I want to make it plain at the outset, so that no member of the Seanad will think that it is news to me, that the Bill does not provide health services for all and that, therefore, there are several means tests in it. I say that because it is a form of attack on me by many people, as if it were news to me. If there were no means test then we should have free medical services for everybody. As we have not provided for that, then we must have a means test. As a matter of fact, for convenience in discussing this Bill, we should divide the population into three groups. They have been referred to as (1), the lower income group; (2), the middle income group and (3), the higher income group. The lower income group is limited by a means test. That is really the group of people who are now entitled to free medical services, whether dispensary services, hospital services or whatever they may require. They will continue to get a free medical service under this Bill and there will be some improvement as far as their position is concerned.
It is expected that medical services will be considerably extended and improved as time goes on, and the lower income group will have the benefit of such improvements, whatever they may be. There is also a very big change in respect of maternity so far as women in the lower income group are concerned. The woman in the lower income group will have a choice of doctor. I must say that when I was first drawing up this health scheme for submission to the Government I considered that that was one of the most important reforms in the whole scheme —namely, to give a choice of doctor to the woman in the lower income group. It is extraordinary that it has not been referred to more frequently by those who were discussing this Bill, particularly by those who have been advocating a choice for the patient and especially, perhaps, by those who talk about the doctor-patient relationship and matters of that kind. Women of that class have, for almost 100 years now, been compelled to go to the dispensary doctor. Almost to a man, I should say that dispensary doctors are very good people. They do their work very well and I am quite sure that they would give as good service to these women as anybody else could give them. However, we must remember that it is not only a question of good service. Women in that condition are very sensitive about their condition and are very particular about what doctor they will consult. I think that not so much from the point of view of giving a better service but from the point of view of giving these women a right that they had not before, this particular reform is very important.
There is also a provision that every woman in the lower income group will get a bounty of £4—that is, whether the woman is insured or not. When the Social Welfare Bill was going through the Oireachtas it was noticed by many Deputies and Senators that we had not improved our social welfare code in relation to maternity benefits. At the time, I explained that I intended to have that dealt with in the Health Bill rather than in the Social Welfare Bill. The reason was that I felt that the uninsured woman is just as much in need of this particular benefit as the insured woman. That being so, it could only be dealt with—at any rate administratively—with any great ease in a Health Bill rather than in a Social Welfare Bill.
Another matter to which I should refer here and which has given rise to some discussion is the question of the red ticket. I have been accused by certain people of proposing to do away with the red ticket and to substitute therefor a white card. To a certain extent that is true but it is not done for the purpose of doing away with what was regarded as the slur that attaches to a red ticket. It is being done as a matter of convenience for the person in the lower income group. It is obvious that if a person in the lower income group must conform to a certain means test, he or she cannot get the treatment unless somebody applies a test and, naturally, whoever applies the test will give the person a note of introduction to the doctor who is supposed to treat the patient. Up to this, that has been the red ticket. The trouble is that if a man wants the doctor to call to his house to examine, say, his child, he must get a red ticket before going to the doctor. If it should happen that a second child in the same house should get ill in the middle of the following night, the father must again go for a red ticket.
It was to obviate the trouble of that system that I suggested that a card should be issued. I refer to it as a white card in order to distinguish it from a red ticket, but I do not mind very much if it is red, like the other. The card would be issued to the head of the family and would be valid for, say, 12 months and any time he might require a doctor to come to his house, he would present the card and the doctor would attend himself, his wife or his family. It was merely put in as a matter of convenience and not in any way to camouflage the fact that the person must produce a ticket or a card in order to get the dispensary doctor to attend. The lower income group therefore are entitled to free service of every kind which they may require.
