statement and one I could not help recalling when I listened to Deputy Molloy and also to Deputy Allen. I would remind Deputy Allen that one of his colleagues said to me in Government that even if we had £600 million a year in oil revenue and even if there were no question of not being able to provide sufficient resources we must still have charges because that is an ideological attitude. That was said to me and I will give the name privately afterwards.
I do not think the Deputy needs to give the name.
The view is that it is good for the soul, it is good for the body politic, it is good for the patient, it is good that people should take out cash and pay at the point of usage. That is a very strong ideological viewpoint; it is a political and philosophical viewpoint as well. On the other hand, I have said to many of my colleagues that I would prefer throughout my lifetime as I earn money to pay a reasonable level of taxation. Then, using that taxation, when I need the services at the point of casualty, emergency or ill-health. I should be able to avail of those services without having to go through the trauma of having to find the money when my income is totally reduced or when my circumstances are totally changed.
Deputy Desmond is perfect, no abuses of any kind.
That is an ideological viewpoint, very ideological. In relation to the public ward charges, apparently Fine Gael are now reserving their position on the £10 charge. I know their frontbench spokesman has the problem, if you like, of reconciling a Fine Gael budget with the position of Fine Gael in Opposition but I would remind the Deputy that his party in Government proposed no less than a £20 a day charge. In fact, I can give the exact dates, 22-23 November but I do not think I can breach Cabinet confidentiality to the extent of showing the formal document to the Deputy.
The Deputy will never be there again, anyway.
Within the confines of privilege in this House — I am not quite sure what privilege it is but we all enjoy it anyway — I can say that the Fine Gael Party in Government for four years proposed year in, year out charges of £15, £20. In fact, the last supplication I had before resigning was: whether I would settle for £5. I said no, because in principle I am opposed to that kind of charge. I can assure the Deputy that it was to be £20 a day, and the yield in a full year——
Why was it not in our budget then?
Deputy Flaherty will have her opportunity.
So that we can be quite accurate on the matter, the yield in 1987 was to have been £22 million. Deputy Molloy, on the other hand, suffered a rather premature ideological schizophrenia when he came in and spoke about the charges. On the one hand while he abhors hardship, he is greatly concerned about administrative costs and he foresees all sorts of problems there. Yet, he did say that the PDs are in favour of charges——
If people can afford to pay them, why should they not?
——for people who can afford to pay them. Now I will give a classic example to Deputy Harney.
Perhaps the Deputy would do so through the Chair.
I am talking about a particular imposition. Let me take the example of a woman in Tallaght——
——or Dun Laoghaire——
——whose husband is the sole wage earner in the house and has two children and who does not qualify for a medical card. As we all know, in terms of qualification for a medical card — and I had to fight bitterly for an increase of 3 per cent on 1 January — for a husband and wife the ceiling is £98.50 and if they have two children one adds £22 or £11 per child under the age of 16. This means that to qualify for a medical card that family living in Tallaght cannot have an income of more than £120 a week.
Whether they live in Tallaght or anywhere else they should not have to pay but, if they pay £40 a year——
I will explain it to Deputy Harney. She can speak later. I will explain this dilemma of progressive democracy to the Deputy with great care.
It is Deputy Desmond who is in a dilemma.
I would ask Deputy Desmond to refrain from engaging in a tête-a-tête with Deputy Harney. Perhaps he would address the Chair when we would be able to proceed in a more orderly fashion.
I will indeed. I stand corrected. I would ask you, a Leas-Cheann Comhairle, to convey my concern to Deputy Harney. I am citing the example of a family with £120 a week, not a princely income by any manner or means, well below the general level of earnings. In the transportable goods industry the corresponding figure in respect of a male adult industrial worker is £170. But a woman with a husband and two children living in a local authority house, with an income of £120 per week and paying a local authority rent, say, £10 or £11 a week will not qualify for a medical card. Even if the husband is spending £9.50 a week on transport to and from his place of work he will not be able to claim that money as expenses in his application for a medical card. That means that that family earning £120 a week are not eligible for a medical card. But that woman may have to take a bus from Tallaght to bring her 13-year old child into, say, the Adelaide or Meath Hospital. Before doing so she must go to her general practitioner who may say her child has an acute infection requiring referral to a consultant. She pays her general practitioner £12 for that piece of medical information and she spends £3 travelling into town and back again on the bus. In addition to that, when she arrives at the Adelaide they may say: "Sorry, before we can see you or permit a non-consultant hospital doctor to see your child, you must pay £10." She may never see a consultant, they may be off engaging in private practice where they get £40 per consultation. So she pays over a minimum of £10 in the out-patients' department for her child to be further examined, probably by a non-consultant hospital doctor, constituting a total outlay of £25.
Deputies Molloy and Harney say there is no objection in principle to out-patient charges being imposed in respect of those who are able to pay. I would remind them that under these regulations that woman is deemed to be able to pay.
Deputies
There are no regulations.
I would remind those who are currently pirouetting on the tip of a PD needle that this is what we are talking about. May I point out that the only exemption given here in relation to that child from Tallaght——
If the Deputy was so concerned about Tallaght, why did he not build a hospital out there? God knows, Deputy Taylor tried hard enough.
I want to point out to the Deputy that the only exemption given in relation to children is in respect of diseases and disabilities of a permanent or long term nature, those prescribed by the Minister with the consent of the Minister for Finance — presumably those who are permanently physically and mentally handicapped. Those are the only children or people exempted. Deputies should remember that this is what we will vote on this evening so they must make up their minds——
The Deputy will be voting on our amendment this evening.
The Deputy's party amendment is a matter of conjecture because we have not yet seen the regulations. As any hireling barrister would know, one must vote on the specifics, one cannot vote on prospective exemptions that are not defined.
We are voting on the Bill this evening. The imposition of out-patient charges of this nature and in this manner, is regressive and creates grave hardship on people of very low incomes. It is repugnant to what is deemed to be a health service. It is administratively a mess just as the Health Estimate is now a mess. That is not necessarily with the contrivance of the Minister for Health, Deputy O'Hanlon, but it is with the contrivance of the outgoing Government, a contrivance which caused my resignation, and the mess remains.
(Interruptions.)
The yield from this exercise will bring into the Health Estimate this year, even in its emasculated and attenuated form, a very substantial reduction. A gross Estimate of £1,168 million has gone down £5 million since Deputy Boland was there. To the total Estimate of £1,168 million this exercise will add an additional £6 million, and we have to wait for the VHI to do all those wonderful things for all those unfortunate working class people in Tallaght who will join the VHI and will get magnificent tax relief for the exercise.
They are not working in Tallaght, because they cannot get jobs.
We will all be happy ever after as we all pay our charges. Of course, taxation must be reduced, and the only way to reduce taxation is to impose charges and the higher the charges the lower the taxation, and the rising boats will then produce employment and a very happy society, and so the simplistic ideological view begins to gel in this House. The only problem is that the three parties in Opposition are very sour because they are not in Government.
Will the Deputy's party support our amendment?
In relation to out-patient charges it is proposed to exempt those who are medical card holders and their dependants. That is certainly generous. If we decided to reverse that policy we would be universally held in contempt by all the other western European countries. Also exempted will be all children who suffer from diseases and disabilities of a permanent and a long term nature. The interesting thing about that is that if a child over six weeks of age, a healthy child gets a severe burn at home, which is a common cause of childhood emergency, before rushing him to an out-patients or casualty ward the mother or the father will have to go and find £10. That is the reality.
The only other exemption in relation to children refers to children who require attendance on an out-patient basis in respect of defects which have been noticed at a health examination provided in accordance with the Health Act. That is the old story. The Fine Gael Party will be deeply concerned to learn that it was proposed to introduce a charge of £1 in that regard as well. Without a doubt the PDs would have gone along with that. I would ask the Minister clarify that situation. There is no doubt in my mind that under the exigencies of this legislation the mother or father in the case outlined will be obliged to pay the £10. Within subsections (3) and (4) the exemptions are specified and they are only in respect of defects noticed at a health examination pursuant to section 66 which I presume is the school health examination, or a particular examination notified by a public health nurse and those who are suffering from diseases and disabilities of a permanent nature. Therefore this charge is not an out-patient charge, it is a charge in relation to out-patients and a charge in relation to accidents and emergencies. It applies across the board. There was a bit of public misunderstanding that one could differentiate between ordinary out-patient attendances and accident and emergency attendances. At least the Minister has had the political honesty and the administrative sanity to admit that it applies to the whole lot, lock, stock and barrel. I hope the people appreciate that.
