Health Services (Financial Provisions) Bill, 1947—Second Stage.

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

When I was in the Seanad with the Health Bill before the Summer Recess some Senators expressed a certain amount of anxiety with regard to the financial provisions and they asked me who would pay for all these new services. I told the Seanad on one of the later stages that the idea was that local authorities would not have to pay more for health services for some time to come than they had been paying in the past and whatever increase there might be on the health services by each local authority, it would be paid by the State until we would reach the stage that the State was paying 50 per cent. And the local authority 50 per cent.; from that onwards we would pay on the basis of half and half.

That is what is embodied in this Bill. As a matter of fact, this Bill is brought in to implement that idea. I should make it clear, as I did point out at the time to the Seanad, that in calculating what the health expenditure is we do not take capital expenditure into account: it is only the current expenditure on health services. So far as capital expenditure is concerned, the greater part will be financed from sources other than the local authority. The usual method at the moment of financing capital expenditure is to get 75 per cent. from the Hospitals' Trust Fund and 25 per cent. is put up by the local authority, raised by way of loan and afterwards paid back.

As regards the provisions of this Bill, they have been explained in a memorandum which was circulated, because there is a good lot of what is known as legislation by reference. The rather difficult sections in the Bill have been explained in the memorandum. In order to implement the system I have mentioned there is a standard expenditure. The standard expenditure will be determined for each local authority and that will be taken as the amount that the local authority will have to contribute for some years to come.

Section 4 provides that the State will pay whatever expenditure there is over and above the standard expenditure. Up to this there have been various State grants payable to local authorities for various specific purposes. It is proposed to abolish this and to make the financing very simple by having a lump sum paid over by the State each year to the local authority. Sections 5 to 8 deal with these State grants. These State grants have been growing over a long number of years and have been growing haphazardly. The licence duty grant was brought in in 1898 under the Local Government (Ireland) Act and that is devoted by the local authority to the payment of certain salaries and for the upkeep of inmates of mental hospitals. There is an estate duty grant which was introduced in 1888 for some of the public assistance services.

In more recent times grants were brought in: for instance, the free milk grant, maternity and child welfare grant, grants in respect of school medical services, tuberculosis and venereal diseases. Instead of having all these various grants brought into the accounts in each year, they are all being abolished and there is one simple amount being paid over which will, at any rate, save a great deal of clerical work and a great deal of calculation both by the local authority and by the State authority.

Section 7 provides that the estate duty grant will no longer pass through the Guarantee Fund. It was part of the Guarantee Fund, which Senators know was a fund to guarantee the State against loss through the collection of annuities. This will not mean a very big reduction in the Guarantee Fund, because it only amounts to about £150,000 in the year, whereas the agricultural grant is about £1,870,000, and reducing a fund of £1,870,000 each year by £150,000 will make very little difference. It is only used as a guarantee to the State that the annuities will be collected. At the present time health services are costing something over £5,000,000 per year.

Does the Minister mean central and local expenditure?

Yes. Of that amount the local authority is paying 84 per cent., and the State 16 per cent. The purpose of this Bill is to see that the State contributes all the additional expenditure until we are in the position that the local authorities are paying 50 per cent., and the State is paying 50 per cent., and then they will remain at that percentage from that on.

This Bill deals with finance only and it is the only point in the White Paper that is implemented. There are many other points in the White Paper which was issued which will come up for discussion later on. This is for finance only.

There will be a gradual increase in health services. It is very difficult indeed to give any sort of estimate but possibly at the end of another two years there will be another £750,000 spent on health services so that the Estimate that is brought in by the Department of Health each year will show an increasing amount and it is expected that if the development of the health services proceeds as we anticipate, we may be spending, between the local authority and the State, between £9,000,000 and £10,000,000 at the end of nine or ten years. The Estimate, of course, will appear each year and members of both Houses will have an opportunity of watching the progress of expenditure, at any rate, by reference to the Book of Estimates each year.

This Bill is necessary because the local authority is now preparing its estimate for the coming year. There are extended health services coming in next year and it is well to tell the local authority that in budgeting for the coming year they need only provide what they spent last year even though they intend to extend the health services. I am, therefore, bringing this Bill before the Seanad and explaining to the Seanad that the Bill is urgent in that respect, that it should become law if at all possible before the end of the financial year, in fact, as soon as possible, so that the local authority may make its estimate for the coming year.

I hope the Bill will be acceptable to the Seanad and, in view of what I heard some Senators say here before my Bill was taken, I hope Senators will give me some amendments that may improve the Bill, and I will be quite happy to consider them.

It is a great pity the Minister for Health would not be allowed to coax the Seanad. He would meet with a certain amount of success.

He would get his Bills through more rapidly.

