National Health Insurance Bill, 1941—Second and Subsequent Stages.

Question proposed: "That the Bill be now read a Second Time."

Parliamentary Secretary to the Minister for Local Government and Public Health (Dr. Ward)

This is a Bill to amend the National Health Insurance Acts, 1911 to 1936, by modifying the financial system on which the existing Acts are based so as to permit the release for expenditure on additional benefits of part of the income of the National Health Insurance Society which at present is carried to reserve. For a proper understanding of the Bill, it is necessary to go back to the position of health insurance before the passing of the Act of 1933 which amalgamated all approved societies and branches and replaced them by the National Health Insurance Society. There were then some 85 of these different societies and branches, and their assets consisted partly of cash investments and partly of book credits known as reserve values. These reserve values represented that part of the liability which each society assumed by admitting to membership persons who were over the age of 16 years when they became insurable for the first time. Provision was made for their redemption by a sinking fund which was formed by putting aside a proportion of the weekly contributions and used to convert these national investments into actual cash investments. The retention of part of the contributions for the sinking fund was made possible by the assumption by the Exchequer of a liability to pay two-ninths of the actual expenditure by societies on benefits and administration until the reserve values had all been converted into cash.

Each approved society was a separate self-governing entity with its own benefit fund and invested assets. While every employed person was compulsorily insured he was free to join any society which would accept him. Owing to competition between societies some societies might expand their membership, others such as those confined to a particular trade or class might maintain a stable membership and others for various causes might suffer a steady diminution in membership. As no society had any guarantee of continuity of membership the method of finance had to have regard to that fact so that the principles of actuarial valuation might apply to them as in the case of voluntary insurance bodies. An actuarial valuation applies at regular intervals, usually five years, a test of the sufficiency of the existing assets of a society to provide in the future for its liabilities towards all persons in the society on the valuation date. It is a measure of the funds which a society should have so that, if it never recruited another member, these funds, together with future contributions, would provide all the benefits to which the members would be entitled until, in the course of time, through death, transfer or lapse of membership, the society had ceased to exist.

The National Health Insurance Act, 1918, effected certain modifications rendered necessary by experience of the working of the scheme which showed that the finances of societies required strengthening. This was achieved by additional State aid and by reducing the sums retained for the service of the sinking fund to redeem reserve values. The sums diverted from the sinking fund were used to establish a contingencies fund for each society and a central fund available for all societies. The object of the contingencies fund of a society was to provide a first line of defence against a deficiency in the benefit fund on valuation. The contingencies fund was left out of account on valuation, but if a deficiency emerged it was used to make good the deficiency. So far as it was not used it was credited to the benefit fund and became available in that fund at the next valuation. The object of the central fund was to come to the aid of a society with a deficiency which its own contingencies fund could not cover. Assistance to a society from the central fund was given only when it was clear that the deficiency was due to circumstances over which the society had no control. Its income was derived in part from a proportion of reserve value deductions, part from State grant, and part from the moneys available from unclaimed stamps. The State grant ceased in 1921 and since then the central fund is supported solely by moneys out of unclaimed stamps.

Another fund, known as the reserve suspense fund, was set up to deal with the necessary adjustments as regards new entrants to insurance; the transfer of members from one society to another; or lapse from insurance. Since unification transfers are now confined practically to international transfers to and from Great Britain. These complicated technical arrangements were an essential part of the old individual society system. When the financial position of some of these societies gave cause for anxiety some ten years ago, and it was evident that a continuation of the system would result in the further growth of anomalies and inequalities between different groups of persons, indefensible in a national insurance system, the Act of 1933 was passed unifying approved societies in the National Health Insurance Society. It was recognised that the reserve value system was no longer appropriate to a national society and that the principles of actuarial valuation were capable of considerable modification. Departmental consideration was given to the matter and discussions with the actuarial adviser were directed towards the question of what changes in the financial system were possible and desirable. One of the first obstacles to progress was the absence of reliable standards applicable to this country for the measurement of factors affecting the actuarial basis of the scheme. All previous valuations had been made on standards originally based on British experience which had ceased to apply. The first task was to collect information on which a reliable standard of measurement could be based. The provision of the information required was undertaken by the new society, and data covering a period of years was supplied to the actuary who furnished a report on the sickness experience of the society.

In the meantime consideration of the financial position generally had continued as a result of the valuation made on unification at the end of 1933, which had disclosed a deficiency of £46,700. The contingencies fund of £183,000 had been drawn on to meet this deficiency, the balance, small in relation to the future liabilities, being carried forward. In making this valuation, previous methods and standards of sickness and mortality, etc., as in previous valuations had been used, but the report as to the sickness experience showed that these standards did not provide a proper measure of the society's liabilities and that a valuation on the basis of the society's own experience would show a large deficiency which would call for a reduction in benefits or an increase in contributions. It was considered, however, that the principles underlying valuations of individual societies could not properly apply to one national society to which all persons entering insurance must necessarily belong. Although the excess of income over expenditure amounted to sums varying from £150,000 to £200,000 a year, which were being added to reserves, nevertheless, on the old valuation system, these reserves were insufficient. It was, however, felt that in a comprehensive national scheme as distinct from a commercial scheme or a scheme worked through a multiplicity of societies new considerations might be taken into account subject to the best expert opinion available.

The Department's actuarial adviser was, accordingly, consulted and the result is contained in his very informative report dated 28th March, 1941, which has been presented to the Oireachtas. That report confirmed the departmental opinion that fundamental alterations in the financial structure of the scheme were possible and that, instead of continuing to accumulate reserves, an appreciable proportion of the society's income might safely be regarded as available to provide additional benefits for its members.

The Bill now before the Seanad provides for the repeal of all those sections of the National Health Insurance Acts which deal with the crediting and debiting of reserve values and transfer values and with the provision of a sinking fund for the redemption of reserve values by means of a deduction from contributions. It also repeals the provisions relating to the contingencies fund, which, as already explained, is formed by placing to temporary reserve a proportion of the contribution income. The result of these repeals will be that the whole contribution income of the society, which hitherto has been apportioned between the benefit fund, including the administration account, of the society, the contingencies fund and the sinking fund for redemption of reserve values, will be credited to the benefit fund and administration account of the society. The Bill also provides for the repeal of those sections of the existing Acts governing valuation and the manner of dealing with a surplus or deficiency arising on valuation. Instead of these provisions, the Bill proposes that, as at the dates on which a valuation under the existing Acts would normally be made, there shall be made a comprehensive actuarial review by an actuary appointed by the Minister with the consent of the Minister for Finance.

In his review, the actuary is to have regard to the amount by which the income of the society, other than that available for administration expenses, exceeded the expenditure on benefits, medical certification and the provision of transfer values during the preceding five years, and he is required by the Bill to report as to the amount of such excess which, in his opinion, may be made available for additional benefits in the next succeeding additional benefit period. The type of report contemplated would correspond to the report to which I have already referred and which governs the amounts which will be made available for additional benefits in the five years beginning 1st April, 1942. The Minister, after considering any such report, is to determine the amount which may be made available for additional benefits, and the society may submit for his sanction a scheme for the provision of such additional benefits. The Bill proposes to make no change in the list of additional benefits contained in the existing Acts.