I have dealt to some extent with the ideological reason given but another administrative reason is also given. The Department of Finance argued incessantly over four years that if we got people to pay £10, then instead of going to out-patients they would go to their GP's and would not be availing of consultant services. As we all know, one does not get access to consultants in an out-patient setting unless one first goes to the GP. The overwhelming majority of busy consultants will say that if one has not got a note from the GP, one should go back and get one and then make an appointment to attend out-patients. The argument used by the Department of Finance that it would force people to avail of primary care at their GP's does not stand up at all. It is an agrument which has incessantly been trotted out in favour of out-patient charges. Another argument used in relation to the casual attendance of people at casualty and emergency clinics, is that people go in because they are lonely, and they attend out-patients clinics on a weekly basis because they can meet people to whom they can talk and there is a bit of warmth and comfort and everybody likes to talk about their health. They clutter up out-patients. The easiest way to deal with that is to organise an out-patients setting effectively. Most of our hospitals do not do so. Most hospitals are badly administered. It is not the fault of the Department but the fault of the 1970 Health Act when our revered predecessor, Deputy Erskine Childers, believed that everybody would behave like gentlemen and that if one simply devolved the system down everybody would go away and do what they wanted to do and that if you gave money to the health boards the system would be well organised and everybody would work effectively. As we know life is different.
If senior consultants were available in the out-patients department and were prepared to say to people who came in that they should not be there at all, that they should see their GP and that they did not propose to treat them, there would be no problem. That requires a decision by a senior consultant but what generally happens is that a junior hospital doctor invariably decides that he will not take the responsibility and the person is subjected to at least a minimum series of tests or a multiple series of tests. Now we have a situation where there is an out-patient attendance charge for such persons. I would ask the Minister what exactly we have by definition of out-patient attendance. I presume it will include X-ray attendance. Presumably an X-ray will require a £10 fee and a lab test would presumably attract a £10 charge along with other specialised investigations. I presume those attendances at specialist out-patient clinics will automatically attract a £10 charge. People should know, they are entitled to know, and there is a great deal of confusion.
I have never opposed the idea of a non-statutory requirement. This is rigorously imposed by some hospitals. The Western Health Board and the North Western Health Board have done this. On a Sunday afternoon after a hurling or football match fellows with grazed shins and torn ligaments turn up at these hospitals at 5 o'clock in the evening having taken five or six pints and discover they cannot walk. They want to clutter up and avail of the out-patient services of an accident emergency department. They want X-rays at 10 o'clock Sunday night and all the other services. I have no hesitation in charging those people for those services. I believe this can and should be done on a non-statutory basis and the authorities should demand that people pay for dressings, stitching and so on. As I said, I have no objection to this but I do object to a larger number of people on the margin being statutorily obliged to pay for such services. It is easy to argue that their case will be decided at the discretion of the chief executive officer of the health board, but we all know how difficult it is to get an administrative decision, and by the time the unfortunate person got a reply in relation to the hardship clause and the £10 charge, he might have died or developed other conditions. It will be extremely difficult to administer this provision.
I am opposed to this proposal but I want to discuss how the system will be administered. How can we administer this system when the Minister for Finance arbitrarily decided to save a further £11 million in the Health Estimate through no recruitment? In the Principal Features of the Budget it says that vacancies will be filled by redeployment or promotion. The Estimate was then revised in terms of alleged savings up to £14,400,000. The teaching hospitals and the acute hospitals which will be concerned with the imposition of this charge will receive their allocations from the Department probably next week, but if they are told to build in new systems for the imposition of those charges, we will hear howls of derision about the massive reductions in their budgets. They will get no increase in 1987 over the 1986 figure. In other words, in real terms there will be a 3 per cent or a 4 per cent cut in their provision for 1987. I can hear the hospital staff telling the Minister to get knotted because of these out-patient charges because they do not have any staff to implement this scheme.
The new £10 in-patient charge will require a very complex administrative system because everybody going into the hospital will have to fill in a complicated application form for exemption, or payment and the patient will have to state whether he or she has a medical card, if she is pregnant, or if he or she has AIDS. No money is being provided to operate this system.
The Minister alluded to the £10 charge for in-patient services and said we would receive the appropriate regulations in due course. But he also said that medical card holders and their dependants, maternity patients and certain categories of children would be exempt. It appears from that statement that children's hospitals will be liable for the £10 in-patient charge. Will the staff of Crumlin Hospital, Temple Street Hospital and Harcourt Street Hospital oblige a parent to pay this £10 charge if they bring in a child over six weeks old suffering from a conventional condition and requiring in-patient treatment? If so, we should be told. In the original Government assessment when these charges were being computed it was felt that children up to 16 years of age should have total exemption. If they are not getting total exemption we have to know.
There would be an uproar if this charge were imposed in maternity hospitals. It would require an amendment of the 1947 Act if we were to impose this charge where infectious diseases were concerned. If we were to amend that Act I am sure Dr. Noel Browne would write a new book about it. When the regulations are published we will have a chance to put down a motion asking to have them rescinded. I presume the Minister will go ahead and introduce the £10 charge for in-patient maintenance services but we must know whether the children's hospitals and the maternity hospitals, as well as the maternity unit in the general hospitals, are exempt.
The Minister said that the Voluntary Health Insurance Board have been asked to prepare appropriate insurance cover for these out-patient and in-patient charges. It must be pointed out that only one-third of the families in the country are in the VHI scheme. There is an implicit assumption that the rest of the population are going to join the VHI. There are 350,000 subscribers to the VHI, mostly those in the upper income group — category three, those above the £15,000 limit and a substantial number of people in category two are also members. I am one of these people and I believe a number of self-employed are also covered by the VHI. I do not know how the VHI will introduce a scheme with proper departmental monitoring because at times it is very difficult to know what is going on in the VHI.
The Department will want to have an input into the VHI and ensure that where a new scheme is introduced there will be a departmental supervisory role. As a matter of public policy I appointed a senior officer from the Department of Health to the board of the VHI but, I regret to say, one of the first actions of this Taoiseach presumably — unlike the last Cabinet, I understand this Cabinet do what they are told — was to remove from office, or secure the willing resignation of, the officer concerned and replace him by the former chairman of the VHI. Once again the Department of Health are reduced to writing to the VHI for data which have to be cross-checked carefully in the Department.
I am concerned about two things. First, the VHI are to introduce new schemes. This will be an interesting exercise because we have to prevent a number of things in any new schemes being introduced. I presume the VHI will introduce new schemes, "quite attractively priced", to quote the Minister's phrase which I rather like and it is not a departmental phrase. However attractive they may be we do not want the range of total revenues to the VHI from those new coverages to result in cross-subsidisation of other schemes. We had to fight a battle with the VHI and with the private interests in Blackrock and in the Mater to prevent cross-subsidisation from the other schemes into the new D and E schemes.
I hope the Minister will examine thoroughly the proposals being brought forward by the VHI because I have no doubt they will advance all sorts of reasons why there should be a general increase in their premium rates and another increase for the new coverage they will introduce. The VHI could succeed once again in increasing substantially their reserves. They would love to start building their own hospitals and buying out their own hospitals in a country which cannot even afford to maintain its existing hospital structures, both public and private, which find themselves in great difficulty.
I welcome warmly the points in the Minister's statement with regard to the mental handicap and psychiatric services. The Department of Health, virtually on their own — that is not an unfair comment — have pioneered major innovations and radical reforms in those areas. I am glad to see that the Department have strengthened their advisory services in both the psychiatric and mental handicap areas. That is all to the good. I am very worried — and I can appreciate the enormous pressure which must have been brought to bear on the Minister for Health, having fought the battle for four years to maintain the capital programme of the Department — about the fact that it has now been reduced by £3 million. The allocation is now down to £57.56 million for 1987. That is a great disappointment to me because it impinges in particular on the development of psychiatric hospitals.
The major proposals with regard to Roscommon will have the support of the Minister of State if he is enlightened. There is nothing more enlightening than being a Minister of State in the Department of Health. One is enlightened every morning and every evening if one stays there long enough. This enlightenment can be of great benefit to the soul and of enormous benefit to Roscommon in the process. I hope that the Minister of State will fight for his allocation out of the £57 million for the development of the psychiatric services in Roscommon and that areas such as Naas will not in any way be deprived in terms of the proposed development.