He would get his Bills through more rapidly and he would avoid amendments more easily, which possibly is his real object. However, this Bill, as the Minister has explained, carries out certain of the financial provisions which are necessary in view of certain provisions of the Health Bill and certain promises made by the Minister with regard to the onus which would fall upon local authorities and, while there were certain things in the Health Bill to which objections were taken and which objections were very clearly stated then, this Bill, in itself, as the Minister has very clearly explained, is absolutely necessary to carry out the Health Bill and, as such, the Health Bill being law, I think there can be no objection to it. I think the House should certainly pass the Second Stage.

I am glad the Minister has taken this step. I am glad that he has taken it in the particular way in which it has been taken. Local authorities have become so accustomed to find that every grant that comes means an increase in the rates that it will be a really new experience to have a grant made available which will not mean an increase in the rates.

The Minister says we will spend £9,000,000 or £10,000,000 on our health services in about ten years' time. He says we are spending £5,000,000 at present, of which 84 per cent. is provided out of local taxation and 16 per cent. from the Central Fund. The Minister should try to prevail on the Government to adopt the policy which he will pursue in regard to our health services in other local services and strike a fairer balance between the responsibility of the State and the responsibility of the local authority.

There are one or two points on which I would like to have an answer from the Minister. How will this money be disbursed? What method will be adopted? Will the advice of the health council be sought by the Minister with regard to the expenditure of this money? It is only the Minister and his Department who can have any knowledge as to the comparative conditions of health services in the various counties. Obviously, some counties are more backward than others in this respect. Some counties have spent a considerable amount of money out of their own resources in raising health services. It will be rather worrying to some of these counties who, so to speak, have borne the burden of the day, if they find themselves in the position that because their health services are tolerably advanced in comparison with others, there must be a stay on the development of their services until others are brought up to their standards. It would be very undesirable that that should be the case. I would like to have an assurance from the Minister that counties that for a number of years have had a reasonably progressive policy, will get the assistance of these grants and will be helped to develop at the same pace at which they have been developing over a number of years. County Cavan was one of the first counties to start building up its county health services by the appointment of a county medical officer and doing what it could with regard to its institutions, such as hospitals. A great deal of money has been spent there over a number of years.

It is of importance to have some indication from the Minister as to the method or policy that will be adopted in regard to the disbursement of these grants and the standard by which it will be determined what is to go to the various counties. Generally, the step the Minister is taking will be heartily welcomed and I am sure he will get all the co-operation that is necessary to ensure that the money spent will be beneficial to the health of the people.

In so far as the intention in this Bill is to simplify the administration of grants from the central authority, it has my entire approval. I could never understand why that complication should have lasted so long. Since I have been in public life, everybody has been complaining of the terribly tangled way in which these grants are mixed up. They are mixed up with estate duties and at one time were mixed up with the liquor duties. Now, sensibly and apparently without any difficulty, the whole thing has been cleared up. So far so good.

I also welcome this arrangement whereby no further increase is going to be put on the local rates and under which the amount of the contribution from the central authority towards health services is to equal the amount now paid from the local rates. I should like, in connection with this finance and arising out of the White Paper, to ask for some information. The White Paper is very enigmatic on the finances of the voluntary hospitals. We are told that a capital of some £9,000,000, now held by the sweep trustees, is going to be used for the purpose of rebuilding. If it is going to be used for that purpose, the capital source under which the hospital deficits are now being met will disappear. Is it the intention of the Minister to meet those deficits, as long as they continue, out of State grants? In fact, are hospital deficits to be recognised as health services? It is important to be told that, as the hospitals are, at present, in doubt with regard to their future.

There is another provision in this Bill which I may not understand and which creates in my mind no little alarm. I am exceedingly surprised that no reference is made to it in the explanatory memorandum nor was there any reference to it in the speech of the Minister or in the speeches of those who have already spoken. I would not like to say that the Minister deliberately abstained from making any reference to the section. Since he did not, I shall do so now. I refer to Section 2. I ask Senators to examine that section. It is provided in sub-section (1) that the Minister shall, as soon as may be, after the 1st April declare that such health services as he thinks proper shall be recognised health services. Under sub-section (2) the Minister may from time to time declare that any health service which is not then a recognised health service shall be a recognised health service, while under sub-section (3), the Minister may from time to time declare that any health service which is then a recognised health service shall cease to be a recognised health service. Senators will see, therefore, that the Minister is taking power to create or abolish health services according to his own free will. That seems to me to be a most astounding proposition.

Under the Health Act, which was passed last summer, a number of health services are included with a considerable amount of elaboration. The working of those services is to be subject to regulation—maternity and child welfare services, the treatment of infectious diseases, services with regard to food and drugs, etc. In spite of that, the Minister under Section 2 of this Bill is, according to my reading of it, going to supersede all those services. He is taking power to declare that any one of them is not a recognised health service. I take it, too, that he can discriminate and say to one local authority, "I do not recognise your health service" or that he can say to one hospital, "I only recognise your health service." That seems to me to be a most astounding proposition. It is very arbitrary power for a Minister to take in a measure which purports to deal only with financial policy. I do not think he should get such complete, overriding power—power of a dictatorial character to say what is or what is not a health service.