Under Section 3 of the Act of 1911 two-ninths of the cost of the provision of additional benefits including the cost of their administration is borne by the Exchequer. It is contemplated that the amount to be made available for additional benefits in each of the next five years will be £175,000 of which about £39,000 will be borne by the Exchequer. The Central Fund is to be reconstituted as the National Health Insurance Reserve Fund, and will in future be the only resources of the scheme held in reserve to meet adverse experience. It is of the highest importance that the existing capital assets of the society which represent the investments of its benefit fund, should be maintained intact and should not be encroached upon. They are under no circumstances available for distribution. They perform the function of producing by way of interest, an income which is a supplement to contributions. If this interest income were to fail then it would be necessary to replace it by an increase of contributions. If adverse circumstances were experienced in which the income of the society fell to a level lower than that necessary to provide ordinary benefits, or if the claim rate so increased that the income was no longer sufficient to meet it, then the proper procedure would be not to encroach on capital assets but to increase contributions or reduce benefits in order to restore equilibrium.

For this reason the reserve fund is of importance. Its purpose is to perform the functions of a contingencies reserve fund and it is proposed that it should be allowed to accumulate by its own interest and by the addition from year to year of certain moneys made available from the proceeds of unclaimed stamps until, in the opinion of the actuary, it has reached a figure which will constitute a reasonable reserve. He will consider its position at each quinquennial review and will advise as to the amount, if any, which may be transferred from it to the benefit fund of the society. Any amount so transferred will be taken into account in deciding the amount made available for additional benefits. The Bill also deals with the disposal of moneys representing unclaimed stamps, and proposes that an amount not exceeding £15,000 of these moneys be paid each year to the Exchequer as an Appropriation-in-Aid of the cost of central administration, the balance being credited to the new reserve fund. Under the existing Acts, the State bears two-ninths of the expenditure on benefits and administration by the National Health Insurance Society. It contributes a substantial amount by way of State grant on contributions, provides the cost of the district medical referee scheme and in addition the whole cost of central administration, including the cost of printing contribution cards and of the printing and sale of insurance stamps. Including expenditure in respect of National Health Insurance by allied Departments the whole State expenditure at present on National Health Insurance is £321,000 a year. The present Bill will add to that expenditure by the State, two-ninths of the cost of the additional benefits to be provided amounting to £39,000 annually.

The remaining provisions of the Bill are rather technical in nature. They deal with the winding up of the contingencies fund, the sinking fund and the reserve suspense fund; with the cancellation of reserve value; with the provision of transfer values in cases of transfers of insurance to or from Great Britain or to or from the military forces fund; and with the allocation of interest income amongst the various funds and accounts on which interest is earned.

Before I conclude I think it well to say that this Bill is, to some extent, experimental in character. The changes made in the finances of the scheme are fundamental, but it must not be taken that they permit of any loosening of supervision and control over the existing financial resources. Because the income of the scheme has regularly exceeded the expenditure, it must not be assumed that a satisfactory position exists, allowing of large extensions of the benefits, limited only by the amount of that excess. On the contrary there are indications that the position is far from satisfactory in certain respects and the actuary in his report of 1939 dealing with the sickness experience and also his report of last year dealing with the general financial position has drawn particular attention to these.

It is clear from his reports that the rates of incapacity for which payment to members is being made by the society are exceedingly heavy, particularly in regard to disablement benefit, which are two or three times the corresponding British rates, and far exceed the amount of incapacity for which provision was made in the financial basis of the scheme in this country. He states that unless drastic administrative measures are taken successfully to eradicate the "claim habit" the incapacity experienced will have to determine the actuarial basis of the scheme. This is a question which is actively engaging the attention of the society and the Department.

The actuary also draws attention to the comparatively low proportion of persons of insurable age who are insurably employed in this country, while pointing out that in recent years a considerable increase in members has occurred, particularly at the later ages, and concludes that the insured population, both as regards numbers and age distribution, is not in a stable position. He adds that since changes in numbers and age constitution may have a marked effect, not only on the capital liabilities of the scheme, but also on the average cost of benefits, it must be remembered always that this instability in the insured population is a factor of fundamental importance in considering the effect of far-reaching amendments of the financial arrangements and enlargements of the scope of benefits. The need for extreme caution is evident. It must not, therefore, be assumed that, because recent experience allows of a temporary enlargement of benefits, there is a certainty of continuing these additional benefits indefinitely.

Apart from the very important considerations advanced by the actuary, it may well be that an increase in the incidence of unemployment, due to present economic conditions, might have the effect of so seriously reducing the contribution income of the society, that expenditure on additional benefits might have to be curtailed.

Mr. Foran

As one very closely associated with national health insurance, both under the old system and the comparatively new, I sincerely welcome the introduction of this Bill. It is somewhat late in coming but, nevertheless, it is extremely welcome and marks a considerable advance in social insurance in this country. To call our system national health insurance was a misnomer, as there was no relation whatever between the societies and national health. They paid out certain cash benefits, but beyond that they made no effort whatever to deal with the health of their members. This Bill marks a departure in that respect. It makes it possible for the unified society to deal with the health of its members. There is available from the accumulated funds and from the Central Fund now a matter of £175,000 per annum. Part of these funds will be devoted to hospital and convalescent treatment, dental and optical treatment. This will go some way towards helping the sick insured people. To that extent the Bill is timely and very well worth while.

This Bill is merely a step forward in social insurance in this country. It does not go nearly far enough, but it makes it possible in the immediate future to develop social health schemes somewhat comparable with some of the schemes in operation on the Continent. We can say that, as a first step in that direction, it is well worth while. The unifying of all the various societies which existed up to some few years ago has proved a very wise step. The present National Health Insurance Society, with which I am very closely associated, is one of the most efficient organisations with which I have ever been associated. In the management, the staff, and right through the whole organisation of the society, one sees efficiency and competence. The very fact that all these societies have been merged has made it possible to accumulate a reserved fund of £4,500,000. Now, under the actuarial system, it would take us another seven or eight years, possibly, to arrive at a period in which we would be actuarially sound and could possibly give some extra benefits. This departure to the assessment basis makes it possible for the present generation of subscribers or contributors to derive some of the benefits from this accumulated £4,500,000 of reserve fund. It is worthy of note that this £4,500,000 is invested entirely in this country. There is no rake-off going outside the country at all.

The societies have been clamouring for a considerable time to get the Government to come to their way of thinking, in order that the present generation of contributors would derive the benefits that they are entitled to. That is being done under this Bill. From what I know of the society, the Parliamentary Secretary can rest assured that this money will be wisely and well spent in the interests of the members at large. £175,000 is a very considerable sum to have at the society's disposal over each year.

With that it will be possible to deal with the health of the members in general. It deals with dental, hospital and convalescent treatment, which was unknown under the old régime. It may be in the future that this society may be able to finance their own convalescent homes, hospitals and dental clinics. At least that is the ambition of a number of people on the present management committee. While I say that, I am not at all satisfied that these benefits go far enough. I think that they might be more extensive. It has to be realised that the cash benefits are not to be improved. From what I know of the insured population they would be willing to pay a larger contribution in order to get larger benefit. Another feature that is very badly wanted in the way of insurance is the merging of workmen's compensation under a proper scheme of national health insurance. The national health suffers very considerably from the absence of compulsory insurance under the Workmen's Compensation Act. It does occur that workers meet with accidents in their employment and the employers not being insured they are unable to pay compensation. The workers then fall back on national health insurance, and the payments have to be met out of funds of national health insurance.