I welcome the additional points made by the Minister for Health in regard to the document entitled "Health: The Wider Dimension" which was published in the run-up to the general election. Because of the run-up to the general election that document did not receive the attention of politicians which it richly deserved. I hope the Minister will provide an opportunity in the months ahead to have that document discussed. Enough rubbish was discussed by the Committee of Public Expenditure in relation to the Department of Health, with due respect to Deputy Allen and his colleagues, and there were enough hares run around this House in regard to the development of the health services in recent years, mostly initiated on the Fianna Fáil side. No doubt those days are now over. I am glad to see the Minister is meeting with the chairpersons and the CEOs of the health boards.
I am sure that all being solid and strong Fianna Fáil chairpersons, they will bear with the Minister when he notifies them of their allocations. If I were in his position I would fear for my life. They will recoil from the major reductions in allocations which they will have to explain. No doubt being solid Fianna Fáil men, in Cork, Roscommon and Dublin they will explain to the populace at large that the job has to be done and Fianna Fáil propose to do it in terms of what can only be described as serious reductions in our health services. That fact cannot be glossed over in the framework of this Bill.
The reductions will be substantial. This will mean that the on-call services, both accident and emergency, will be reduced. It will mean that hospitals who run an accident and emergency service until midnight or until between 2 a.m. and 3 a.m. will cut back on the time available. One will not have the privilege or the opportunity of paying £10 for the service because they will not be able to get into the hospitals as they will be closed.
The Department of Health have reduced expenditure as a proportion of GNP from 8.5 per cent to 7.5 per cent over the past four years. They are probably the one Department of State which over and above all others curbed, reduced and reshaped the delivery of services. I regret to say that there is a political viewpoint and a Department of Finance viewpoint, which is very disturbing, which regards the health services in 1987 as fair game for another major cut. This Bill is a watershed in that regard. The revenue which it is hoped to collect is a miserable £6 million, if we will ever see it. It will not enhance in any way the quality of the delivery of services. It will not ensure a return to primary care under our health services. Once again, it will build up another layer of bureaucracy within our health services. In the end the people will not have the delivery of the services enhanced in any way.
We are opposing the Bill. The Labour Party spokesperson on Health, Deputy Howlin, who is unable to be present will deal with any further health legislation that comes before the House. Tonight when dealing with a budget matter it is appropriate that I should be involved. When the Estimate for 1987 is settled and the outturn for this year is seen to be substantially more than the net Exchequer provision we will have another debate in the House. I should like to sympathise with the Minister and assure him that if he brings forward measures of a constructive and practical nature he will have our total support. In fact, he may receive more support in his term of office from us than he anticipates. We regret that we must start our role in Opposition by voting against the measures before us because the Labour Party over the years have made a constructive contribution to the development of our health services.
I would like to support this legislation for a number of reasons. The over-all economic situation and prospects were spelt out quite clearly last night by the Minister for Finance. This evening, the Minister for Health has made it perfectly clear what this means in respect of the health services. I would absolutely agree that the imposition of charges for very selected categories of persons is infinitely better than the alternatives which would include the cutting or restriction of services. The charges that are being proposed under the Bill for out-patients and the circumstances in which those charges will be applied, I strongly suggest are preferable to the kind of charges which I understand were being suggested by the previous Government.
I would like to emphasise again the categories of people that will be exempted from these charges. These are: medical card holders and their dependants; maternity patients; children under six weeks of age; children who suffer from long-term illnesses and disabilities; children referred from school health examinations and clinics and people receiving treatment for infectious diseases.
That, the House must agree, is a comprehensive list of exemptions designed specifically to protect the most needy in society. In particular, I would like to point out that in the imposition of those charges, the provisions in the Health Acts will be applied which allow chief executive officers of health boards to determine that if a person not in these categories clearly would suffer hardship by paying the charges, he may be exempted. All in all, therefore, I believe that very adequate provision has been made for the most disadvantaged while at the same time providing that those who can pay should make a further contribution to the cost of the services.
If one considers what precisely is involved in these proposals, I would suggest that they will be seen to be quite reasonable. I am personally very well aware of the way that the casualty Departments of hospitals are being misused at present. These departments are being used by people for all kinds of minor ailments and illnesses which are proper for their general practitioners. Yet, these departments which should be seen as catering for emergencies are being diverted by the demand for treatment for non-emergencies. Obviously, one of the great attractions of using a casualty department is that the service provided is free of charge. In other words, to an increasing extent, the general practitioner is being by-passed. If one considers that the charge of £10 which is now being proposed is more or less the level of charge made by a general practitioner, I think it will be accepted that the proposals in respect of casualty services now being proposed, are justified.
In addition, I would like to point out that the charges proposed will be applied only for the first visit in respect of a particular illness. The return visits will be free of charge. In this regard, many Deputies will be aware that in a number of health board areas at present, voluntary contributions are being made by people for these same services but to my knowledge these contributions are expected for all visits to a consultant or casualty department including return visits. I have had experience of dealing with the local hospital in Roscommon where an excellent emergency service is provided and, having made 12 visits, I was charged £5 for each visit. That is an indication that the new charge will represent a reduction on existing charges. In fact, what is being proposed now is a more equitable arrangement and indeed in those health board areas will not come as any surprise or increased burden.
Furthermore, as an indication of the care being taken to make sure that commonsense arrangements will be made, it is the intention that if a person goes to a casualty department and in respect of that visit requires an X-ray or a pathology service, a single charge of £10 will be made covering the treatment provided in those circumstances. That should clarify the question raised by the former Minister, Deputy Desmond.
Inevitably, the worst possible motives will be read into these proposals, but, as I said at the beginning, given the circumstances in which the country finds itself economically at the moment, the charges proposed and the exemptions which will be made, should not pose a significant hardship on any sector of society. And even for those people who will be required to pay, the Minister has stated that arrangements are being made with the Voluntary Health Insurance Board so that those people can insure themselves against those charges at minimal cost.
Finally, I would ask Deputies to consider these proposals from the point of view of the contribution they will make to preserving the essential elements of the health services. This, it must be agreed has to be the priority in our approach during these very difficult times. The charges represent less of an imposition than those proposed by the previous Government for prescriptions. In my view had we adopted those proposals the needy in our society would have suffered severe hardships. I recommend the Bill to the House and seek the support of Members for the measures.
It is important to state what is a truism, that the health of the people of the country is one of the most important aspects of the responsibilities of a Government. It can be taken from that that the basic principle of socialism, whatever about PDism, Fine Gaelism or Fianna Fáilism is that no person should have to pay or be deprived of a service because they do not have the money to pay for it or that the quality or level of the service should be restricted in any way because of a person's inability to pay for it. It is our contention that the health services should be free at the point of delivery and that those who can afford to pay for the services should do so through their taxes. The tax system should be in such a comprehensive state that everybody pays to the limit of their capacity so that those who cannot afford to pay for a health service at the point of the delivery, for whatever reason, are not required to do so.
It is obvious that the proposals in the Bill, and in the regulations the Minister proposes to introduce concerning charges for maintenance on a daily basis, and the severe cutbacks in allocations to health boards, represent an attack on the fundamental principles I have outlined. There is no doubt that two types of hospital service operate in the State. We have one service available to private patients who have the money to pay for it, who can go at will to visit their private consultants and who are assisted by the VHI which, in turn, is subsidised indirectly by the taxpayer. The public patient who cannot afford the VHI or to pay doctors or for hospital services is treated differently. They must take their place on queues and waiting lists for a whole variety of services, not just hospital services. This move by the Government is a deepening and strengthening of that trend.
I am a bit puzzled by the Fine Gael spokespersons. They made very strong speeches against the increase in the health charges from 1 per cent to 1.25 per cent but they disappeared when the vote was called. Their spokesman on Health, Deputy Bernard Allen, made great play of the fact that they will oppose the regulations on the charge per day per bed but he was not very clear about what his party will do on this Bill tonight. Perhaps the next Fine Gael speaker, Deputy Flaherty, will clarify exactly what Fine Gael's attitude is to hospital out-patient charges and daily maintenance charges. If by speech it is intended to convey to the population that Fine Gael oppose these measures, they should also vote against them. In the previous Dáil a number of Deputies, including the then Deputy Liam Skelly, spoke on numerous occasions against Government policy but went willy nilly into the lobbies in support of the Government.
The former Deputy is no longer here to defend himself.
Proinsias De Rossa
I should hate to see the same fate befall any of the present Fine Gael incumbents.
