A Leas-Cheann Comhairle, may I with your approval and the approval of the House, share my time with Deputy Mervyn Taylor?
Private Members' Business. - Health Service Charges: Motion.
Is the House agreeable to the request made by Deputy Howlin? Agreed. Would the Deputy indicate what the division of time is?
I will take the first 25 minutes and my colleague the remaining 15 minutes.
I move:
That Dáil Éireann annul the Health Services (Amendment) Regulations 1987, Health Services (Out-Patient Charges) Regulations 1987, Health Services (In-Patient Charges) Regulations 1987; Numbers 114, 115 and 116 of 1987.
I want to give notice to the House also that the Labour Party will be rejecting all the amendments circularised to our motion. We feel that the issues are clearcut and straightforward and that the Members on all sides of the House will have to decide when it comes to the vote where exactly they stand on these issues and whether they wish to have these charges imposed. We take a jaundiced view of the amendment circulated in the name of the Minister for Health which talks of the provision by the VHI of a special scheme to cover the charges. We understand that the charges are to be imposed as and from next month. It is highly unlikely that the scheme the Minister refers to in his amendment could be in force by the time the charges take effect.
When the Minister for Health who was then Opposition spokesman on Health rose to speak in this House on 16 October 1984 his concern was that the state of the health service was in jeopardy. His proposition was that the health service was being run down and in the course of an impassioned speech in this House he said, and I quote from the Official Report, column 2502.
If we go any lower in our spending on health services, then we must ask what level of care we want to provide for the people. Do we want to provide an acceptable level of care?... I have no doubt that as a result of the Government's policies lives will be lost if we continue on the downward spiral...
He went on to say:
It will dismantle the health services that have taken many years and much hard work to build — health services, I might add, which we can be justly proud of.
There is an irony in the fact that we are here tonight to try to undo some of the damage which this same man, now Minister for Health, who so recently saw himself as the defender of the health services, has done to those services in the very short period he has been in office. The irony lies in the fact that to many people around the country, including a large number who work in the health services or, indeed, the majority who work in the health services, it is becoming increasingly clear that the Government who had purported while in Opposition to be the staunch defenders of the health services for the last year are guilty of gross hyprocisy in pretending that they would be the ones when returned to office who would look after those who were ill.
The messages of the billboard posters, some of which still stand around the country, were that the previous Government's policy would hurt the weakest in our community, that health cuts hurt the weak and the elderly. Those same individuals who paid for those particular pieces of propaganda now propose to continue on the path of dismantling the health services. The attack which has been mounted on the hospitals and other health agencies during the past couple of months has been without parallel in its ferocity. Every day details are becoming available of more lay offs, more essential vacancies which cannot be filled and more projects which cannot be proceeded with. It all adds up to a deterioration in the health care available to our young people which forces those of us involved to speculate that Deputy O'Hanlon was right in his predictions of three years ago. If this goes on, lives indeed will be lost but it is the Minister who will have to accept responsibility for any tragedies which may occur.
Not content with bringing about a situation which threatens to produce chaos in the service the Government propose also to charge all but the very poorest members of our community for access to a service which has for many years been free at the point of delivery. The three regulations to which this motion refers were published on 14 April last. They are the concrete expression of decisions taken and announced by the Minister for Finance in the budget. When they are put together they add up to an outright and vicious attack on a fundamental principle. That principle has underpinned the health services for a generation. It has provided a basic bottom line guarantee to those who are ill or infirm, to the parents of small children, to the aged and to those who sought the assistance and support of the State in times of great distress. It is the principle that health care should be free at the point of delivery for those in need. That principle which informed Fianna Fáil philosophy as well as the philosophies of other political parties will die if these regulations are allowed to take effect.
The first of these three regulations seeks to limit the number of people entitled to free outpatient services to children with a limited range of severe conditions. Those conditions are set out in the regulations — mental handicap, mental illness, PKU, cystic fibrosis, spina bifida, hydrocephalus, haemophilia and cerebral palsy. Children who suffer from these conditions are exempt from the proposed outpatient charge, so are the children under six weeks and children referred to outpatient services following a school medical examination.
In the case of every other child from the age of six weeks until the time that that child becomes an adult there will be a £10 charge each time the outpatient services of a hospital are needed and availed of. The list of conditions which would exempt a child is so limited that it does not include a whole range of serious illnesses which require frequent references to hospital outpatient services. Asthma is not mentioned, though it is one of the commonest complaints among children. I come from a county which has an extraordinary high prevalence of asthma. Indeed, there have been cases of young children dying of this condition. Neither is there any exemption in the case of congenital heart defects or of a range of physical disabilities and handicaps. These are but some examples of the list of complaints which are not included and which will have to be paid for.
Perhaps, of even more importance is the fact that where children are concerned the vast majority of cases requiring outpatient services are cases involving accidents. The number of children taken to hospital for stitches or X-rays as a result of accidents greatly outweighs the number of all other cases. So far as the imposition of the £10 charge is concerned, it costs relatively little to exempt the categories I have outlined. It enables the Government to paint a veneer of compassion over what is actually an exercise in vandalising the health of ordinary people. That is all it is — a veneer. No doubt great play will be made in this debate of the categories exempted from the charge. We will be told about the people who will not have to pay, but the stated intention of the Government is to raise almost £7 million through this charge this year. This means that almost 700,000 people visiting a hospital will have to pay, or three out of every four non-medical card holders will be asked for £10 in return for a basic service which has become established as a right over many years.