It often occurs that men and women meet with accidents and they have been known to take in settlement lump sums far less than they were entitled to. The society takes up these cases and in a number of cases it has succeeded in substantially increasing the amount already arranged between the insured worker and the employer. That will show the need for closer association or affiliation between workmen's compensation and national health insurance. Another matter that the Government might devote some attention to is the relationship between unemployment benefit and national health insurance. It has been realised that the amount provided for a man or woman a long time unemployed and drawing unemployment benefit is insufficient to maintain them in normal health. Any doctor examining a person who has been a long time unemployed, trying to live and maintain a family on the amount allowed under the unemployment scheme, will know that such a person is ill-nourished and not in a sound, healthy condition. It might be advisable at some stage to merge these two schemes and put them under one head. Some of us believe that this national health scheme is capable of great development, and capable of conferring much greater benefits than people are able to obtain to-day. The Parliamentary Secretary in his statement made a reference to the unclaimed sums account and under the Bill he makes arrangements that the Central Fund will get £15,000 per annum from this fund.

I do not know how he can justify that claim. That money does not belong to him. It belongs to people who bought the stamps and failed to put them to the purpose for which they were provided — that is, to return them to the National Health Insurance Society. To that extent, the National Health Insurance Society has lost the money, not the Central Fund, and I think it is very unjust to apply £15,000 of that fund to the cost of central administration. I hope the Minister will explain that unfair seizure of £15,000 which properly belongs to the National Health Insurance Society.

The amount allocated for administration funds for the society is 4/5 per member. Out of that already the society has paid the entire compensation of all people dispossessed of their jobs, which ran into a very large sum of money. In addition to that, they are charged with paying the cost of the buildings in O'Connell Street. I think they paid somewhere in the neighbourhood of £88,000 of that from the Central Fund. The Parliamentary Secretary referred to the enormous drain on the insurance funds, due to disablement benefit. There is no doubt that there is a very serious drain on the funds of national health insurance, due to disablement of one kind or another. The society has been extremely active and has done everything in its power to reduce the amount spent on that phase of its activities, but, as things are, it cannot turn down people who are unable to work. Therefore, these benefits must be paid.

Generally speaking, the Bill is very welcome, not for what it contains but for what it makes possible in the future. I hope that the Government will make an effort—and make it soon — to co-ordinate and consolidate the Acts governing national health insurance, which are very confusing to the average member of the society. They are bewildered by all the Acts to which they have to refer and upon which they have to get information. It is time that these Acts were simplified and consolidated, so that the insurance population would have a proper understanding of the law under which insurance is operated.

It is quite possible and timely for an extension of national health insurance to be made. The income limit should be raised. I do not think that many people would object to coming into the national health insurance scheme now, when extra benefits are available. Heretofore, they did not think it worth their while to come in because of the paltry allowances available. Now that the amount has been substantially increased, large numbers of people would be willing and anxious to come under the national health insurance scheme. I hope it will be made possible for them to do so. I believe it is necessary to extend and develop national health schemes, generally, in this country. Up to now, the term "national health insurance scheme" has been a misnomer here. From now on, I believe that big efforts will be made to improve the health of the members of the society. With £175,000 available, the members will be able to get special treatment in hospital and convalescent-home treatment — two very essential features of a national health scheme in any country. These will be initiated under this scheme of extra benefits. As regards maternity benefit, I do not know how that is to be dealt with. We cannot very well give kind; but I suggest that it would be possible to give an extra cash benefit. At a time like that, extra cash is very necessary and I believe that we ought to encourage the raising of the birth rate. By increasing the maternity benefit, we shall be moving in that direction. A good deal of money will be spent, I understand, on dentistry; whether there will be enough material or men to work the scheme, I do not know. Optical and specialist treatment will be introduced and, to make these things possible, this Bill is well worth while. I heartily welcome the Bill as a step towards developing a proper system of national health and social insurance.

Mr. M. Hayes

Could we learn from the Parliamentary Secretary what the relationship is between the £175,000 that will be available annually and the amount normally disbursed in benefits annually? We should like to know what proportion the £175,000 will be of the amount annually disbursed in benefits.

Dr. Ward

I do not think I could furnish that figure. Senator Hayes is aware that this sum of £175,000 will not come out of the benefit fund.

Mr. M. Hayes

I am not asking where it comes from.

Dr. Ward

The Senator desires to know what is the annual expenditure on benefits?

Mr. M. Hayes

Yes, so as to see what the percentage increase will be.

Dr. Ward

The total amount expended on benefits in 1941 was about £750,000.

Mr. Hawkins

We ought to congratulate the Committee of Management of the National Health Insurance Society on the great efforts they have made in recent years to bring national health to the stage to which they have brought it. We should also congratulate the Minister and the Government on having acceded to their request to change the law, so as to enable them to enlarge the benefits payable. There are a few points which I should like to raise, although Senator Foran has covered the ground very well. I believe that the income-limit, which is at present £150, should be raised to £400 or £500 and, if necessary, that the contribution should be in proportion to the salary received by the person. If it were not made compulsory, it should, at least, be left optional to any worker in receipt of a salary up to £400 or £500 to become a voluntary subscriber to the National Health Insurance Fund. As Senator Foran has pointed out, with the increased benefits and with widows' and orphans' pensions, there is a great attraction to many of our workers to come in, and it would be a source of income to the society, because the people in receipt of fairly good salaries would not be liable to be a drain on the society.

Another point to which I wish to refer is that of money benefits. At present, a member of the National Health Insurance Society who becomes ill is entitled to benefit of 15/- a week. While, under unemployment insurance, he is entitled to a family allowance, as it were, when he becomes ill there is no allowance made for the family. I believe in a time of sickness more money is required to keep a person than would be necessary if he was in good health. But it is also necessary that the family should have some income. There should be a family allowance attached to the benefits, just the same as there is under unemployment assistance.

There is another point. Where a man is unemployed for a long period, and then probably gets a few weeks' employment, and finds himself suddenly taken ill, he is entitled to no benefit because he is probably in arrears. That is brought about by unemployment. I suggest that, where a man is unemployed for a period and gets into arrears for national health insurance, due to unemployment, that that should not be counted, and that an arrangement should be made between the Department of Industry and Commerce and the National Health Insurance Society that that man would not be described as being in arrears.

I think we have, under this Bill, taken a step in the right direction, and, as Senator Foran has pointed out, it is not so much what the present Act brings about as the opportunity it gives to the National Health Insurance Society to become a real national health organisation. I suggest that the time is here when we should review the whole health organisation. I believe that our dispensary districts and doctors have, as it were, outlived their usefulness. The dispensary districts were set up almost 100 years ago, when transport was not what it would be now if we had normal times. We have a school medical inspection system carried out, speaking for County Galway, by a county medical officer and an assistant county medical officer. One or other of these medical men visits a school, I understand, about once every three or four years to carry out medical inspection, while at the same time there is in many of these districts a dispensary doctor drawing £360 or probably £400 a year, while the number of red ticket cases he is called upon to attend are in many cases very few.