Deputy Allen has already said that the proposals in this Bill and the proposed regulations to be made in the future constitute one of the most stringent attacks on the health services perpetrated at any time by any Fianna Fáil Government. They seem anxious to push the trend towards privatising the health services and creating a two-tiered health service, one tier of which is readily available to those who can afford to pay but the second of which provides queues and waiting lists for those who cannot afford to pay. They seem to be determined to ensure that a person who is ill and poor will not get the best available services. It is significant that when calls for cuts come from the right it is always the education and welfare services which are the first target. It is significant that these are the services which are of most concern to the least well off. I know Fianna Fáil hate being described as being on the right but this legislation places them very firmly in that position.
Whatever one may say about the dire circumstances of those who are unemployed, it is a growing phenomenon that a large number of people who are employed are on such low wages, perhaps marginally above the various eligibility limits for medical cards and so on, that they are increasingly caught in a poverty trap and liable for payments such as those proposed in this Bill. There is no doubt that the imposition of these and future charges will cause severe hardship to many families. Deputy Desmond has already outlined the possibilities for a family in Tallaght who must bring a child to a doctor and then to a hospital, perhaps to be kept over night. That will be a continuing reality.
Despite the assurances by the Government that there will be a hardship clause and that people may appeal against charges, people generally are in such fear of getting into debt that rather than face the possibility of going into hospital and not having the money to pay, they will avoid going to hospital and avoid the embarrassment of being asked awkward questions in front of everybody in the waiting room as to whether they can afford the £10 charge. That is the fear people will have, regardless of the way the system is worked.
In relation to asthmatics, parents who are themselves asthmatic go without their inhaler drugs in order to provide other items of necessity for the rest of the family. I know of young people who are asthmatics and cannot get their inhalers if they do not have a medical card. They do not have the money to buy these inhalers and they are not prepared to go begging for the small amount of money required to keep them alive.
This imposition of charges for out-patient treatment and maintenance is an attack on the dignity of people. It will introduce a whole new range of means test at hospital level. These people generally have enough to put up with in relation to means tests for rents if they happen to live in a local authority house or if they seek supplementary welfare allowance or a medical card. This will be a further lowering of the dignity of people who find themselves in unfortunate circumstances.
What we are seeing is a gradual privatisation of the service. We are told that the VHI would provide a safety net for people who would find themselves outside the medical card limits but caught for these charges in hospitals. The Minister said a review was being carried out in relation to the VHI. I wonder what kind of review it is. They have moved far away from what was originally intended. They have moved into the area of providing luxury hospitals and services for a small proportion of the population who, because of their high incomes, benefit most from the £30 million subsidy which the State provides indirectly to VHI through the taxation system. There is definitely a need to review the operations of the VHI to see exactly where they fit into the provision of hospital and other services. More and more patients are being forced into the VHI because of the continual reduction in the level of public services.
The VHI are providing and subsidising very exclusive four star luxury accommodation in hospitals for people who should not be receiving subsidised medicine, given the present nature of the system. I have no objection to people getting luxury treatment in hospital provided the same treatment is available to all patients. I do not accept that there should be two levels of service, one for the public patient and another for the private patient who can afford that kind of service, which the VHI have assisted in creating.
If one is to accept the statements of the Minister and of previous Ministers from all sides of the House, there is an urgent need to review and reform our health services. We must also look very carefully at the way money is spent on these services. It is significant that despite the large amount of money expended on paying consultants, doctors and chemists on a fee per item basis, the new Government have not faced this problem and we are faced with a proposal to charge some of the poorest in society for visiting the out-patients department in a hospital or who have to spend a few days or weeks in hospital.
The vested interests in the medical profession must be taken on but I have no faith in the ability of Fianna Fáil to do this. I do not believe they have the courage or the will to tackle the medical or the pharmaceutical profession or the drugs industry who are taking in hundreds of millions of pounds from the medical services. I am a member of the Eastern Health Board and it only recently came to my notice that when chemists fulfil a prescription for a patient under the GMS they are paid a basic prescription fee and the drugs are sold at a wholesale rate. However, if a person goes to them with a green book — which denotes long term illness — the drugs are supplied at the retail rate. The Eastern Health Board attempted on a number of occasions to switch people from the green book to a medical card to use the resources of the board more efficiently but the chemists' representatives kicked up blue murder. There was no way they would allow a switch from the green book to the medical card for these patients because it would mean a loss to them of the difference between handing out the drugs at the retail price and the wholesale price. That is an anomaly I would have liked to hear the Minister say he would tackle. He did not announce that but he indicated that he expects savings of £8 million in administrative costs and so on. How does he intend to do that? Will the travel expenses he expects to save on be those of the consultants or will they relate to the expenses of the unfortunate person who has to go to a hospital for physiotherapy once a week and who cannot get an ambulance or a taxi for this service?
The introduction of the proposed charges is an attack on the patient rather than on the rip-off in the health services. There is a failure by the Government to apply themselves to where real savings can be made. If the Minister tackled the fee per item system for chemists and doctors, the overwhelming control which the consultants seem to have on the medical services and the way in which consultants appear to have the use of public hospitals provided by taxpayers' money to treat their private patients, he would save far more money and would not only be able to maintain services as they are for public patients but improve them significantly.
The Workers' Party will vote against this Bill. We have put down two amendments and, as the Progressive Democrats will either abstain or vote for the Bill, we appeal to the Minister to at least exclude children from the proposed charges. As I understand it, the Minister can make regulations in consultation with the Minister for Finance without coming back to this House. If the Bill is passed tonight, the House should have the right to examine the regulations which the Minister is bringing in and, in the light of the wisdom of the House, either to refuse to sanction them or to amend them.
I should like to refer to some remarks made by Deputy Desmond who, regrettably, is now absent. He indicated that Fine Gael were champing at the bit in their attempts to implement not just the £10 per day in-patient charge but even higher charges. That remark is clearly untrue because Fine Gael had every opportunity, having bade farewell to the Labour Party in highly publicised circumstances, to do exactly what they liked with their own Book of Estimates and budget. There was no recourse to such a charge. I also very much object to Deputy Desmond's practice — in which he is engaging far too often — of breaking a certain element of confidentiality which is contrary to all the traditions of the House. You, a Cheann Comhairle, corrected another Deputy in the House for referring to a Member who was not present and there are no members of the former Cabinet here to indicate whether he is telling the truth and to answer the charges he made. Deputy Desmond should refrain from this practice, although I know his tongue tends to run away with him at times in a colourful and entertaining fashion ——
The person whom I was concerned to protect was outside this House.
There is no responsibility to protect people within it? I wish Deputy Desmond could hear my remarks but I will make them to him personally. He is opposing this Bill. There have been many changes on the road to Damascus and it is very difficult for all of us to adjust to our new roles. Everybody is adopting a new role in Government and in Opposition ——
Proinsias De Rossa
Not everybody.
Quite. The transformation is remarkable, none more so than in the case of Deputy Desmond who in the debate an hour before this admitted that he had, as Minister for Health, proposed the imposition of charges.
Will the Deputy be voting this time?
I will, and I will let the Deputy know in a moment what we intend to do. Deputy Desmond is now trying to present himself as spokesman of the caring party. He was seen by many people, on occasion by some Fine Gael backbenchers, as one of the sharpest cutting edges of the last Government who perhaps outdid many of the so-called right wing Fine Gael partners in his excesses. I find it incredible that he is now turning about in this double-sided fashion and being the spokesman of the poor overnight. This is quite difficult to adjust and particularly having regard to remarks made as I have mentioned.
Remarks against coalition.
I agree. I share that view now. The Bill we are dealing with tonight will not be opposed by the Fine Gael Party, but we see a significant difference between in-patient charges and out-patient charges. While we will not be opposing it, and could not ——
Why waste time talking about it? Just get it into the record?
This Bill gives us the first opportunity to deal in totality with the £10 in-patient charge on which we have very strong views, and we have views about the out-patient charges which I would like the Minister to deal with.
In-patient charges are out and out-patient charges are in, is that it?
That is it in a nutshell. I support the amendments put down by Deputy Molloy and by The Workers' Party in relation to the laying of the order before this House. It is important that this should be done. I ask the Minister to accept that amendment and to include it himself tonight before the Bill is finalised. It is democratically desirable, a very necessary check and a major new departure in the financing of the health services.