I have mentioned children in particular because the first regulation covered by this motion deals with exempted children. The second regulation, number 115, specifies the charge of £10 and again sets out a small number of exemptions. The purpose of these exemptions is to provide a cover for the charge itself. Nowhere is it mentioned in the regulations that people who are of limited means will be exempt from this charge. Only those who are so fundamentally in need as to require a medical card will be exempt. The third regulation will have the effect of introducing a charge of £10 per day for inpatient services up to a maximum of £100 over a 12-month period. That maximum, I would emphasise, is £100 per patient, not per family, and the charge applies irrespective of income. Again there are a small number of exemptions. I must remind the House that the budget target is such that this charge will have to be levied 600,000 times in the remainder of this year. It is hard to see that many people will be exempt. The great bulk of people will have to meet the cost.
Anybody reading the local papers throughout the nation last week will have seen the litany of concern and cries of despair in response to the announcement of these charges and levies. They will affect in the most wounding way citizens up and down the country and the front pages of local papers testify in great detail to the extent to which the medical profession in the first instance realise how these irresponsible charges will bite, hurt and wound.
Taken all together, I would classify these charges as immoral and no amount of exemptions or exceptions will make them moral. They are a crude and vicious instrument whose only effect will be to undermine the standard of health care. If they are applied as rigorously as the Government say they must be and if the financial targets associated with them are to be achieved as the Government say they must, they will cause untold suffering and hardship up and down the nation.
There will be even worse effects. It is all too easy to envisage situations where necessary treatments will be foregone because of the fear of these charges, where children will simply not get the X-rays, where old people will try to nurse themselves at home rather than face the humiliation of going to a hospital with an empty purse. I have already met people who are in terror of the prospect of facing an illness and simply not having the means to cover the charge proposed by the Minister. I know and every Member of this House knows that hospitals will not turn away people because they have no money with them. I have total confidence in the ethics and standards of our medical profession, but I know that people have their pride even when they have little else and that there are many situations where they would simply be unwilling to expose themselves to the fear of humiliation which these charges would visit upon them.
The health services are supposed to be there as a guarantee to people, a fallback in cases which are often very traumatic in themselves. They are the caring services, the human services to which people turn in the most vulnerable period of their lives. To introduce a further element of trauma on top of the original difficulties will have the effect of undermining this basic guarantee, this fundamental principle to which I have referred and will ultimately render it meaningless.
There is yet another reason why these charges are immoral. Let us consider, for instance, the case of a high income earner on the top tax rate. If anyone falling into this category chooses to take out the top VHI plan to cover, perhaps, an extended stay in one of our private nursing homes or medical centres such as the Blackrock Clinic, this State, which is so hard pressed for money, will subsidise that patient's stay by giving him full tax relief on his VHI policy. How is it defensible that the State can be so generous where the health of the well off is concerned and yet will make the poor pay for a basic service? How can there be morality when we turn the screws on those who can least afford to pay while those who are much better off are actually subsidised to choose private medicine? They are subsidised to avail themselves of care which is not available to the weakest and poorest in the community.
Consider another example. We often talk in this House and elsewhere about a free health service but the health service is only free for some. For the great majority of PAYE workers who pay social insurance, the health service is already well paid for. They are paying for it on a weekly basis. Those who have paid week after week through their taxes and insurance contributions are paying for the assurance that the service will be there when it is needed. They have paid for years in the confident expectation that, if they or their spouse or children become ill, the service will be there to take care of them, without imposing upon them a burden which at that crisis point they would be unable to carry.
There are, of course, those in the community who do not pay — the outstanding millions in farmers' health contributions are testimony enough to that. The thousands of workers who pay their way are entitled to feel now that there is little point in continuing to pay for an assurance that the health service will be there when it is needed and free at the point of delivery because that will no longer be true if these regulations are put into effect.
Is there nowhere else we could look for the money to meet the difficulties we face as a nation? Must we as a people, as a community, seek to solve our financial problems at the expense of the sick? Surely we cannot justify such drastic measures as being necessary when at the same time, in the same Budget Statement, we can abolish the land tax and make no effort to raise capital taxation? What sort of mentality recognises a problem and seeks to solve it on the backs of the weakest?
We are well on the road now to establishing private medicine where you pay for what you get, where if you can afford it you will get the best and on a gradualist basis if you cannot afford it, it is going to be tough. There are many countries — I cite Canada as one, which can hardly be classified as a socialist country — where such an attitude would be anathema to all parties. More and more, the view is becoming clearer that we are on the road to privatising medicine. The Irish Medical Times of 17 April 1987 has a subheading: “Hospital Plan, Ward Closures as Grants are Slashed”. Newspapers up and down the country point to the disintegration of our services. I ask the Minister to think again, to look elsewhere for the resources we need to meet our debts. I ask him to turn back from the path of private medicine and continue on the path of providing a proper, defensible and affordable service for all the people.
The amendments put down in the name of the Minister and of Deputies Allen, Cullen and Keating evade the fundamental issues. We have a clear-cut decision to make in this House. Are we in favour of going down the road outlined by the Minister for Finance, endorsed by the Cabinet, of confronting our economic crisis on the backs of the weakest, or are we going to demand an alternative, another way, another route? For all those reasons, I urge Members on all sides of the House not to evade the fundamental issue, but to address the core issue and support the very simple, very clear annulling motion that we as a Labour group put forward here tonight.
I call Deputy Taylor. He has 16 minutes.
One has to call a spade a spade in this kind of situation. The truth of the matter is that the imposition of these charges by the Fianna Fáil Government is a disgrace and an outrage. There is no other way in which it can be described. It constitutes a vicious assault on the standards of working people who cannot afford to meet charges of that nature. We have heard hysterical speeches in Private Members' Time over the past few years about the position of Fianna Fáil, the great caring party, on preserving the rights of ordinary people. What have they done here? They have even excelled the Fine Gael Party. The Fine Gael Party in Government brought in a measure imposing charges on out-patients. Was that monstrosity enough for the Fianna Fáil Government? No, they had the charges imposed not only on out-patients but on in-patients as well. They had to go better than Fine Gael. Let it go down in history where the comparison lies between those two parties. They are imposing £10 on all kinds of visits to hospitals.