I think there is a good deal of waste in the system. Of course, this is hardly the proper time to raise this matter, but if times were normal, with transport as before the war, with telephone facilities and the progress generally that we have made, there is no necessity for half of the present number of dispensary doctors. I do not mean to cast aside these medical men and to put them on the unemployment list. In my opinion, some of them are unemployed as it is, but of course they are drawing salaries. My idea would be to amalgamate the districts and to put one of these men in each of the amalgamated districts in charge of health, school inspection and such work. In that way we would make far greater progress. We know that the county medical officer or his assistant can visit the schools and carry out inspection there only once every three or four years.

The county medical officer in Galway has applied for an assistant. I do not believe in assistants, because I think that when one is appointed he believes that the assistant is to do all the work. We should get rid of the idea of having assistants. We should have a man in the dispensary districts who would know the family history of the young people there. We would make far more progress if we developed in that way. It is something that might be done in the future. I cannot argue that point now, because transport being what it is, doctors cannot get around for want of petrol.

Senator Foran has covered the main proposals in the Bill. We are very proud to know that we have so many members of the Seanad interested, and that they can see the value of the work of the committee of management of the national health insurance. As a worker I think the workers will appreciate very much what they have done and the great progress they have made. I know that the committee have been urging this step for a long time and that it is not their fault that these benefits have not been granted before this.

I urge upon the committee and the Parliamentary Secretary that it is absolutely necessary for dependents to get allowances in case of illness. I do not know why that should not be when it is the case with unemployment assistance.

I think the limit of income should be raised to £300 or £400. In that way you will bring in a greater number of workers, workers who would be a less drain on the society's funds, because the man with a fairly good income is not going to be so liable to sickness, except by reason of his own carelessness, as the man with a smaller income and who is harder worked.

We have heard the Parliamentary Secretary and we also know from the reports of the National Health Society that a big drain on their funds is brought about by so many people malingering, as they term it. Here again the real cause of the drain may be laid at the doors of medical men. I do not like to be too hard on them, but we see when we look up the accounts that they have drawn from national health insurance £60,000. I know that one man did not get it all and that it probably went to many, but that is what they have got for issuing certificates. In the actuary's report one sees that people malinger longer here than across the water. I wonder would that have any relation to the number of certificates issued by doctors? I believe that that system should be abolished. After all, if a dispensary doctor is in receipt of £300 or £400 a year in a dispensary district, I fail to see why it should be necessary for him to receive any fee for issuing certificates in connection with injured workers.

Mr. Hogan

I have very little to say in reference to this measure. It has of course all the faults of legislation of this kind, legislation by reference. It is very difficult to go through all the various Acts, which this Act amends, to find out the true meaning of some of the matters embodied in this piece of legislation. There was one matter to which I was anxious to hear the Parliamentary Secretary make some reference but he did not. I remember some years ago great difficulty was experienced in respect to people who went across to England and who later when they came back ill to this country were seeking benefit here. Most people do not understand the regulations in respect to national health insurance as thoroughly as they should. A person who is insured here who goes across to England in many cases does not notify his or her society that they are going to England. Their cards are collected in England and given to some society there. Their membership of the society here lapses after a year or so and when they claim benefit they cannot get it either from the society in England or the society here. At least two or three years ago that was the position. I have come across several cases of very great hardship in which people could not get benefits to which they were entitled either from the society here or some society in England.

I should like if some consideration were given to that aspect of the problem because, if all we hear is true, from 50,000 to 80,000 people have gone across to England in the last 12 months, and it may well be that in a short time we shall have an unusual demand made on the societies here and in England. Possibly the society here or the Government has anticipated that development and made some arrangements to deal with it, but if that has not been done this would be a very suitable time to embody some provision of that kind in this measure. I do not think the Parliamentary Secretary would be over anxious to come to this House again with a supplementary measure in the next 12 months simply to deal with a matter of that kind. When a person gets ill in England he is very anxious to come home for treatment as he would be likely to get better consideration from his family and neighbours than on the other side. I think this is an important point. I do not know whether it has been anticipated or not but if I am not anticipated I suggest that this would be a very good time to make some attempt to deal with the matter. Whether the Department will deal directly with the Department in England or whether the society will be able to attend to it, it is a matter that is clamouring for consideration if some steps have not been already taken to deal with it.

Mrs. Concannon

I should like to join with my colleague, Senator Foran, in congratulating the Government and the Parliamentary Secretary on their courage and initiative in introducing this Bill. In particular I should like to congratulate the Parliamentary Secretary on the masterly statement with which he introduced the Bill on Second Reading in the other House. Though I myself have been associated — at one remove — with national health insurance, since it was first made part and parcel of our social system some 30 years ago, and more directly since the Government did me the honour of associating me with Senators Dr. Rowlette and Foran as trustees of the Unified Society about six years ago, I must confess that I never got such an unclouded vision of the very complicated and elaborate financial system on which national health insurance was based until I studied—I use the word advisedly — in the Dáil Debates the Parliamentary Secretary's introductory statement. I studied it very carefully and for the first time I felt that if I would not get full marks in an examination on the subject, I could claim that I might come nearer to an honours marking than ever before. One must have some grasp of the financial structure of the previous Acts and the circumstances which made them fundamental to our system of national health insurance, to understand the full significance of the Bill we are now considering. This is a very modest and unpretentious Bill — the Parliamentary Secretary rightly described it as a short Bill of 16 sections — but it is a bold measure inasmuch as it does something that has not been done in this country since the national health insurance was initiated. It represents a beneficent revolution to that extent. The full implications of that "revolution" have been explained by the Parliamentary Secretary. May I sum it up for ordinary people like myself by saying that it releases the living present from the stranglehold of a problematic future?

We have often heard of the clutch of a dead hand. In a system of national health insurance, which had more thought for the theoretical "last man" than the actual men and women of the present, there is something more throttling than the clutch of a dead hand, the clutch of a hand yet unformed in the womb of time. The object of the Bill is to give the men and women whose contributions have built up the substantial funds of our National Health Insurance Society, the full benefit of those contributions or, at least, as full benefit as possible while fully safeguarding the financial stability and solidity of the society.

The departure from the hitherto accepted system would not have been possible had it not been that in this State there is only one approved society through which, to use Deputy Norton's striking phrase, "the insurable section of the Irish race has to filter itself," and which acquires from that fact an assurance of permanence, coterminous with the Irish race itself, at least as long as it makes health insurance a part of its social system. This means that there is no theoretical "last man" to queer the pitch for all his predecessors. The Bill is, therefore, to a certain extent a complement to the Unification Act of 1933 and it has particular importance as a justification of that Act. It is a justification of the courage and the vision which the Government showed on that occasion when, in spite of strenuous opposition, it merged all the societies in the State into one. Under the old system it was only selected societies, favourably circumstanced and capably managed, who could give their members additional benefits. Of the other 85, some were in such a parlous condition that their ability to continue the payment of even the statutory benefits was problematic. That was a cause of great injustice to the ordinary insured person. They had all to pay the same contributions but it depended on the society to which they belonged whether they would get their full benefits, additional benefits or even have an assurance of the statutory benefit, without levy. Now, owing to the way things have worked out, every insured person who is a member of the National Health Society can be sure of all benefits, statutory and additional, to which his contribution record makes him entitled. We have compulsory national health insurance by one society that is obviously in a highly favoured position. But that would not count if it were not carefully managed, and I am sure the Parliamentary Secretary can corroborate the tribute paid to the management by Senator Foran.