In the implementation of this proposal I would like to ask the Minister to consider whether another group might be looked at favourably and perhaps excluded from the charges. One of the main purposes behind this was to curb excessive use of highly staffed medical facilities. Persons referred to out-patient departments by doctors are clearly not in this category and if they are eligible under existing regulations they will have already paid a charge and will have cut down on the feature outlined by Deputy Desmond. Some consideration should be given to whether in those circumstances it would be appropriate to initiate a charge because the treatment is initiated not at the out-patient department but at the point of the doctor who refers them there.
Secondly, if the Minister has time to respond I would like him to indicate what kind of arrangements will be made for the payment of these charges. This obviously is a very touchy issue, given the nature of out-patient services and the experience of these charges when implemented previously by the then Minister, Deputy Woods. The previous charges proved unworkable simply because out-patient departments are oriented totally towards the delivery of emergency services and are particularly unsuited to the management or collection of moneys. How does the Minister propose to organise that? This provides a very difficult problem for doctors whose main concern is the health and care of patients. How is that to be married to the need to check? This is obviously a procedural arrangement.
The question of children was raised by The Workers' Party and they made the valid point that children are referred to hospitals quite regularly and, as I know from direct experience, are much inclined to need medical attention regularly, often for minor ailments. Many parents will have medical cards but many will not. There is a tradition of presenting children at hospitals, particularly children's hospitals, where one feels that one gets an expert's attention which may be crucial in the case of a child's health. We have no objection to the implementation of charges per se and we would not oppose charges in principle. However, we oppose the proposal to bring in a £10 charge for in-patient services and we will vote against it because this has been a selected budgetary measure put in place of a series of budgetary measures which we had provided as an alternative.
The main change which the incoming Government made in relation to new savings was the abolition of our proposed saving of £16 million by the implementation of prescription charges. The major element in that, based on assessments from the Department, related to savings on drugs. The anticipated revenue from individuals was of the order of £2 million to £3 million out of that proposed saving. The proposed contribution from individuals under this is £6 million. Furthermore, it is in the context of a very different budget. It has far greater implications for people than the random payment of £10 at the point where one might want to go to an out-patient department if one were ill and in need of hospitalisation.
It is not an individual's choice to end up in hospital. Generally hospitalisation is recommended by a doctor, lasts as long as that doctor considers it necessary and the person then goes home. He or she has no choice about the length of the hospital stay or of alternative ways of dealing with it other than perhaps to get no treatment. Therefore, it is very different from the proposal to put charges on out-patients. For the average hospital stay which is of the order of about ten days, coincidentally, the figure has been set at £100. Many people have no VHI. If one third of the people have VHI and probably the same percentage have medical cards — I am not sure of that percentage but Deputy Desmond has the figures — there is a middle segment who can least afford these charges and will be most hit by them. The only alternative they will have is to insure themselves, and it is quite clear that that is the Government's intention. Therefore, the effect will be that the average person must take on an insurance policy which will be an extra tax on him or her. This budget introduces other taxes that we had not proposed. We find this charge unacceptable when other savings are available which would have a more acceptable health outcome.
Deputy Desmond was louder than anybody else in his criticism of the excessive use of drugs and hospitalisation and he said we were in love with hospitals and medical care. He said on many occasions here that we spend more time in hospitals and we use more medicines than people in most other jurisdictions. This is a problem and in so far as out-patient charges may in some way relate to that, we support them. We do not support in-patient charges and we ask why the Minister did not implement some prescription charges. Even jurisdictions across the water that have a public health service much more complete than ours have implemented such charges for the good of the individuals and to restrain them from excessive recourse to drugs. We have a practice of overprescribing drugs here. The net effect of this approach would be an economy and an improved approach to health.
Other health areas in the budget worry us very much. The £10 million in increased savings in the area of recruitment is an example. The implications of this are difficult to comprehend but, given the demands on the health services and the fact that they have been screaming for so long about a lack of money, this further slicing off was to make up for the fact that the proposal to eliminate prescription charges was abolished. That saving and the revenue brought in from the hospital in-patient charges combined to make up for that. That is why we object to both of these measures. Our proposal to effect a saving in another fashion was far more defensible.
There are areas in the health service that need expansion. The Minister in his speech referred to the area of mental handicap, an area which concerns me very much. I have argued with the outgoing Minister that there is a total lack of provision for services particularly in the north Dublin area and I am sure similar needs exist throughout the country. These excessive, unspecified cuts, with the further £5 million in various efficiency measures that will take place in other Estimates, must leave very little room for manoeuvre. There was little enough room for manoeuvre anyway but these must make any kind of development virtually impossible. I wonder how the Minister will be able to honour any of the commendable intent in the latter part of his speech in relation to psychiatric services and services for the mentally handicapped.
The Minister has taken the soft option on this. The most vulnerable people in the PAYE sector, those with the least disposable income, have been hit. The reason we find this charge, referred to in the Minister's speech, so unacceptable is because there was before him a package of much more acceptable ways of dealing with the revenue problems. I will be interested to hear the Minister's response as to how the Government adopted what was rejected and what was regularly on the table from the Department of Finance during the years as an option for saving. This has shocked the people and gives a lie to the matter I referred to earlier, the cynical posters which were put up all over the county and which must if they have any sense of honour, haunt those Members on the benches opposite.
The health cuts hit the old, the sick and the handicapped. I do not propose to present that as simplistically as the Government did in their election programme because the issues are much more complex and the problems facing the country are far more real than that. That is why we on this side of the House are trying to maintain a difficult line, which is to support measures to control spending which we consider are necessary in the interest of the public good. We reserve the right, and we are indicating our intention to act upon that right, to object to specific elements which we believe are not justified and are not necessary.
I intend to be very brief. The purpose of my contribution is to stress the desirability of adopting the amendment proposed by my party colleague and spokesman on Health, for the Progressive Democrats, Deputy Robert Molloy. The advice available to the Minister doubtless will be to the effect that section 5(5) of the Health Act, 1947, makes provision in a general global way, which applies to all the Health Acts which are to be construed together, for the manner in which regulations are to be brought before this House. That is the negative or permissive manner of subordinate legislation which involves merely laying the relevant legislation before each of the Houses of the Oireachtas by making it available in the Library of the Oireachtas. The onus is then on anyone who wants to cancel or annul the particular measure to bring a motion in that regard before the Dáil.
There are some matters, and it is well recognised in legislative practice, which are of such significance and importance that they are dealt with in another manner. That is, that the person who proposes to make the regulation was to bring it before the House to have it expressly approved rather than to have it implicitly approved by lack of challenge which is the situation in relation to other regulations made under the various Health Acts. I am submitting to the House that on this occasion the regulations provided for in this amending Bill are of such wide-reaching significance and importance that they deserve to be dealt with in a manner which requires positive approval before they have the force of law rather than the negative, implicit approval based on the fact that nobody has found them of sufficient importance to oppose them.
These regulations are of far-reaching significance, especially for the weakest in society. Everybody in the House is aware of this because the Minister acknowledges it by assuring the House of his intentions in relation to the regulations that he proposes to bring forward. I suggest to the House that it is incumbent on us to provide a protection for those people especially when we can do so at no cost, except perhaps the minor administrative inconvenience that any Minister for Health has who wishes to make regulations under this section alone, to come to this House and have those regulations approved. Could anything be a more simple safeguard and less expensive in time and effort than that simple alteration which Deputy Molloy proposed compared with the enormous hardship and suffering which could occur were we in future to allow a Minister, with less sensitivity than the present Minister is demonstrating in the regulations he is describing to the House, to come before the House with draconian and wide-reaching proposals to impose charges of very different kinds on out-patients? What protection will there be if it is cast on the Opposition at that time to seek to annul those regulations rather than putting the onus on that Minister, whoever he may be, to justify what he doing and to get the explicit support of the entire House? What I am underlining is the balance that Deputy Molloy's amendment proposes to establish.
This legislation is merely enabling legislation. It has capacity for good and capacity for harm. Its capacity for harm is best safeguarded against by requiring a Minister for Health who proposes to avail of the powers made available to him in this legislation to come before the House and justify his use of those powers. It is not much to ask. It has no ideological content, as is shown by the variety of contributions in favour of the principle by speakers from a variety of backgrounds and with a variety of different viewpoints as to how the legislation should and should not be used, but merely gives this House what it should always seek, that is, some degree of control over the powers it delegates to Ministers to exercise on its behalf. I ask this of the House, that it considers whether this particular set of powers is of such potential for injustice as to require this additional safeguard. I ask the Minister therefore to accept Deputy Molloy's reasoned and reasonable amendment to the legislation and to make a distinction between the power being conferred on the Minister by this 1987 amending Bill, and the generality of regulations under the Health Acts.