It is well known that there are two tiers of medical services in this country. One is called the luxury or private system and the other is the public system. This Government in deciding where they would let their vicious axe fall, chose to apply it, not on the luxury system, the Fitzwilliam Squares, or the Blackrock Clinics, but on the public system, the lower end of the scale where people go who have no money to pay. That is the system this Fianna Fáil Government singled out to come the heavy on, making a vicious imposition of £10 a visit. It will be recalled how in the debate on the Christmas bonus, Fianna Fáil waxed lyrical about hunger stalking the land over a once off payment of £5 at Christmas. Here, they impose a charge of £10 when one's child is injured in an accident and up to £100 if the child must have an operation. I tell the House that this will be remembered to this Fianna Fáil Government for a long time. We shall wait and see how the other parties vote on this motion because here, for once, is an opportunity to rescind these measures by law. Every Deputy in this House who has working people in his or her area has an opportunity to show by vote where he or she stands. It will go out loud and clear where they stand on this.
Let us examine how this scheme will work. Never mind hunger stalking the land as the Minister's colleague, now the Minister for the Environment, Deputy Flynn, said on the previous occasion. Fear stalks the land, a terrified fear in many families, that a husband, wife or child could be struck down and would not be able to get medical treatment in the out-patient's department or go into hospital for an operation, something they have had as of right since the foundation of this State. When they had not £10 in their pocket and knew they had to wait for days to get food on the table, it was comforting to know that if disaster struck, if a child was injured or sick, they could take the child down to the Meath or St. James's Hospital where he or she would be given a warm welcome and caring treatment. They might have been on the breadline, but at least from the health point of view that was always open to them.
What category has the Minister attacked? Take the case of a family on gross pay of £125 a week a husband, wife and two children, outside the band for a medical card, living, let us say, in Tallaght but the same would apply in any working class area up and down the country. If a child gets sick, they take him or her to the doctor. That costs £12. The doctor says the child must go to hospital. They have to make their way from Tallaght to Crumlin Hospital and back with the child. That will cost approximately £3 in bus fares. Just a look at the child costs £10 in hospital — never mind the medicine or the worry — that is £25 in all. Out of a weekly income of £125 a sum of £25 has gone already. The next stage is that following an examination in out-patients the patient may be told that an operation is required and he will have to stay three or more days in hospital. If that person has to go to hospital for an operation he may have to pay £100. How will such people find £100 out of a weekly take-home income of £125, or less? In the light of those charges, will the Minister explain, comments he and his colleagues made in the House in recent years? In the course of a debate on a Private Members' Motion on 18 November 1986 the Minister said:
Fianna Fáil have a long tradition of a caring social philosophy which they cherish and of which they are justly proud.
It is some social philosophy to charge the weakest section of the community, people who can barely scrape by from week to week, for hospital care. What type of caring philosophy is that? The Minister's colleague, Dr. Donal Ormonde, on the same day, as reported at column 2639 of the Official Report said:
... we in Fianna Fáil are forced to highlight the plight of the poor and the needy and to put down a motion condemning the failure of this Government to provide essential health services for the old, the sick and the handicapped.
What are Fianna Fáil doing now? They are taking away a basic facility that has been the entitlement of people here for generations. That is some medical service. The Minister on 4 December 1986, as reported at column 1602 of the Official Report said:
Fianna Fáil are concerned and aware of the ever-increasing costs of health care, but that does not mean that we must abandon what has been traditional in Ireland, which is a caring, social philosophy. Through consultation and planning we must ensure a proper and adequate level of health care for those who are not able to provide for themselves out of their own resources.
It is quite a different story we have now. Your colleague, Deputy Flynn, now Minister for the Environment, said on 26 November 1986——
I must remind the Deputy that he should address the Chair.
I am addressing the Minister through the Chair.
The Deputy has not given that impression.
I am reminding the Minister, through the Chair, of what his colleague said, as reported at column 649 on that date when he was referring to the once-off £5 reduction in the Christmas bonus:
What this Government are doing is mean and stingy.
I wonder what Deputy Flynn would call this new proposal, £10 for a visit to an out-patient department or £10 to bring a child to a hospital following an accident. Deputy Flynn continued:
Whether they like it or not, real poverty stalks this land tonight. This Coalition have no understanding of the difficulties of the old and the unemployed. What does £5 mean to the Minister? It is the price of two gins and tonics in the room next door...
What does £10 mean to the Minister for Health?
It is often said that the three right wing parties, Fianna Fáil, Fine Gael and the Progressive Democrats, have a similar approach to the question of cuts but that is not right. I detect a clear distinction on the question of cuts between the three main parties. Fianna Fáil say they are against cuts but they vote for them while the Progressive Democrats say they favour cuts but vote against them. The Fine Gael Party say they favour cuts and vote for them. In their amendment the Fine Gael Party say that the out-patient charges are all right but the in-patient charges are wrong. They also propose bringing in a prescription charge. Such suggestions are par for the course for the Fine Gael Party.
In the course of the debate on Second Stage of the Bill implementing these charges the Minister was asked who uses this system. There was a lot of play made of the fact that many people who can afford to pay avail of those free services. That may be correct but we all know that most of those who use those services do so following accidents or in an emergency when a doctor is not available. Most of all people avail of those services because they cannot afford to pay the local GP £12. It is those people the Government are attacking by this measure. What is involved in this? I understand that the total saving will be £6 million, a paltry sum, which will be saved off the backs of the poorest section of the community. Did the Government not consider any other measures for raising £6 million? Did they not consider other measures that might be more in tune with the so-called caring attitude of Fianna Fáil? Did they sit back and think that ten years ago capital taxation raised £12 million more than it does today, leaving aside any adjustment for inflation? I am sure that did not occur to them because when they got into Government they could not wait to abolish the wealth tax. The money taken in wealth tax would more than have covered the amount being raised by these monstrous charges.