I think the Parliamentary Secretary, when he made the necessary preliminary inquiries, must have assured himself that the society was well and carefully managed. The staff officers are senior members of a very fine body of men and women. They were recruited, I think I may say without exception, from the cream of the older societies, and a secretary of brilliant ability, and an assistant secretary of rare competence and experience; have given of their best. Everybody connected with the society will agree with me in saying that the society owes its best achievements to its chairman, Most Rev. Dr. Dignan. His Lordship, persuaded that national health insurance properly adjusted to the characteristics and needs of the country, can be made a great instrument for securing the health and well-being of the nation, has thought it not inconsistent with the duties and character of a patriotic Irish Bishop to devote to the society an amount of time, energy, labour and thought, involving great personal sacrifices, which the nation can never repay.

The House will be glad to know that, associated with the Bishop of Clonfert, as chairman, is the vice-chairman, Dr. Rowlette. It is not necessary in this House to stress the great ability and great sense of public service and integrity that Dr. Rowlette has brought to the society. These men have been a wonderful combination, and we have now come to the stage when we can congratulate ourselves. It is true that we have a long way to go before we can make the vision of these men a beneficent reality — this is only a step to it. But the National Health Insurance Society that we are now considering has been released from its fetters, and is free to make its way to the splendid goal which these men have set before them.

Dr. Rowlette

I do not intend to take up the time of the House for many minutes in joining with other Senators in welcoming this Bill. In fact, Senator Foran in his speech covered the ground clearly and comprehensively. What I have to say is rather to emphasise some of his points, or to underline some of his suggestions, than to add anything fresh to the discussion. Many people may ask — and the Parliamentary Secretary has met them in advance — whether this scheme is financially secure. They will suggest, and some have suggested, no doubt, that to leave the actuarial system on which national health insurance both in this country and in Great Britain has been carried out for some 30 years, indicates some lack of success in carrying on the scheme, and suggests that, possibly, there may be a financial difficulty somewhere that has to be met by making the financial restrictions somewhat less rigid than they were. I think that the Parliamentary Secretary has made it clear that there is no financial risk in accepting the scheme put forward in this Bill. Each scheme of benefits will be prepared for a period of five years, and for five years only, depending strictly on the actuarial report as to the actual sum of money which can be available for that five years, on the basis of the five years' previous work. That renders it impossible for the scheme to bankrupt itself, or to risk the society in any way. It substitutes a scheme based on the living financial position of the society, for a scheme built on actuarial ideals which, as Senator Mrs. Concannon has just said, and as experience has proved, tied the living members of the society by unnecessary fears.

There is only one point in the Parliamentary Secretary's statement over which I was a little puzzled. I understood him to say that the State will continue to contribute two-ninths of the money expended by the society on administration and benefits. I cannot very well reconcile his statement with the provision in Section 7, clause 3, which appropriates to the State a sum not exceeding £15,000 per year from the unclaimed stamps fund. Hitherto the unclaimed stamps fund has been like Mahomet's coffin, suspended between Heaven and earth, and not really accessible to anybody. Now it is taken, as regards £15,000, if such is available, as a contribution towards the State's expenses — not a contribution from the insurance fund, but a contribution which will lessen the amount contributable by the State each year to the society. It seems to me to interfere with what has always been one of the fundamental financial principles of the Act, since, over 30 years ago, it was laid down that two-ninths of the money spent on benefits and administration should come from the State. In future, the unclaimed stamp fund, which has accumulated almost by accident for the purpose of insurance, will not go direct into the funds, and will not go to this Society for its work, but is to diminish the amount contributed by the State. These funds do not come from the State. They are not public funds in the sense of being funds credited to the State, and it seems to me that the State has a certain responsibility in departing from what has hitherto been the fundamental condition of contributing two-ninths to the fund for benefit and administration. I hope the Parliamentary Secretary will reconsider this section, and see whether he can return to what has been hitherto the financial basis of benefit expenditure and administration expenditure.

He said, too, that the entire expense of certification was borne by the State. Not being familiar with the actual details of that, it surprises me, as it was understood that for some years past a certain contribution was made by the Society towards the expenses of certification. I am not challenging the Minister on that, because he knows, and I am only speaking from memory, which may have misled me.

Senator Foran has suggested and outlined very generally what it is hoped to be able to provide if this Bill meets with your approval. He expressed an opinion in favour of an increase in the cash benefit which is given in the case of maternity. I would like to associate myself with that. I was rather disappointed in the debate in the Dáil recently, when I think the Parliamentary Secretary said that he was not sympathetic regarding the increase of cash benefits at all—I may be wrong, but I understand that was the general impression left by his utterances on that topic—and that the Government did not think it well to increase the cash benefits. I do not understand the reason for that. It seems to me that cash benefits which may have been considered fair and justifiable 30 years ago have lost a great deal of their values to-day.

The cash benefit which, let us say, in the first years of the Insurance Act of 1912 or 1913, might have provided a fair and reasonable amount of comfort or amenities for the woman who drew the benefit or whose husband was entitled to the benefit, cannot bring anything like as good a return to-day. Therefore, there is no logical reason why there should be — if there is to be — a ban put on the increase of cash benefits. It might be asked why we should not increase the benefit in some other way by providing necessities or benefits in kind for the woman at this time, which is always one of difficulty and, amongst most insured people, one of financial stress. If one gives that a little consideration, one finds that the administrative difficulty would be so enormous as to make it impracticable. I think it would lead to grave abuse and grave discontent, owing to the inequalities which would arise from the practical difficulties. I hope the Parliamentary Secretary will tell us that, as it is the Minister's duty to approve or disapprove of such schemes, the Minister is not determined to disapprove of such a scheme if it be put forward.

At the outset of his speech Senator Foran said that this Bill is a step forward. It is a step forward and a very important one. It releases the system of national health insurance from the bands which tied it too tightly and hampered its development, and gives it an opportunity to develop as never before. But we should remember that it is only one step forward. Senator Foran has pointed out that there are many ways in which national health insurance may be developed. I agree with him entirely that, up to the present, although it is called national health insurance, it has not been in a position to do anything towards the care or improvement of the health of the people. It is true that, for some years, in the early years of national health insurance, it extended to treatment of tuberculous patients, and in that respect only it was concerned with the improvement of the health of the people. That function was — quite rightly, I agree — shifted from the national health insurance scheme to the local authorities and became part of the general public scheme for the treatment of tuberculosis. I am not sure that certain funds from the national health insurance moneys do not find their way to the local authorities who carry out these schemes of treatment of tuberculosis. If that is so, it would seem that the members of the society are contributing twice over to the expense of the tuberculosis schemes throughout the country. They are contributing in their ordinary capacity as ratepayers, bearing their share of the burden on the rates, and they are contributing also as members of the society. That is a point which should be cleared up.