All I am asking is that this House puts the Minister of the day to a slight administrative inconvenience in order to safeguard the interests of those who some time in the future may not have as strong a voice as they may have now. We should have regard to that danger. It is my belief that if all the Deputies of this House assemble here this evening to cast their vote on this issue, this measure will pass regardless of whether the Government give it their support. I appeal to the Minister that in a spirit of generosity, cooperation and reasonableness perhaps, he ignores the advice I anticipate he will receive to the effect that section 5 of the 1947 Act is sufficient safeguard and to accede to what is offered in a generous spirit here, as a genuine effort to improve this Bill and to make it more just.
The previous speaker, Deputy McDowell, was making the point that he thought this Bill might be used for good or for bad and that the regulations that might arise thereunder might have to be looked at by the House from time to time in that light. The Labour Party do not agree with that view. We see that this Bill is not needed. We see that the proposal which is associated with this Bill, which was announced by the Minister for Finance in his Budget Statement and by the Minister for Health here today, is a disgrace and an outrage and should not have been brought before this House. Already from around the country and certainly in my constituency I have had reports from very many people in the course of today. There is a sense of absolute fear and apprehension of what the implications of this measure will be for so many people who are living literally on the breadline, from hand to mouth, and whose money runs out before the next pay day comes around.
The Minister talks of priorities and says we must have a sense of priority in the various measures we introduce. What greater priority could there be than to ensure the basic health needs of those who cannot afford to pay for them? What greater priority could any country seek to provide for its citizens who are in poor financial circumstances, as tragically so many are today, than to ensure that their health is provided for? Who is it that goes to the out-patients' departments in the hospitals, anyway? Let us consider that aspect. Is it the people with "mercs", or other big expensive cars, or big incomes? Deputy Harney made the point that we do not have to provide these services for those on £40,000. Those people would not be seen dead inside an out-patients' department, queueing up for hours on end, waiting to get a basic and necessary service. They go to the other system, the other side of the coin, to which Deputy De Rossa referred.
There are two systems of medicine in operation in this country, two systems of doctoring, of hospitals. One you might refer to in a genteel fashion as the public system and the other — let us call a spade a spade — the luxury system. Those who participate in, or avail of, the luxury system do not go down to the out-patients' department. They do not sit there for many hours waiting to have the basic medical needs of themselves, their wives or their families attended to. It is the people who are in poor circumstances who go there. That is where the attack is directed in this measure and in so many of the other measures that have been introduced in this budget. The Government say that only those who can afford to pay and those alone are to be affected by this measure. Is that really so? Just look at the matter. The Minister of State, Deputy Leyden, outlines those who are exempted — that is fine. He has not set out those who are not exempted.
Deputy Desmond analysed a section of one category that is not exempted — those, and there are so many, on low income, taking home £130 or £140 per week or maybe less, to support a wife and some children. Many of those work in the public service and their salaries are frozen now also. Apart from the salaries of departmental secretaries, principal officers and so on, the salaries of those who are employed by the local authorities or who are employed in menial tasks in the public service and bringing home very low pay are to be frozen also. These people opt to remain in employment but their wages are being frozen in this budget; they are the ones who are being attacked here.
If attacks had to be brought in on medicine, why was not some tax brought in on the luxury end of medicine — the Blackrock Clinic operating now in all its grandeur and grandiose glory to furnish the needs of the upper echelons of this country who have been barely touched by the budget introduced by this Government? Where is the surcharge brought in on their medicine? Are their medicine, their service, their expensive clinics and that line of service, encompassing the Fitzwilliam Squares and so on, being surcharged? No, it is the weaker section. I have heard so many speakers on the Government side — the Taoiseach, the Minister for Health and other Ministers — say that they seek to protect the weaker sections of the community. There is some idea that if you repeat the phrase often enough maybe you will come to believe it yourself. Perhaps with some type of media hype with constant repetition, people will come to believe that it is so. The Taoiseach and the Minister for Health can repeat it all the times they like. The facts show otherwise. They show that the attacks here are directed at those on the lowest levels of society, those bringing home £130 per week, those who are struggling, perhaps with their first home and with a mortgage. The people subscribing to the VHI will have their premiums increased and the Minister for Health tells these people, who are struggling on low wages and waiting until the money comes in on the following Friday because they are out of money, to find a charge of £10 to bring a sick child to the hospital.
The Minister for Health gives a whole list of reasons for people using the OPD services. In fairness to him he mentioned, as the last one, what I believe is the correct and true reason, that the service is free. The reason for this is not because they want to avail of something to which they are not entitled but because it is free.
Of course the country is in a difficult economic situation; we know that. The Minister said in the course of his introductory remarks that the priorities for the country must be identified. I would ask him, what are the priorities? Here is one selected to be hit, this one, attendances at OPDs or having to go to hospital as an in-patient, something in respect of which a person has no choice. When VAT was introduced it used to be said: ah, well, one had a choice, one could decide whether to buy an article and suffer the imposition of VAT. When one is sick or one's children and one is worried — one may be worried needlessly but the Minister as a doctor will known that many people's worry is real nonetheless — one does not have any choice, that is not like deciding to buy an article on which VAT is charged. This is quite involuntary. One may have to go around and beg, borrow or steal the £10 to have one's child attended to. The Minister says that the priorities for the country must be identified. That is a fair enough suggestion. One might well ask the question: what are the priorities that he and his Government have selected and brought forward in this budget? For example, did he select the introduction of some realistic capital taxation? Could that not be said to be a fair and reasonable priority the Government might have considered having regard to the fact that capital taxation now is but a mere fraction of what it was ten or 12 years ago? Oh, no, no such suggestion; I do not hear anybody of the three main right wing parties advocating that.
When Deputy Bernard Allen was making his contribution — one that means life and health, bread and butter to so many people — I noted down some words he used in the course of his remarks, four, five or six times. Value for money, he said; efficiency, he said; wastage, he said; expenditure control, he said; management, he said — these are the words being used when there are families without a penny in their pocket waiting for Friday to come, their child ill, coughing. What are they supposed to do, are they to use the GP service? No, until now the OPD was always the bottom line, this constituted the fall-back position for those who were on the floor. They knew they could always go to the outpatients' department of a hospital. That has been traditional going back for decades. One might not have had a penny in one's pocket but at least one knew that one could resort to that fall-back position and go down to the out-patients' department of a hospital. It may not have been a wonderful service at all times, one may have had a long wait once there or have experienced difficulty getting there. At least one knew that one would not be turned away because one could not produce £10. One knew that one's child would be attended to, which constituted some sense of comfort to those people.
The Minister says that they will provide an insurance system instead. The hard fact of the matter is that, tragically, I know in my constituency, Tallaght — and it must be the same up and down the country — there are thousands of people who do not know of and could not afford to take out insurance on the pieces of furniture they have in their corporation or council houses; they just could not afford to pay the relevant premium. They would not have the expertise to go and see a broker to arrange such insurance. Those people who are at risk do not insure their meagre belongings in their homes — and there have been many such cases where fires have occurred and their entire belongings have been destroyed. In many cases, particularly in local authority dwellings in Tallaght we discovered they had no insurance or were not covered at all in respect of those items. Yet the Minister says: do not worry about that, we will set up an insurance scheme for you so that you will be able to take care of your health and that of your wife and children by arranging insurance cover through the VHI. I might tell the Minister that that proposition is not realistic. Such people could not afford to take out that insurance or to pay the premiums, they would not know how to set about doing it. Yet a basic health facility, that of life and limb are at stake here. I have no doubt that people will be frightened to go down to the out-patients' department of a hospital. I know they are already in a state of fear about the provisions of this Bill. So many people have already telephoned me today about this, asking me what they can possibly do in this position, how could this charge be imposed in respect of a basic matter such as health? They have asked: if we need to have an operation how do we find £50. Yet it is something people have to have when the need arises. This Bill constitutes the most unfeeling, unthinking measure ever. I am amazed that the Government have introduced it in these times of difficulty and stress.