Fianna Fáil are great for abolishing taxes that affect their supporters. Those who backed Fianna Fáil were caught under the wealth tax. It is the interests of such people that Fianna Fáil serve and I hope that message goes out loud and clear from the House. Fianna Fáil abolished a modest farm tax when they were returned to power. Can anyone imagine the mentality of a Government who purport to represent the interests of working people who abolish a miserable farm tax and being in a new tax that will raise £6 million from those on the lowest pay? In some cases those people only avail of the health service when life is at risk.
In the run-up to the general election I heard Fianna Fáil people say that there could be no further taxation, that the country had reached its limit as far as taxation was concerned. The Taoiseach made a statement to that effect and all the Fianna Fáil documentation carried it. Is not the £10 charge for in-patient and out-patient services a tax? In my view it is additional taxation and the Government have chosen those who cannot afford to avail of the luxury system to pay for it. The people who use those services cannot afford to go to the Blackrock Clinic. The Minister has told us that he will provide insurance cover for those people, that he will have rules and regulations coming in in May. We do not know what the VHI will do but I must stress that this involuntary tax will have to be paid by the weakest section of the community. There is a choice about some of the other taxes imposed, luxury taxes, but there is no choice about this tax. If the need arises and people have to bring their children to out-patient departments of hospitals they will be locked into that system and will have to pay. If the people do not have the money they will be pursued and may have to pay legal costs.
I appeal to all Members to use this opportunity to vote against those taxes. The way Members vote on this motion will be noted in the record of the House for all time. If they vote for the charge they will be remembered forever as having put the lives of people in danger. It is wrong that such fear should be allowed to pervade working class families. Any Member who votes for that will have to live with it for a very long time.
I move amendment No.1:
To delete all words after "That" and insert:
In view of the serious state of the public finances and the need to maintain an adequate level of essential health services and protect the less well off in the community, Dáil Éireann approves the Health Services (Amendment) Regulations 1987, the Health (Out-Patient Charges) Regulations, 1987 and the Health (In-Patient Charges) Regulations, 1987 Numbers 114, 115 and 116 of 1987 and supports the decision of the Minister in regard to the categories of persons exempted from the charges and the provision by the VHI of a special scheme to cover the charges.
I listened with interest to Deputy Howlin and Deputy Taylor and it appears that they have not read the regulations carefully because neither of them referred to the fact that there is in the regulations a hardship clause which gives the CEO the right to exempt persons who are unable to pay for themselves in hospital either as outpatients or inpatients. Deputy Taylor suggested that I had brought fear to the people. I admit that I brought the hospital charges before this House and that the outpatient charges were passed by this House, but we did not bring any element of fear. We went to great lengths to explain that people need not worry about the charges because if they are not in a position to pay the charges there is that hardship clause that the CEO can implement as well as all the exemptions that are listed in the regulations. I suggest that it was Deputy Taylor's side of the House both tonight and on the night we debated the health charges who brought in the element of fear when they suggested that persons would be turned away from hospital because they did not have £10 in their pockets. That did no service to the Irish people.
In the debate about the level of resources which should be devoted to health services it is necessary to look beyond current demands when assessing the appropriate level of provision. The reality is that demand for health services which are provided free at the point of use is, to all intents and purposes, insatiable. This is not a statement of political dogma. It is a matter of fact. It is, therefore, necessary to analyse this question in some broader perspective and commonsense would suggest historical trends and our standing on the international health spending league as obvious criteria.
Looked at historically, the health spending in Ireland enjoyed rapid growth in the sixties and seventies and it is only in the period from 1981 to 1987 that this growth trend has changed. In the period 1973-74 to 1986 net non-capital spending on health services increased from £143 million to £1,194 million. This represents a real growth in the proportion of national output devoted to health services. Health spending as a proportion of GNP increased from 5.2 per cent to almost 7 per cent over this period.
This remarkable growth in resources was reflected in a significant expansion in the quantity and quality of health services provided, in the emergence of new services, particularly in the community care programmes, and in the broadening of eligibility for publicly funded health services. The increased level of resources also facilitated the development of a range of personal social services reflecting a broadened remit for the Department of Health and their agencies. This period of sustained growth in health spending is the backdrop to the efforts now being made to contain spending.
This situation is not unique to this country. Similar trends have been recurring in European countries, notably Denmark, for the past number of years where the same problems are being addressed. Every country in Europe has had to curtail their levels of expenditure and, indeed, they have been approaching that task in a pragmatic manner during the past four years. That is what we should have been doing instead of being in confrontation with the various health agencies and making no progress in rationalising our health services. Denmark, for example, closed 700 beds per year for seven years consecutively. In general the responses are the same here, that is, there is a need for the containment of the level of resource than can be devoted to health.
This historical background is highly relevant to the current debate about health spending, for it was during the decades of growth and expansion that expectations of a continuation of those trends were formed. These expectations would be realisable in a situation where the economy continued to grow and where spending on the development of social services generally would be funded from the wealth thus generated. The reality of course is that our capacity to spend has by far outstripped our capacity to raise revenue and a growing proportion of the resources available for current spending is absorbed in servicing the enormous burden of indebtedness which we have incurred in bridging the gap. Unless we restore order to the public finances, the community's expectations in areas such as the health services will of necessity have to be lowered well beyond what can reasonably be expected in 1987. This is the reality we must face. I should say, however, that, despite our over-all financial difficulties, the Government found it possible to increase the approved expenditure on health services from £1.298 billion in 1986 to £1.315 billion in 1987.