I am entirely in agreement with Senator Foran and others who have suggested that the care of health should be a proper part of any scheme of national health insurance. It may be remembered that, when the National Health Insurance Bill was first brought in in Great Britain in 1911, it was proposed to include this country in the same scheme, word for word as it would apply to Great Britain. It was quite clear to those who gave it thought, that a scheme based on a purely British — and local, in that sense — scheme was not necessarily the best scheme for us, and great opposition was put forward in this country to the application of the scheme to Ireland.

As a consequence, the scheme for medical treatment disappeared when the scheme was applied to Ireland. That was in fact the acceptance by the British Government of the day of the expression of public opinion in Ireland from very varied classes of people. It was the official attitude adopted by the then Irish National Party, it was adopted by chambers of commerce and other such bodies who may be taken as representing employers, and it also received the support of the Catholic Bishops in meeting assembled. Whether these bodies were wise in opposing that part of the Bill or not is not worth inquiring into now, but it was the wish of the country that that part should be dropped and it was dropped.

Shortly afterwards, an investigation was made to try to find some other scheme which might be applied to this country instead of that applied to Great Britain. The investigation did not proceed any further than the report of the Committee, but twice later the country more seriously investigated this problem. The Irish Public Health Council, which was appointed in 1919 and reported in the following year — of course, under the old régime—recommended the establishment of a national medical service which should embrace in its functions the medical treatment of insured persons and also embody or take over the existing public medical services of the country, poor law medical services and so on. That received pretty generous support but, when the report of that Council appeared in the summer of 1920, it was quite impossible to get clear consideration of a constructive improvement.

A few years later, in 1924, the then Minister for Finance appointed a committee, under the chairmanship of Professor Magennis, to investigate the whole system of the medical services of Eire and, after consideration lasting some two years, it recommended a scheme very similar to that which the Irish Public Health Council had recommended six years before. It was postponed on account of the expense that would be involved, and it has never risen for consideration since then. It also provided a comprehensive scheme of medical treatment and a public health service. In 1929, I think, when the Government of the day brought in the National Health Insurance (Amendment) Bill, one of no very great scope, one of the speakers on the Front Opposition Bench opposed the Bill. In fact, I think he moved its rejection. At any rate, he very strongly opposed the Bill, or any Bill claiming to reform national health insurance unless it included medical benefit.

That gentleman when he moved across the House and was in the more responsible position of Minister for Local Government and Public Health brought in a further National Health Insurance Bill in 1933 which is now law and as far as it goes I think a very good Act. I agree with what has been said by Senator Foran and Senator Mrs. Concannon as to the great improvement in the system since that Bill has been working, from 1934 or thereabouts. We cannot rest content with any scheme of national health insurance which does not deal much more radically and thoroughly with the question of the care of health and of the general health of the country than has been done in the past or even could be done on the strength of the Bill now before the House. It must go much further and take the whole problem into its purview.

Much could have been learned three years ago from schemes at work in other countries, although to what extent they are at work now God only knows. Much could have been learned from schemes in operation on the Continent, in countries such as Czecho-Slovakia and other continental countries. More could have been learned that would be suitable for adoption here from some of the foreign schemes than could have been learned from the system which was worked in England for the last 30 years. One would have hoped, but for the events of the last few years, that before now the Government might have appointed a small commission, some foreign experts and some people with expert knowledge of this country, who could have prepared a comprehensive scheme for consideration by the Government. That, of course, is out of the question for the present, and that is the reason that the present Act, which is a good Act within its limits, falls short of what anybody who is interested in the topic would have considered proper and necessary.

Senator Foran made some very sound, and I believe healthy recommendations, that national health insurance should be closely associated with other forms of social insurance. He did not try to suggest the machinery nor do I. He suggested that there should be close association with other forms of insurance and that we might have a whole system of social insurance that would deal with questions of health and with closely allied questions, such as workmen's compensation, out of work grants, and so on. In that I have no doubt we would be following the system in so far as it has been operated in other countries where more attention has been paid to this matter than we have paid to it or indeed than we have had an opportunity of paying to it. I welcome the Bill, and like my colleagues connected with the Society I am grateful to the Government for having brought it forward. It is a useful Bill. It promises much better service than we have had in the past, but it is by no means the thoroughgoing measure we would like to see.

There have been some comments made about abuses in connection with the present scheme. I can assure the House that the Society, as regards both its officials and the committee of management, is well aware of some of these abuses and does its best to check them. The difficulties, however, are very great. People are sometimes out of work for a long period and they fall into bad health and they properly and legally claim national health insurance benefit. Some may claim benefit who are not so entitled. These people are receiving the constant attention of the officials of the society as well as of the Committee of Management. I want to say this with a sense of responsibility, that the State, the public and the Society have not received from certain district justices the support they are entitled to receive in the carrying out of the law in regard to national health insurance.

There have been cases of non-compliance with the Act where people who were legally bound to insure have not done so, and cases where employers have not stamped cards. When these cases come before the courts they have been treated as if they were trivial. Perhaps I should not say that so broadly, because there are justices who carry out the law, but there are many other justices who do not treat the law in these cases with respect, and bring it into contempt by the trivial penalties they impose, where penalties are imposed at all. One case of a deliberate fraud was brought into a District Court in which a woman had not attended for examination for a certificate but had been impersonated by someone else. As well as I remember a healthy daughter was impersonated by her aged mother, who was not insurable. Either no penalty was imposed or it was a contemptuous one showing that the offence was not regarded seriously. The district justice made the remark that this woman was only acting in accordance with the Constitution.

I am not quoting actual words used, but the justice said that the Constitution laid it down that the interests of the family came first. It was enough to excuse or justify such an offence as was committed by this woman who was so devoted to her daughter. That sort of thing happening in the courts brings the law into contempt and increases very much the lack of respect for law among people who may think they will benefit to some extent by what they consider to be petty frauds and what the district justice may think to be petty fraud. I do not think the Government have any control over the sayings and judgments of these district justices but if they have any control in this respect it should be exercised very rigidly. The society and the State should be put into a position that they could look to the district justices for the proper and rigid carrying out of the law in cases of this kind. I am glad that this Bill has been brought forward and I am glad, as far as one can judge, that the House does not show any hostile or critical attitude towards it. I would like it to go further and I hope the Parliamentary Secretary will go further in one respect than I understood him to go from the attitude taken up in the debate.

Dr. Ward

In so far as there has been any criticism of the Bill, I think it has been effectively answered by some of the speakers. In fact, there has not been very much criticism. There has been little or no criticism of the Bill in so far as its terms are concerned. The debate has ranged over a very wide field, embracing the entire social services. That, of course, is a very interesting subject, but I do not know that a Bill such as this is the proper occasion on which to embark on a full discussion of our entire social services. To begin with, some of the social services that were mentioned here by Senators in the course of this debate are administered by other Departments. Unemployment assistance, unemployment benefit, employers' liability in so far as the State has any functions in relation to it, belong, in the main, to the Department of Industry and Commerce. I quite appreciate that that is a condition of things that many Senators desire to terminate. The idea permeating the debate to-day apparently aims at the establishment of a social service department, whereunder all the social services would be co-ordinated and administered, with one Ministerial head. I do not think that, on this Bill, we can usefully pursue the discussion of that very big subject. We are all agreed upon one thing — that this Bill is a considerable advance on the present position, that it opens up new possibilities of a far-reaching character in so far as the provision of treatment for insured persons who are in ill-health is concerned, and that it is a necessary preliminary step, at any rate, to any of the further desirable developments Senators have in mind, just as unification was a necessary preliminary step to the step we are taking to-day.