In my opinion this section requires to be most carefully examined. I think that no such power should be taken by the Minister without a statutory obligation being placed on him to consult with the consultative council set up under the Health Act, and also to consult the local authorities concerned. I certainly shall seek to have the section amended on the lines that I have indicated unless the Minister can assure me that I have struck a mare's nest which, as far as I can see, I have not.

I am not sure if I understood exactly what Senator Baxter wanted to get at. I would like to point out that all the health services that we are dealing with here, leaving out the voluntary hospitals which we are not concerned with in this Bill, are administered by the local authorities. Therefore, as far as the expenditure on them goes, the local authority takes the initiative. Senators know that in connection with many of the services the local authority must get the sanction of the Minister before they incur certain expenditure. At any rate, that is how it works out. The point that Senator Baxter made was a point that indeed gave me some cause for thought too; that in this scheme which we are bringing in now, we are, as it were, saying to each county: "What you are spending now is the standard expenditure and you will not be asked to spend any more". As Senator Baxter has said, it is possible that one county may be more progressive than another and so it will for all time practically—until it comes to the 50 per cent.—be spending more than the county not so progressive. When I went to examine the matter I found that, generally speaking, all the rural areas were much the same. The urban areas, it is true, are more progressive. In a number of the urban areas they have developed mother and child welfare services. A number of the urban areas have also developed a venereal disease service and a few other services of that kind. I think we must admit that a service like the mother and child welfare service would be more expensive in the country than in the town, and that we are not too unfair in saying to the towns: "Well, now, you have done a certain amount for this service and we are tying you to that"; and to the country, which is doing less: "We are tying you to that". We are also going to help the country more than the town. We are not, I think, doing a great injustice either to the rural or the urban areas if we adopt that kind of plan.

Senator Sir John Keane talked about the White Paper being somewhat enigmatic so far as the voluntary hospitals are concerned. We do not mean to be enigmatic. I should say, of course, that a White Paper is not too specific on many things as a rule because, generally, it is designed to be an outline of policy—to invite comments and criticism so that the Government may know what the general opinion is on a scheme before they go farther with it. With regard to the money, the £9,000,000 that is there now will be spent on buildings as soon as we can get on with a building programme. We have a number of big propositions on hand at the moment. Some have reached the stage where contracts are to be invited and some are not so advanced. I should say, with regard to all the schemes that are before the Department, they will be quite sufficient to absorb the whole of this £9,000,000—that is before they are completed. That, of course, will take a few years. It is hoped that we will have more money coming in, but, if by any chance the money did not come in, so far as I can see, the State would have to step in and do it somehow, because the hospitals must be built, whether sweepstake money is available or not. So long as the sweepstake money is there, however, we can draw upon it.

With regard to deficits, we are covering these deficits year after year. They are rather disturbing, I must say, in this way, that some hospitals have consistently a very much higher deficit than others, and it is not easy to see what the explanation is. It is a matter which must be examined so as to find out what would be a fair and reasonable system to adopt with regard to these deficits for the future. There is no doubt that the deficits must be met from somewhere because we must see to it that our voluntary hospitals carry on.

With regard to the health services which the Senator mentioned, it is not easy to put down all the health services. We can, of course, say straight away and even embody in the Bill that all services covered by the Health Act of 1947, mother and child, infectious disease and the cost of institutional services are included, and also the services of local authorities to which grants are payable by the Health Department, mental treatment services, because these also are dealt with by the Health Department as well and that part of the public assistance service which deals with medical treatment. The difficulty, however, is that the Health Department itself has not yet settled down. Some services are still coming over and some going away. Senators will probably find within a few days that the Health Department will be making an Order handing over certain services to the Department of Agriculture. At the same time, other services are coming over from Local Government, and until we settle down properly and know what exactly are the services of the Health Department, it would be very difficult to make a list of the services.

Take as one example the school meals service. Three or four Departments spent a long time debating what Department that service should go to. Some feel that it should go to Education; some feel that it should go to Social Welfare, while others feel that it should go to the Health Department. In all probability, I think it will go to the Health Department, but questions like that will arise and it would be difficult at the moment to give a list until these matters have been settled. It might happen that, in a year's time, some other service might come over, and sub-section (2) is necessary from that point of view to enable the list to be amended. Some service might also go away from the Health Department to some other Department, and I, therefore, ask the Senator to be patient until we see where we stand with regard to health services in general.

I do not think any injustice can be done. We do not do much injustice to a local authority, either by leaving a service out and saying it is excluded, or putting a service in and saying it is included, and there is no inducement to a Minister watching finance from a central point of view to leave a service out or to put a service in. It would be well, therefore, to let the matter stand, for some time, at any rate, until we see what the Health Department will be dealing with.

Question put and agreed to.
Committee Stage ordered for Friday, 19th December.