It is important to realise that in the health services we have an area of expenditure which has within it an inherent tendency to grow. There are growth pressures on the health system from demographic factors and due to the continuous development of new health technologies. In our system patients use the service without regard to cost. Similarly, the incentive structure facing health service providers encourages the consumption of more rather than less. Thus, if left to its own devices, the health system would simply continue to grow, absorbing an increasingly greater share of the resources available for public services generally. That is why we need to pay particular attention to the health services in the overall strategy for controlling public spending.
Looked at from an international perspective, the concern about health spending is not peculiar to Ireland. The size of health expenditures and their inherent potential for growth is a matter of concern in developed countries generally. This observation is all the more relevant given that our spending on health services as a percentage of GNP compares favourably with other developed countries, given our relatively less favourable position in terms of GNP per capita. In other words our spending on health services tends to reflect the levels of richer rather than poorer countries. This is the background to the Government's decision to curtail public spending on health services during 1987. It is, of course, but one part of the broader strategy which aims to regain control over the public finances. I find it disturbing that while there is broad agreement both in this House and more generally on the nature and scale of the public finance problem we face, there is a failure in some quarters to make the logical connection between control of the current budget deficit and Exchequer borrowing and the measures which have to be taken in relation to public services in order to bring about the necessary adjustment in spending. This is not an inability to understand what is at stake but a reluctance to face up to the realities of the situation and take concrete measures which will make a real contribution to the resolution of our problems.
In relation to the health services, it has to be stated quite plainly that our existing problems derive principally from the fact that the previous administration made virtually no attempt to contain the level of over-spending of agencies which between 1985 and 1986 aggregated £55 million. In other words £55 million was over-spent by the Coalition during the last two years and that has placed an intolerable burden on our Government who are now faced with the problem of trying to correct that. Naturally that proves difficult but we will tackle it and deal with it. This lack of control and the natural tendency of the agencies to spend to the absolute limits of their credit left this Government in a situation where hard measures have to be taken to protect the infrastructure of the services. If we do not take these measures, and we recognise that they are not popular, the situation of our health services would be worse in years to come.
Resources which should be put to providing services have to be put to servicing a serious level of indebtedness created by the previous Government. What is called for now is a rigorous control on personnel and overdraft levels. This will be the central feature of my administration until the health services are brought into line with what the realistic financial climate can bear.
In bridging the gap between what would be required to maintain health services at existing levels and what was available, the Government had a number of options open to them. The challenge was to meet the shortfall in a way which would impact least on the most vulnerable members of the community preserving essential services and protecting those which cater for the handicapped and the elderly.
I turn now to the specifics of the motion before the House. At the outset, I again want to make it clear that the charges for in-patient and out-patient services will be imposed only on those who can reasonably afford to pay. This underlying principle is clearly reflected in the regulations which provide the statutory basis for the levying of charges. The motion is, in effect, a challenge to this principle.
I will go into detail later on the protection in the regulations for those on low income, the unemployed and those who will not be charged because of their financial circumstances. As all of these groupings are exempt from any charge and will continue to avail of in-patient and out-patient services free of charge, I can see little basis to the challenge to charges on those who can reasonably afford to pay, given the budgetary constraints under which the health services are now operating.
After all, the revenue from the charges will be of direct and immediate assistance to the maintenance of those services not only for those who have been subject to a charge but also for those who will not be asked to pay. Surely this is a progressive method of redistributing the wealth of the country. I referred earlier to the economic and budgetary situation which the Government have inherited, an inheritance, I may add, which has placed us all in severe financial difficulties and has lead to the necessity to introduce the charges.
The grounds on which the measures taken in the regulations have been challenged have nothing to do with equity or hardship but are clearly in the area of political opportunism of a disturbing nature given that it is the old, the vulnerable and disadvantaged who have been needlessly subjected to distress over these measures.
I have referred to what has been said by members of the Opposition in terms of creating fear in the minds of people that if they turn up at the hospital they will not receive the necessary attention if they do not have £10. Nothing could be further from the truth. Hospital managers interviewed on radio have pointed out that nobody will be turned away. We went to great lengths to ensure that in the regulations there will be provision for hardship. Apart from expectant mothers and those who hold medical cards, the CEO has the right to waive charges where those charges will cause hardship. Added to that there is the VHI scheme on which I will be saying more later. The grounds on which the measures taken in the Regulations have been challenged have nothing to do with hardship, but are just political opportunism.
I wish to state quite clearly and unequivocally and to put it on the record of this House that charges will not be made where they would cause undue hardship. This fundamental rule is enshrined in the Health Act, 1970, and repeated in the regulations in order to avoid any possibility of doubt as to its reality. Both sets of charges — the in-patient and out-patient charges, will as and from 18 May be subject to this rule. I and indeed other Members of the House have received numerous representations from persons anxious about their circumstances. In most cases that anxiety is groundless and in the others the situation will be far less costly than anticipated.
I would now like to explain in detail the categories of persons who will not be charged.
1. Medical card holders and their dependants. Approximately 40 per cent of the population are holders of current medical cards which covers approximately 1.3 million people.
2. Women receiving services in respect of motherhood. This covers all in-patient and out-patient services which are in respect of maternity.
3. Children up to the age of six weeks. Children referred for in-patient or out-patient services arising from a health examination at primary school, health centres or clinics and children suffering from prescribed diseases or disabilities. I will refer at a later stage to this last mentioned group in view of the fact that the motion seeks to annul the regulations which prescribe these diseases and disabilities.
4. Persons receiving services for the diagnosis or treatment of infectious diseases prescribed in the Infectious Diseases Regulations, 1981.
5. Lest there be any doubt about it, persons who are deemed by the chief executive officer of a health board to be unable without undue hardship to pay an in-patient or out-patient charge for themselves or their dependants will also be exempt.
I refer Members to paragraph 4h of the in-patient regulations and 4g of the out-patient regulations. This provision gives a chief executive officer the discretion to waive charges if he considers they would cause undue hardship. Contrary to views already expressed this discretion is a reality and is statutorily based. I hope at this stage we will not hear any more from people trying to instil fear in the minds of the public, that they dare not go to hospital for fear of being turned away, because that will not happen.