Senators might reasonably say that there has been a very long distance between these two steps. There has, and all I can say in that regard is that I hope the distance between the step we are taking to-day and the next important step will not be as great as that was. The experiment of unification has been very encouraging. Without unification, I could not come before the House with these legislative proposals. More than that, were it not for the ability and enthusiasm which the committee of management, from the Most Reverend Doctor Dignan, chairman, down to the members of the Committee of Management, and the staff of the unified society, brought to bear upon their work, making the unified society the undoubted success it has been, I could not appear before you with a Bill such as this. The least I can do is to pay that tribute to the most reverend chairman, the members of the committee and their staff for the excellent work they have done.

Senator Foran was the first to complain about the terms of Section 7 of the Bill. Under Section 7, up to £15,000 is to be paid to the Exchequer from the unclaimed stamps account. In the event of the amount accruing to the unclaimed stamps account being less than £15,000, the State will get the amount accruing. If that amount be £5,000, the State will get the £5,000; if it be £10,000, the State will get the £10,000. But if the amount in the unclaimed stamps account exceeds £15,000, the excess will go to the reserve fund set up under Section 6. The average amount accruing to the unclaimed stamps account in recent years has been about £17,000, so that it can be assumed, if that rate can be relied upon, that, approximately, £2,000 would ordinarily be available for this reserve fund, after making an Appropriation-in-Aid of £15,000. Senators ask why this payment should be made at all to the State, why the State should not bear the full cost of the additional benefits. They think that the State should make its two-ninths contribution to the ordinary benefits and its two-ninths contribution to the additional benefits. That is a good enough debating point. It is very easy to say that the State should give this amount, but Senators should realise that there is a limit to the State's resources, and that we have been increasing our expenditure on social services to a very great extent during the past ten years. Even on this particular social service — national health insurance—the estimated nett expenditure for 1942-43, if this Bill becomes law, is £35,000 in excess of the expenditure in 1931-32. Senators may say that the State can find money for other things, and may ask why it cannot find money for health insurance purposes. It is, however, very hard to get agreement when it comes to a question of selecting services upon which expenditure can be curtailed.

The fact remains that the Exchequer contribution to national health insurance for 1942-3 is estimated at £360,000. That is a very substantial amount and it is not unreasonable to make an Appropriation-in-Aid of the Exchequer of £15,000 when we consider that, in respect of two items outside health insurance services proper—Posts and Telegraphs and Stationery and Printing — the cost to the Exchequer is £15,900 per annum. Apart from that, it should be borne in mind that the Exchequer could, with reason, argue that it ought to be relieved to a much greater extent, in present circumstances, than is represented by this small sum of £15,000 per annum. Let us not forget that, when the State originally undertook to pay two-ninths of the cost of the benefits and their administration, we were operating under a system of finance that is being abandoned under this Bill.

Under the system of finance that we are now abandoning a certain proportion of the contribution income had to be set aside for the purpose of servicing the reserve values redemption and interest fund. These reserve values represented the liability the society undertook in respect of its members. The State would be entitled to contend, now that we are abandoning the redemption of reserve values, abandoning the reserve value system entirely, that it would be entitled to be relieved of the contribution that it made towards the finances of the national health insurance in order to make up for the deduction from the contribution income which was found necessary to service the reserve values. I have no enthusiasm for defending the Exchequer in this particular regard, I confess, but when the matter is raised it is my business to draw the attention of the House to the case that the Exchequer could make, not for relief to the extent of £15,000, but relief to a very much greater extent.

Senator Hawkins raised some interesting points that are a fair distance outside the scope of the Bill but, in so far as I can, I will refer to some of them. He raised the question of increasing the income limit and the provision of family allowances. Now, personally I have no fundamental objection at all to raising the income limit but it seems to me, and I will ask Senators who are interested in this question to devote their thoughts to it, that if you are going to increase the income limit to £400 or £500, instead of having the limit of £250, you must at the same time increase the amount of benefit available. Senators will appreciate that, if we are to bring into insurance benefit people with an earning capacity of say £10 a week, there is not much use in providing 15/- a week benefit for them at the time they are ill. If we are going to branch out in that direction then we must, as a logical sequel to it, adopt the principle of relating the amount of benefit to the income, and that opens up another very big field.

On the question of family allowances much the same line of argument might be pursued. It would be very desirable. I have no hesitation at all in agreeing that, when the breadwinner is ill, 15/- a week cannot possibly maintain himself and his dependents or even maintain himself if he had no dependents, but I do not think that national health insurance was ever intended to maintain a breadwinner and his dependents during his illness. If that principle is to be adopted, clearly in an insurance scheme benefit must be related to the premium and premium to the benefit. Within the financial foundation of national health insurance under the present scheme we cannot provide £1 a week or 25/- a week for a bread-winner or 2/6 or 3/- a week for each dependent. It just cannot be done within the present framework. If the people interested, the contributing parties, the National Health Insurance Society, the State, the insured persons, and the employers, come along and say they will go 50-50 or 33? in this matter, if agreement is reached on these principles you will find me in a very receptive mood, but I am afraid it is a fairly thorny problem with so many interests involved.

The same argument applies to the abolition of the arrears penalty. Any interference with the financial framework as it stands at present to the detriment of the funds of the society must carry with it the corollary that someone has to pay. The money to recoup the society must be found somewhere if you are going to deprive the society of part of its income by one method or another. I was surprised to hear Senator Hawkins, who lives in the country, say that the dispensary system had more or less outlived its usefulness. Speaking with considerable knowledge of the dispensary system both as an administrator and as a man who actually operated it for a number of years, I am not prepared to agree with Senator Hawkins at all in that matter. I do not know what volume of agreement I might get on that in this House. My deliberate view is that our dispensary medical service is streets ahead of the medical service of the panel system in England. That is probably another of these matters we could argue a good deal about, but I speak from experience inside the system and looking on from outside also.

He also made a point which one would have some difficulty in relating to this Bill, namely, that doctors under the Medical Charities Act do not appear to have much to do. He bases that conclusion on the sparsity of red tickets. I only want to answer the point because it has been made, not because it is related to the Bill, and I want to say that in many districts the number of tickets is no reflection on the amount of work a doctor does. Doctors as a general body are a kindly class of people taking them all round.

Mr. M. Hayes

With exceptions.

Dr. Ward

With exceptions. Of course Senator Hayes has a wide and varied experience. Probably he would have got nipped by the medical profession some time or other, and he might feel sore, but leaving out exceptions and taking them generally they are not at any rate a harsh body of men.

Mr. M. Hayes

Hear, hear.