If there are some priority needs then I say the Government should introduce some capital taxation or at least restore capital taxation to the level obtaining 12 years ago, using that money to provide this small basic need — the £6 million they hope to raise from these charges. I would remind the House that £12 million more than is at present being raised from capital taxation was raised 12 years ago. One might well ask: what would the equivalent figure be were it updated to take account of inflation? I would advocate that the Government should restore even a modest measure of capital taxation rather than take from those who cannot afford it, those on low incomes or social welfare, robbing them of that basic, fall-back position to which they could resort.
What about the farmers? Could they not make some reasonable contribution now instead of the modest contribution they were making until now by way of the land tax? The Government had to abolish that tax, about which the farmers did not complain, it was so small anyway. Perhaps they could have raised that tax somewhat, using that money to provide this basic floor facility or, alternatively, impose a tax on luxury medicine so that this basic floor or fall-back position for those in appalling circumstances could be maintained, when they would have the solace, of knowing that they did not have to worry, that there was somewhere they could go when their children fell ill, when there was something happening they did not understand.
Those are the priorities this Government might well have considered but chose to ignore. They chose to hit those who can least afford the charges, notwithstanding repetition of comment to the contrary. No matter how many times the Taoiseach or the Minister repeat it the facts show otherwise. An analysis of the details show that those at the lower end of the scale are hit hardest by every such measure contained in this budget, while those in the upper echelons escape virtually unscathed. It is an outrage and a disgrace. I appeal to the Minister even at this late stage to withdraw this proposal, abandon it, to find his £6 million in some other way. There is plenty of scope for him to do so. He should not impose this appalling visitation on the poor when they have had that basic facility available to them for decades. Their fathers and grandfathers always knew they could go down to, say, the Meath, St. James's Hospital, or wherever, where they knew they would be received and get the attention they needed.
I welcome an opportunity of making a few points on this important Bill we have been discussing for the past two and a half hours or so. As one who has been a Member of this House over a number of years, having listened, as I did earlier this evening, to Deputy B. Desmond, it was difficult for me to forget some of the things over which that Minister presided in the last four years. I had to ask myself: was I listening to the same person who sought to put out of the hospitals to which they had become so accustomed many psychiatric patients who had no alternative?
On a point of order——
I am going to assume that Deputy Desmond is raising a point of order but, if he is not, I will tell him fairly fast.
I must ask you to ask Deputy Harney——
That is not a point of order; that is an interruption.
I wish to make a point of order that the Deputy is speaking an untruth.
That is not permissible. Deputy Desmond is long enough here to know that he is not entitled to make an accusation such as that. He must select some word other than "untruth". I am sure he has it in his imagination to do that.
If I would——
I ask Deputy Desmond to withdraw the accusation that Deputy Harney is speaking an untruth.
I wish to state that what the Deputy said is not true. It is a grossly offensive statement to make about any other Deputy——
Will the Deputy allow Deputy Harney to proceed?
——and I would challenge any other statement——
It is not my intention now or ever to utter untruthful statements about any Minister or former Minister in this House. I spent one whole afternoon visiting patients in the Carlow Psychiatric Hospital and I remember well what they, their relatives and the members of the staff felt about the Minister's activities only a few short months ago. Deputy Desmond showed a lot of concern for the woman from Tallaght who has £120 a week and a couple of children and asked what happens when she or one of her children gets ill and has to go to an out-patients department. No matter where the woman comes from, it is only reasonable that people on low incomes should have free access to both out-patient and in-patient hospital and medical services. Those who can well afford it should pay for it.
There are many cases where people earning incomes of up to £40,000 go to the out-patient services in our public hospitals. Many people I know, people who can well afford to pay, have gone for X-rays, blood tests and used other facilities in the out-patient departments of our public hospitals. It is wrong to subsidise everybody irrespective of their ability to pay. The Progressive Democrats believe that the principle of asking people to make small contributions towards medical expenses is reasonable in cases where people can afford to pay. However, it would be unreasonable to give the Minister a blank cheque, as this Bill seeks to do if not amended, so that we would not be in a position to discuss the details of regulations which may be introduced by the Minister.
I accept that the Minister is saying in good faith tonight that he intends to levy £10 for the first visit relating to a problem and he made other references to the in-patient charges. It may well be the case, in a couple of months time, if we give him a blank cheque on these regulations, that these charges will be increased and this could place an unfair burden on people less well able to pay. Already the Minister for Finance, Deputy Mac-Sharry, has said it may be necessary to bring in a mini-budget in a couple of months time. Tonight we could also be giving a blank cheque to the Minister's successors, because tonight we are bringing in enabling legislation and all that will be required is for any Minister for Health to bring in, by way of regulation, charges for out-patient services in our community, which do not have to be debated in this House.
Over the past number of years we have failed as a society to respond to the economic crisis that confronts us. In so far as this Government are making a determined effort, I want to see them being given support, because I am tired of the politics which says that just because one changes sides in the House something one proposed a couple of weeks ago is now wrong. That kind of hypocrisy must end if politicians are to respond to the demands being made by the people. That is why I was appalled to hear Deputy Desmond outline details of Cabinet information.
(Interruptions.)
Deputy Desmond was able to tell us tonight that various things, and various discussions——
(Interruptions.)
Deputy Sherlock——
Deputy Harney has left the other side of the House and she is now signing the same——
A Deputy
A Leas-Cheann Comhairle, surely the Deputy is entitled to protection from the Chair.
Deputy Sherlock realises that he is not making any contribution to what is being discussed and I ask him not to interrupt. Deputy Harney, without interruption.
I appreciate the Chair's advice but, in view of the contribution being made by the speaker, one wonders why she left the other side of the House.
We can all wonder, but we do not have to express it.
Deputy Desmond gave great details from some document from his Cabinet days about what went on in Government. The ethics of that are pretty distasteful, but that aside, Deputy Desmond spent four long years in that Government and did not seem to make much noise about it while he was there.
(Interruptions.)
We are now getting the benefit of all the information of which we were deprived for four long years. Deputy Taylor referred to luxury medicine, whatever that is, and suggested that it be taxed. If the Deputy means that those who can afford to pay should pay, I agree——
At the cost of other people.
(Interruptions.)
——so that those in real need in our society——
You want to have it both ways.
——can be properly looked after. The only alternative is to tax further and further those in low paid jobs who have for so long been paying high rates of tax.
A Deputy
Farmers?
Farmers, and others. I do not care what they work at. I want to see people paying a fair rate of taxation and an incentive for people who are working. I do not want the taxpayers continually having to pay in their income tax for services to which other people should be able to make some contribution. That is what the Minister is seeking to do and I would ask him, as did Deputy McDowell and Deputy Molloy, to be reasonable and accept the amendment which asks the Minister and his successors to bring before this House, for debate and approval, any regulations that he may make as a result of this Bill being passed tonight.
I will be brief because I want to allow time for a reply. I want to correct one or two impressions that might have been given. This debate has as its background the question of general provision versus private provision or selective provision. Let us be clear about this. Where a private provision in health care has flourished it has always driven down the standard of general care and I defy people to produce evidence to the contrary. In Britain, for example, where people have published work on the differing character of the different health services in their own country and in other countries, they have made the point that so-called private provision in health care is never really private in that the greater proportion of its costs are not provided for privately. People do not pay for the education of doctors, or for the building of hospitals. They provide an increment in addition to what has been State expenditure that has been transferred from public taxation.
Hear, hear.
Therefore, what happens is that the more that is allocated to private provision, the more one drives down the volume of resources available for general care, so one either provides a general health system funded by direct taxation or one brings in a mixed system which indirectly transfers privileges. What I have listened to in the course of the budget is something else — a number of non-supported assertions concerning the behaviour of poorer sections of the community. I have heard in this debate that people are flocking to out-patient centres simply because they are available and free.
Who suggested that?
You suggested serveral times that the out-patient facilities were being abused. It is in the Minister's speech if you care to read it, but I am not so sure that you are in favour of reading other people's speeches at all.
I never said anything about flocking anywhere.
I would ask the Deputy not to indulge in a duologue or a dialogue with other Deputies.
I am addressing my remarks to you. I want to place on the record one piece of research which can be checked. It is in the Irish Medical Journal. 1980, and the officials can point out the details. In a survey of 104 elderly people in North Dublin they were found to have 174 treatable illnesses and they were not being treated because they were beyond the medical card guidelines. For all these assertions about people abusing services, you could find pockets of people who are not coming forward because they feel they cannot afford health care.