The five categories of persons I have just outlined will be exempt from both inpatient and outpatient charges. Due to the different nature of inpatient and outpatient services additional exemptions will be in force in respect of each of the services. The inpatient charges will not apply to persons in respect of long term care in geriatric, psychiatric or mental handicap institutions as separate provisions already apply to such persons.
An overview of the exemptions and of those who will be liable to a charge clearly results in a balanced and equitable approach to the levying of charges. I should add that this is in marked contrast to particular features of the proposed Fine Gael budget earlier this year. The Labour Party refused to support specific measures including the unbalanced and inequitable proposal to introduce prescription charges. The proposal was to impose a charge of £1 per prescription item under the GMS with a refund of the amounts over £5 in any one month in respect of each person. Not one single person who would have been liable to what can only be termed as a disgraceful charge will be liable to an inpatient or outpatient charge. Medical card holders, by definition, are those who are unable without undue hardship to provide medical and related services for them selves or their families. Yet they were being asked to be directly responsible for saving the considerable amount of Exchequer funding as proposed in the Fine Gael budget outlines. On the other hand, the protection of the vulnerable sections of our community is a salient feature of this Government's approach to the raising of additional revenue for the health services.
I wish to turn to the collection of the inpatient and outpatient charges which has given rise to concern in some quarters. It is important to state that the charges which will be introduced are statutorily based. Both sets of charges will have legal effect and health boards and hospitals are legally obliged to levy and collect the charges and, for those persons so levied, to pay. It is the intention that the charges will be made at the time of receipt of the service or on discharge from hospital as appropriate.
In the case of scheduled attendance for outpatient services, health boards and hospitals have been requested to give those attending, prior indication of whether they will be liable for a charge and in the case of inpatient charges what the level of charge is likely to be. Such arrangements will allow for ease of collection as persons will know in advance their liability. It also provides a mechanism whereby persons, unable because of financial constraints to meet the level of possible charges, can have their position assessed as to whether the charges should be waived on hardship grounds. There will, of course, be situations in which it will not be possible to collect the charge at the point of delivery. Accident and emergency cases is one obvious example. I have no doubt that a commonsense approach by both users and providers of the service will avoid any unnecessary difficulties in that area. I should point out that it is not a question of a hospital adopting a "pay up or else" approach to the provision of services. It has always been the tradition in this country that those in need of treatment are provided with the required treatment, and this will continue. As I said a commonsense and reasonable approach will resolve difficulties in this area.
This year's allocations to health boards and hospitals have taken into account that revenue will be raised by the charges for the direct use of the health board or hospital levying the charge. Accordingly, it is incumbent on the relevant staff to co-operate as fully as possible in the collection of these charges. If the revenue is not collected the existing difficult financial situation will be exacerbated. Indeed, listening to Deputies on the Labour benches who do not want these charges, who do not want an increase in income tax——
Capital tax, land tax.
The land tax that was abolished is being replaced by the collection of VAT from farmers so there will be no loss to the Exchequer this year. I am sure Deputy Howlin would agree that the fairest way of collecting tax from farmers is the same as that applicable to everybody else, on their profits. Any shortfall in revenue from this source will directly affect the particular health board or hospital in which such persons are employed and will require a reduction in the level of service and in employment.
The choice is simple: either the charges are collected and the revenue raised or the boards and hospitals will be faced with an even more difficult situation in managing to live within their allocation. Exchequer funding will not be allocated to make good any losses in this area. Shortfalls in the allocation of revenue will also result in a reduction in the scope and level of services already supplied.
Similarly it is in everybody's interest, and I am sure those employed in the health services agree, that in times of severe budgetary constraints every effort should be made to protect services. I have no doubt that managers at hospital and health board level will be available to discuss any potential difficulties in this area. However, the bottom line is that health boards and hospitals require the income from the charges to maintain existing services and also to maintain employment.
The motion as well as seeking to revoke the regulations which impose charges also seeks to revoke the Health Services (Amendment) Regulations, 1987. In order to explain fully the implications of this proposal and to leave nobody in doubt as to its possible effect it is necessary to refer to the Health (Amendment) Act, 1987. The Act amended section 56 of the Health Act, 1970 which refers to the provision of outpatient services. The amending Act enables regulations imposing charges for such services to be made. Regulations made in 1971 under the unamended section 56 of the Health Act, 1970 provided that no outpatient charges could be made in respect of children suffering from permanent or long term conditions or disabilities such as mental handicap, mental illness, cystic fibrosis, spina bifida and cerebral palsy. As section 56 of the 1970 Act was amended I considered it prudent, in order to remove any possible legal doubts as to the situation of such children, to make new regulations under section 56 as substituted by the provision of the Health (Amendment) Act, 1987. These regulations restate the same conditions and disabilities as prescribed in 1971 and make it clear that no charges may be made on children suffering from these conditions. The motion seeks to have these regulations revoked which provide a clearcut benefit to such children.
I should also like to emphasise the point that outpatient charges are not new. They were introduced in 1982 and were part of the Fine Gael budgetary strategy in 1987. Furthermore outpatient charges have been levied for some time by some health boards.
I should now like to turn to the level of charges to be made. The out-patient charge of £10 will be in respect of the first visit for a particular medical condition and will not apply to return visits for that medical condition. A single charge of £10 therefore covers visits to consultant staffed out-patients' clinics, hospital casualty departments and referrals for pathology, radiology or physiotherapy services in respect of a particular medical condition. Regardless of the number of return visits and the number of out-patient services availed of by an individual one charge only will be made. Given that a visit to a general practitioner would be in or around £10 and in some cases more, I consider the charge to be reasonable. It is generally accepted that hospital casualty departments are abused, perhaps unconsciously, but certainly without any consideration to the demands placed on hospital staff and other resources to meet genuine accident and emergency cases for which casualty departments are primarily available. The out-patient charge will bring needful rationalisation to the usage of casualty departments and avoid abuses of such services.