Dr. Ward

Very often people who are entitled to treatment under the Medical Charities Act come to a doctor and ask him to go out in a hurry. Not nine cases out of ten are urgent, but the unfortunate people think they are urgent and that is the main thing. Nine out of ten of the doctors who go out will not bother whether they get a red ticket at all. The ticket should be presented in all cases even before the doctor attends, but I am glad that in urgent cases the other system obtains. Senator Hawkins made another suggestion and I was rather surprised that Senator Rowlette did not refer to it. Perhaps he missed it, but he does not miss much. His statement conveyed to me the suggestion that medical certifiers were induced to certify by the fact that they were going to get paid so much per certificate. That is not a fair suggestion either, and is not consistent with the facts.

Dr. Rowlette

May I say to the Parliamentary Secretary that I made no such suggestion?

Dr. Ward

I said that Senator Hawkins made it and I mentioned that I was surprised that Senator Rowlette did not advert to it and defend the doctors, when he was speaking. It is not part of my business, nor do I look upon it as a special duty by any means, to defend the doctors but I like fair play. It has not been my experience, at any rate, that doctors are induced to certify by the knowledge that they will be paid per certificate and that the more certificates they are able to send in, the bigger the cheque they will receive at the end of the quarter. I do not think that is the determining factor at all. I should be very sorry to think it was. Again, I speak with the practical knowledge of a man who was a medical certifier for 18 years in different areas, urban and rural.

I remind Senator Hawkins or any other Senator in this House who may be thinking on similar lines, that the doctor is very often confronted with a very difficult social problem. I would ask him to bear in mind that when the bread-winner is unemployed and when he lacks for his dependents perhaps the necessaries of life, what might be a very minor ailment in normal circumstances assumes abnormal proportions. The doctor has to deal with a very big psychological problem when these people come along for certificates. He knows if an unfortunate man comes to him for a certificate, that he would not be trying to draw 15/- a week sickness benefit if he could earn £2 a week at work. The man tells you that he has lumbago. It is usually lumbago, muscular rheumatism or influenza. These are the popular diseases. You do not know whether he has or not. How on earth would you know? There are things that doctors do not know.

Mr. Foran

Really?

Dr. Ward

There are—not many. At any rate, the doctor knows that the man is in a miserable condition, physically and mentally. He knows that somebody must maintain him and that he must become a charge either on this particular social service or on some other, and the doctor says: "If you tell me that you have such a pain in your back, that you are not able to stoop to lace your boots, I am not going to certify that you have not." Senators may be very critical of that attitude but, at the same time, realising all the factors entering into that social problem that confronts that doctor when he is asked to certify, I cannot find it in my heart to say that he is doing very much wrong when he gives the insured person the benefit of the doubt, so long as there is a genuine doubt in his mind.

Senator Rowlette, I think, misunderstood me. He understood me to say that the State paid the whole of the medical certification cost. If I conveyed that, I did not intend to convey it. The State pays the whole of the cost of the district medical referee scheme. As to the point that Senator Rowlette has stressed more than once in regard to my attitude towards cash benefit as additional benefit, I do not know whether Senator Rowlette read the debate in the Dáil on this Bill, but I do not recollect stating that I was definitely and unalterably opposed to cash benefit as additional benefit. But I do want to say — and I believe I said it in the Dáil — that if I had a limited amount of money at my disposal — and the amount of money at our disposal at the moment is limited—I would prefer to devote that money to making the sick bread-winner fit to work. I would prefer to apply it to providing specialist treatment, if he requires specialist treatment, than to giving him additional cash benefit and leaving him untreated. I do not think that Senator Rowlette will find any fault with that approach to the problem.

The last point of real importance dealt with by Senator Rowlette was the question of medical benefits. He very adroitly for a man who is not a politician—of course Senator Rowlette is not that—reminded us of a statement made by a member of the Government when we were in Opposition. I suppose most people have had the experience of making a statement at some time or other that had to be modified in the course of time and in the light of experience but, on the question of medical benefits as a principle, I think we are at one all the time. Again, it is a question of how medical benefit can be provided with real advantage to the general community, but particularly to the insured sections of it. As I stated in the Dáil on this question, the provision of medical benefits for the insured person alone has no attraction whatever for me, none at all. I cannot see that it is any improvement on the present position to provide that either the dispensary doctor or some other doctor will be called in to attend the insured person when he is ill, if the dispensary doctor has to be called in and the Medical Charities Act availed of, when the wife or the children are ill. That is getting you nowhere. In my judgment, there is no use in providing medical benefit for the insured person unless that medical benefit can be extended to his family as well.

Again this question is not just as simple as it looks. Neither can I see any great advantage to the insured person or to anybody else, to superimpose a new service on the service that is there already. It is true there is a sentimental prejudice against the Medical Charities Act, but I think it is equally true that good service is provided — a good public health service — under and through the Medical Charities Act. Therefore, we do not seem to be getting anywhere, in fact, we would appear to be heading towards a waste of money if we superimpose on top of the Medical Charities Act and the dispensary service already provided, a service that is new in name only. And why is it new in name only? For the reason that in rural Ireland at any rate — and rural Ireland constitutes a very big geographical area of the whole of Ireland — you will have only one doctor available. He is the dispensary doctor; and if the insured person or insured person's dependents can have his services at the present time under the dispensary system, surely it is not going to improve matters for anybody to have him called in as an insurance doctor instead of a dispensary doctor so long as the service remains the same. I cannot see much in it.

Senator Rowlette's approach to it is, if it could be done, probably the most logical solution and the best, but then again it becomes a matter of money — to co-ordinate all our medical services, to merge medical benefits and the additional benefits of national health insurance in our medical services. If the public health service was not a complete State medical service it would be a modified State medical service. In that direction there is scope for thought. It is quite possible that a scheme could be evolved for a modified State medical service that might not, when all items of expenditure are taken into account, increase the burden by a staggering amount. But that is a big question, and the furthest I can go now in a discussion of that question is to say that it is a matter that is well worthy of serious and careful consideration. Along those lines there might be scope for further development.

Mr. Foran

Is the Minister adamant against cash benefits?

Dr. Ward

Oh, no.

Mr. Foran

He is not. Well, that is great news to some of us, because we heard that he was. Is he definitely rooted to capturing this £15,000, or would he, if we could have an amendment on the Committee Stage, be prepared to give that £15,000?

Dr. Ward

I can hold out no prospect whatever of being able to evade that Appropriation-in-Aid. I could tell the Senator many things outside the House in relation to this, that I do not propose to deal with in debate. At any rate, in the Local Government Department we think that national health insurance came out of the deal with the Finance Department reasonably well.

Mr. Foran

I do not want to obstruct as I hope the Bill will go through all stages this evening; but I do not want to miss my opportunity to try to retain that £15,000. In a matter which involves £450,000, a saving of £15,000 is not going to make much difference, and is not going to be much of a saving.

Dr. Ward

The camel's back was broken by the last straw.

Mr. M. Hayes

The Minister for Finance loves it. that is the position.

Mrs. Concannon

In view of the fact that the first triennial period begins on 1st April, it would be a great thing for the insured members, and a great convenience to the management, if all stages of the Bill were taken to-day.

Leas-Chathaoirleach

We will finish the Second Reading first.

Bill passed through Committee without amendment and reported.

Bill received for final consideration and passed.

Seanad Éireann debate - Wednesday, 25 Mar 1942

National Health Insurance Bill, 1941—Second and Subsequent Stages.

Leas-Chathaoirleach

Seanad Éireann debate -
Wednesday, 25 Mar 1942