The interesting side fo this is the more you move away from public Exchequer provision for health care the less accountable it becomes, the more privileged it becomes. In 1986, 85.7 per cent of the cost of health care was carried by the Exchequer, about 6.2 per cent was carried by levies and 8.1 per cent in charges. The more it is shifted into levies the less accountable it becomes and the worse the character of general health provision becomes, and the more hidden privileges, the hidden transfers from general taxation to private non-accountable health care which is usually not researched is encouraged. It is a massive shift to inequality.
The true test of this and every other measure should be the putting of one question which I hope all Deputies will ask themselves: are the measures contributing to a more or a lesser degree of inequality in terms of income, wealth, the consumption of services or transfers in our society?
I would remind the Minister that he has approximately eight minutes to reply.
The Bill is to introduce a £10 charge for out-patient services, but the debate covered a lot of ground and I will try to deal with all the points raised.
The Progressive Democrats wanted to move an amendment. I do not believe we should accept that amendment because it would delay the passage of this legislation which we are anxious to have as soon as possible. We have had a very wide-ranging debate over the last three-and-a-half hours and if we were to debate the regulations again we would be taking up the time of the House covering the same ground. I do not believe it is necessary at this stage to discuss the amendment further.
Section 5 (5) of the 1947 Health Act provides for the laying of regulations before the Houses of the Oireachtas and within 24 sitting days they may be annulled if this House so decides. Deputy Allen said the legislation providing for charges for in-patients would hit the more vulnerable families and went on to defend the prescription charges. I fail to understand how he could do that because the most vulnerable people in the State are those on very low incomes who are eligible for medical cards. They are the people we had to defend by removing the imposition placed by the Fine Gael budget when they tried to raise £13 million from that section of the community.
Hospital care costs approximately £100 a day, although it varies in different hospitals from £500 to £1,300 a day. We are asking in-patients to pay £10 a day up to a maximum of £100 in any one year. I do not think that is unreasonable. A number of Deputies felt the Exchequer should pay the total cost but people realise the Exchequer cannot afford to pay more to the health services.
Deputy Taylor made a long contribution and said he was opposed to the charges, but he and other Deputies have to face the reality that the national debt now stands at £24 billion, £12 billion of which was accumulated during the term of the Coalition Government. We have to deal with that. If we continue to provide an unlimited amount of money out of the Exchequer for services, we will not be able to deal with this. Deputy Taylor went on to say that our priority should be to ensure that the health of our citizens, particularly those who cannot afford to pay, should be protected. They are the group we wish to help but there are only two choices open to us. The first is to increase taxation, and before we started this debate the Labour Party voted against an increase in taxation which would cost a person with a salary of £10,000 an extra £25 a year. Now they say we should not introduce these charges. The other option, which to me is unthinkable, is to reduce the level of services.
On a point of order, we have an amendment we wish to move. From what we hear, the Minister does not intend to accept our amendment or to propose it himself. Will we have an opportunity to put this amendment before the House and vote on it in view of the arrangment the Chair outlined earlier?
We are in the position I was trying to explain earlier when I asked Deputies to speak specifically to this Bill. I must adhere to the Order of the House which requires me, at 10.30 p.m., to put the question which provides for all Stages. Obviously that will not leave any time for Committee Stage. That unfortunately is the position and is one over which I have no control. I must honour the Order of the House and put the question.
Twelve hours too late.
We should have had more time for this measure.
I am telling Deputies the position as it is, and I am sure Deputies are conversant with what I am saying.
Will the Minister allow us to move our amendment? There are two minutes left.
With your permission I should like to conclude the Second Stage by replying to the points raised by Deputies.
The second choice is that we reduce services to an unacceptable level and I do not think anybody here would want us to do that. We are proposing a charge of £10 for out-patients to be paid on the initial visit only for any specific illness. For example, if a person were to break his leg, and if he were eligible, he would pay on the first visit, but he would continue to attend the hospital until treatment was completed with further charge.
It is important to point out that there is a hardship clause. A number of Deputies mentioned genuine cases who would not be able to pay this charge. We accept that, but the chief executive officers of the health boards will implement that hardship clause. There is a tradition in Irish health care that nobody has ever been refused medical treatment at any level, hospital, doctor or anywhere else, because of inability to pay and I have no doubt that will not cause a problem.
The VHI will implement a scheme which will be very modestly priced and I have no doubt it will not cause hardship. This scheme will give full cover to both the out-patient and in-patient charges and, hopefully, it will be in operation in six weeks time. As I mentioned earlier, people with medical cards are totally exempt from the charges, as are women who are receiving services in respect of motherhood, children up to the age of six weeks, children suffering from diseases or disabilities prescribed under section 52 of the Health Act, children in respect of defects noticed at a health examination held pursuant to the service provided under section 66 of the Health Act, and persons receiving services for the diagnosis or treatment of infectious diseases. I want to add to that the hardship clause. Persons who are unable to pay the £10 charge out of their means will not be obliged to do so.
I commend this Bill to the House.
As it is now 10.30 p.m., in accordance with the Order of the House made today, I am putting the following question: "That the Bill be now read a Second Time, that the Bill is hereby agreed to in Committee and is reported to the House, that Report Stage is hereby completed and the Bill is hereby passed."
Question put.
The Dáil divided: Tá, 76; Níl, 31.
Tá
- Abbott, Henry.
- Ahern, Bertie.
- Ahern, Dermot.
- Ahern, Michael.
- Andrews, David.
- Barrett, Michael.
- Brady, Gerard.
- Brady, Vincent.
- Brennan, Matthew.
- Brennan, Séamus.
- Briscoe, Ben.
- Browne, John.
- Byrne, Hugh.
- Calleary, Seán.
- Collins, Gerard.
- Conaghan, Hugh.
- Connolly, Ger.
- Coughlan, Mary T.
- Cowen, Brian.
- Daly, Brendan.
- Davern, Noel.
- Dempsey, Noel.
- Dennehy, John.
- de Valera, Síle.
- Doherty, Seán.
- Ellis, John.
- Fahey, Jackie.
- Fitzgerald, Liam.
- Fitzpatrick, Dermot.
- Flood, Chris.
- Foley, Denis.
- Gallagher, Denis.
- Gallagher, Pat the Cope.
- Geoghegan-Quinn, Máire.
- Haughey, Charles J.
- Hilliard, Colm Michael.
- Hyland, Liam.
- Jacob, Joe.
- Kirk, Séamus.
- Kitt, Michael P.
- Kitt, Tom.
- Lawlor, Liam.
- Lenihan, Brian.
- Leonard, Jimmy.
- Leyden, Terry.
- Lynch, Michael.
- Lyons, Denis.
- McCarthy, Seán.
- McCreevy, Charlie.
- Mooney, Mary.
- Morley, P.J.
- Moynihan, Donal.
- Nolan, M.J.
- Noonan, Michael J.
- (Limerick West).
- O'Dea, William Gerard.
- O'Donoghue, John.
- O'Hanlon, Rory.
- O'Keeffe, Batt.
- O'Keeffe, Ned.
- O'Kennedy, Michael.
- O'Leary, John.
- O'Rourke, Mary.
- Power, Paddy.
- Reynolds, Albert.
- Roche, Dick.
- Smith, Michael.
- Stafford, John.
- Swift, Brian.
- Treacy, Noel.
- Tunney, Jim.
- Wallace, Dan.
- Walsh, Joe.
- Walsh, Seán.
- Wilson, John. P.
- Woods, Michael.
- Wright, G.V.
Níl
- Bell, Michael.
- Clohessy, Peadar.
- Colley, Anne.
- Cullen, Martin.
- De Rossa, Proinsias.
- Desmond, Barry.
- Gibbons, Martin Patrick.
- Gregory, Tony.
- Harney, Mary.
- Higgins, Michael D.
- Howlin, Brendan.
- Kavanagh, Liam.
- Keating, Michael.
- Kemmy, Jim.
- Kennedy, Geraldine.
- McCartan, Pat.
- McCoy, John S.
- McDowell, Michael Alexander.
- Mac Giolla, Tomás.
- Molloy, Robert.
- O'Malley, Desmond J.
- O'Malley, Pat.
- O'Sullivan, Toddy.
- Pattison, Séamus.
- Quill, Máirín.
- Quinn, Ruairí.
- Sherlock, Joe.
- Spring, Dick.
- Stagg, Emmet.
- Taylor, Mervyn.
- Wyse, Pearse.
Tellers: Tá, Deputies V. Brady and Browne; Níl, Deputies Taylor and Harney.
Question declared carried.