The in-patient charges will be at a rate of £10 per day during which in-patient services are availed of. The maximum payment in any period of twelve consecutive months will be £100. Accordingly, any hospital stay over ten days, regardless of the number of in-patient attendances throughout the 12 month period, will not be charged. In cases of a serious accident or acute conditions which require hospitalisation for several weeks or months the maximum charge will be £100 in any year.
To put this charge in some perspective I should point out that it costs around £1,000 to £1,300 per week to treat patients in some acute hospitals and that our expenditure on the general hospital programme will be £657 million in 1987.
Small and all as they are in relation to the total expenditure involved, these charges might impose some financial strain on a number of people in the middle and higher income groups. There is an obvious need for insurance services to cover the charges and the Voluntary Health Insurance Board will meet this need. At my request, the VHI are making the necessary insurance cover available, details of which will be announced shortly. The scheme will be moderately priced, say of the order of £10 per year for a single person and £25 for a typical family of two adults and two children. Full income tax relief will, of course, apply in the usual way in respect of these premiums. There is one other point I would like to make to the House. Existing VHI policy holders will be covered free for the current year. I have arranged that the VHI will make the new scheme available to all persons who wish to join, irrespective of their age or medical condition. The restrictions relating to age on entry and previous illnesses which apply in the case of new members joining existing VHI schemes will not apply to the new scheme. Anybody, irrespective of age or medical condition, will be fully covered for the new charges from the day he joins.
The House should pass these charges. They are necessary to ensure we maintain the proper level of service. In view of the regulations, the exemptions for those who have difficulty in paying and the introduction of the very reasonably priced voluntary health insurance scheme the House should accept our amendment.
I move the amendment to amendment No. 1:
To delete all words after "Dáil Éireann" and insert:
calls on the Government to rescind its decision to impose a charge of £10 per day for non-medical card patients in public wards; and to raise and introduce instead a modest prescription charge which will reduce the excessive incidence of visits to doctors and the consequent over-prescribing of drugs, to the extent necessary to produce equivalent savings in public expenditure.
I ask the House to support this amendment.
I understand the Deputy desires to share his time with his parliamentary colleague.
I will take 20 minutes this evening and two or three minutes tomorrow evening. I will allow my colleague, Deputy Flaherty, take the rest of the time.
Our approach is socially desirable — I will give the reasons for that later — and at the same time will allow the Government to stay within their budget. In the past few weeks there have been a series of the most savage cutbacks since the foundation of the State. The decisions made by the Minister for Health will mean the loss of thousands of jobs in the health service, the closure of hospitals, the closure of wards and a serious cutback in the range of services available to the public, as well as longer waiting lists. One of the fallouts from the recent proposals put forward by the Minister, which I heard only yesterday, was the imposition of a £1,500 training fee for nurses and a drop in their salaries. How successful that proposal will be remains to be seen.
The cuts proposed by the Minister, Deputy O'Hanlon, make his predecessor seem like Florence Nightingale. The decisions were made with little thought and with a smack of ad hoc-ery of the worst kind. No attempt whatsoever has been made to deal with the fundamental problems of our health system. I outlined some of those in my first contribution to the House as Fine Gael spokesman on health. They are; the management system that prevails at present in the health boards; the irregular practices throughout our health system; the serious wastage of public moneys and public contracts; the common contract, and attending to abuses.
The attitude of the Fianna Fáil Party bears no resemblance whatever to that of the Fianna Fáil Party of January last. They have carried through one of their greatest confidence tricks on the Irish people. They have changed their minds since assuming power. It is the old story of power at any price. I quote from The Irish Press of 9 April an extract from the Minister's speech in January 1986:
There is no further scope at the present time for cuts. The health boards have done an excellent job in preventing the level of service from deteriorating further than it already has.
They all have deficits and it would be wrong at this time to reduce the allocations further. You would be putting lives at risk by doing that.
The Minister should pay attention to what the Deputy is saying.
In The Irish Press of 7 February there are headings such as “Must the old and sick suffer more vicious health cuts?”, “Major Hospital Cutbacks” and “Closures will mean lack of proper care for a large proportion of our community”. What about Clonakilty hospital which is on the chopping block at present? In The Irish Press of 17 February there is also a heading “Better Care for the Old and Sick”. I ask the Minister to set out clearly his plans for the health service. I would like him to tell us what will happen to many of our welfare homes, district hospitals and general hospitals. What will happen to hospitals such as the one I mentioned in my health board region, Clonakilty hospital, where the old are cared for? What will happen to the North Infirmary Hospital which suffered a 20 per cent reduction in its budget for this year? To move to the Mid-Western Health Board, what is the future for Nenagh General Hospital, Thurles General Hospital and St. John's Hospital? What about Barringtons Hospital in Limerick? What is the future for hospitals in Tullamore, Mcnaghan — that will be very interesting — Letterkenny, Roscommon, Kilkenny, Killarney, Dundalk, Ennis and Athlone? What will happen to the staff of the eight health boards who will be affected by the cuts? We deserve a full and clear statement of the Minister's intentions for all these services.
Fine Gael, in responding to the tidal wave of fear and anxiety generated by the Taoiseach and his Health Minister, wish to reassure the public and especially the old, the lonely, the mentally handicapped, the sick, those terminally ill and staff members in all the health services that our party will not tolerate a situation where the Government continue to be less than open and honest with everybody involved about the serious position which now obtains in our health service. A ministerial style that generates fear and anxiety among those who have enough serious problems must be looked at with concern. It strikes fear into the weakest in our society and even the county councillors throughout the country at present fear that the cure as proposed by the Minister will terminate the patient. These councillors agree with our proposals, that a modest prescription charge which would bring in an equivalent amount of money would be far more desirable socially.
People now realise, maybe too late, that our party set out in an honest way the full facts of the health service and told the truth about the problems facing the health service. From time to time the former Minister, Deputy Desmond, who was in the House earlier, and Deputy Boland were viciously attacked by the present incumbent for their decisions. I mentioned the common contract earlier which is one of the fundamental problems besetting our health service. It was the present Taoiseach who presided over the negotiating of that contract and developed the poorly managed, decaying health system that we have in this country. The ad hoc disjointed incremental approach used in the planning and management of our health services was the bequest of the present Taoiseach when he was Health Minister.
Many Irish people wonder why the health services are now so threatened and so quickly threatened. We know that there are cash limits on expenditure. Now we need a planned approach with full consultation with all involved in the health services and on a political level. All the cards must be placed on the table about the problems besetting the health service. Fine Gael will contribute in a realistic manner to the debate which must commence now.
The fundamental questions which must be asked now are what are Ireland's health care needs? How do we decide what these needs are? What type of health care system is most suitable for the Irish people? What funding arrangements should be made for our health services, and what type of management system should be put in place? Do we need large hospitals or should we have smaller units? How should we involve third party funding agencies such as insurance companies? Do we need formalised medical audit systems in place or health professionals audit systems in place? Would quality assurance programmes in all institutions and services facilitate more cost effective utilisation of resources? All these questions I address to this House and it is an area on which we should have realistic discussions. I ask the Minister to establish a special committee of this House to examine these issues in depth because the health service which is costing approximately £1.3 billion of Exchequer funds is in crisis and needs radical treatment.
We have a responsibility to the old, the sick and the mentally handicapped to design a health care system responsive to their needs. The politics of fear, of generating unnecessary anxiety must cease. We need to begin a process of consultation, a process of objective option appraisal and analysis leading to a rational decision-making process. We must not delay any longer. Our health bill is increasing all the time and we seem to be getting bad value for money.
Fine Gael are a party who wish to be constructive, and to respond to the challenges now facing the country. I do not propose to indulge in ministerial or Government bashing, but I say to the Minister and to the Deputies with responsibility for health care in the other parties that we should ask the Minister to consider my proposal to set up a special committee to deal with health matters. Let us seek an objective consensus in what we are to do, to save and redirect our health services, and not to do anything that is foolish and will generate unnecessary fear in our people. Tough policy options must be looked at and faced.
We can face these options if we have a planned approach with consultations and understanding of what the country must do to redirect our future. Health care is an emotive and political subject and it strikes at our very being.
Earlier the Minister mentioned Denmark. We can learn from the more successful and smaller European economies. We can use the resources of the World Health Organisation to undertake a situation analysis of areas of our health care system and to advise on our options. Once we allay fears we will gain acceptance at local and national levels that decisions must be faced. If the decision-making process is open and honest, acceptance will be possible.
On the £10 charges for hospital beds, the Minister is trying to force people into a VHI scheme to absolve him from facing up to the question of the utilisation of our State-funded hospital system by the private sector and in order to avoid making radical changes in the managerial system of our health boards. Surely there should have been an income limit under which persons would be exempted from those charges, and surely a modest increase in premiums of VHI for the well off is infinitely preferable to impoverishing those already in financial distress, that is, those who do not have medical cards and cannot afford VHI, a fair percentage of the population.
I suggest that this £10 in-patient charge is uncollectable. It would create extraordinarily difficult administrative problems for the health boards and voluntary hospitals, and would add another layer of bureaucracy to an already collapsing health system which we cannot afford. Even to administer the exemption process would also create bureaucratic problems. How can we administer this system when we are faced with an embargo on the setting up of new posts?
I believe our amendment, which introduces a modest prescription charge, is socially desirable. I believe the whole area of prescribing patterns and visitation patterns for doctors under the GMS scheme need to be exmained in detail. It is extremely worrying to note that between 1983 and 1985 there has been a hefty increase in the average number of prescriptions for persons who are medical card holders. "Health Statistics, 1986", shows that between 1983 and 1985 there has been a 4 per cent increase in the number of doctors' visits, an alarming 13 per cent increase in the average number of prescriptions per person, as well as a further 13 per cent increase in the average number of items prescribed. Surely the health of the population is not worsening at that rate? This is an area where considerable savings could be made. Those figures underpin an undesirable social practice. I believe the imposition of a modest prescription charge is socially desirable.
My party agree with the broad thrust of the economic approach of the present Government but disagree fundamentally with the manner in which some of the cuts are being applied. On an evening when we are discussing the imposition of health charges, I believe that this ad hoc approach will not allow our national health service to survive. I also believe the critical question facing the health service at the present time is how to develop and manage our health service in the most cost effective and efficient manner having regard to available resources and the real needs of our people. Surely we, as a Parliament, must respond to the document “Health, the Wider Dimensions”? This is for discussion in another debate. However, the present fire brigade approach of the Minister must be condemned especially as he has not addressed the basic problems of the health services. His fire brigade approach will cause even more serious damage to our health services.
I want to discuss now the efficiency and the savings that could be made in our hospital services. Stricter control of our capital projects must be undertaken and I ask the Minister to look at this area. Moneys have been wasted on certain projects such as Tralee and Beaumont and even at present in my own health area, the Cork Regional Hospital which has been built seven years, is showing signs of serious defects which pose major questions about how money was spent on our health services in the past. I ask the Minister to reply to some of the questions which have been raised by the different health boards in recent times. Like everybody else, I have read the papers and have seen reports of job losses, cutbacks in services and so on, but before he does any further damage I ask him to look at the fundamental issues affecting our health services.
I ask the House to support our amendment. I will now hand over to Deputy Flaherty.
Debate adjourned.