We come then to the middle income group, which is made up of three classes: the insured people—some insured people may be in the lower income group, but all insured people not in the lower income group will come into the middle income group—land-holders, farmers under £50 valuation and—apart from these two very big classes—those whose family income is less than £600 per year. These people, with their wives and families, are entitled to whatever benefits are made available for the middle income group and these benefits are principally free hospital and specialist services, subject to certain conditions. The hospital is not always free. If the local authority believes that a person can afford a certain amount for maintenance in the hospital, the local authority may, if it thinks fit, charge that person up to a maximum of 6/- per day for maintenance, but, beyond that, no charge can be made. Services beyond maintenance are free, as are also specialist services.
In that group also, there is a free maternity service with choice of doctor, as in the case of the lower income group, and in the case of dental, ophthalmic and aural services, they will be made available to the middle income group, subject to certain charges in certain cases. When I speak of certain cases, I mean that it is not so much a matter of a means test as of the certain types of treatment. In the case of dentures, there would be a certain charge; there would also be a charge for glasses and a certain charge for appliances for the hard of hearing. These charges, however, have to be settled by regulation, and these regulations will come up for consideration later by the appropriate bodies, to which I hope to refer.
We have, then, the higher income group who are still left in the country above the middle income group. They, by contributing a certain amount, can get maternity services. As the Bill stands—it was amended in Committee —a married woman who contributes £1 per year for the first three years will be entitled to this maternity service, as in the case of the middle income group. After three years, there will be an investigation into the costs of the scheme and the annual contribution may then be raised, not for those already within the scheme but for new entrants, but in no case will it exceed £2 per year.
In addition a person in the higher income group who claims that he will suffer hardship by having to pay for hospital or specialist treatment may be admitted by the local authority to these services, either free or on payment of a certain charge. I should mention that where I say that hospital treatment and hospital maintenance is given to any of these groups, it includes mental hospitals and indeed, I should think that, in the case of a person in the higher income group who may claim that it would be a great hardship on the head of the family to maintain a child or wife over a prolonged period and who would get a certain help, it would probably apply more in the case of mental hospitals than any other. As Senators are aware, a stay in one of these institutions is unfortunately very long and would, therefore, bear very heavily on the head of the family.
In all cases, whether lower, middle or higher income groups there will be infant clinics to which everybody will be free to go for advice. There will be school medical examination for all in the primary schools and those attending national schools will be entitled to treatment for defects discovered in these examinations. The word "defects" has a certain fairly recognised meaning. The principal defects would be dental defects, ophthalmic defects, defects of the ear, deformities or defects requiring orthopædic surgery and tonsils. If the school medical examination takes place in a national school, the treatment for these defects will be free, no matter what group the parents belong to. If a child is attending a school other than a national school free treatment will depend upon the group to which the parents belong. In the case of infectious diseases, diagnosis, treatment, advice and so on are all free for all classes.
That gives, in rough outline, the services to which people are entitled under the Bill, but we must look at this matter from another angle, because, in discussing the Bill, there has been discussion not so much of the services as of other aspects. For instance, the choice of doctor is a matter which is very often referred to and those who have opposed the Bill give the impression that the doctors will be tied State servants, when the Bill goes through. So far as the general practitioner is concerned, whether a dispensary doctor or a doctor in private practice, a family doctor, there is no change. If he is a dispensary doctor, he carries on as he carried on in the past, except that, if any woman in his district is about to have a baby, she may engage him or any other doctor to look after her and if she engages him he will be paid a fee for attending her. To that extent, the dispensary doctor will be better off—he will have less work or more money. I suppose some doctors would prefer one and other doctors the other, but in any case they will have some advantages from it.
The middle income group will go as usual to their family doctor and will pay him. There is no change, so far as that is concerned. The position with regard to any advice or treatment given in the person's home or in the doctor's surgery will remain as it was —that person will be expected to pay the doctor. The only change in that respect is that, if he recommends his patient for either specialist or hospital treatment and if the patient tells him he believes he is entitled to free treatment in the hospital or to free specialist treatment and if the doctor gives this person a note to the local authority recommending that he get this hospital or specialist treatment, provided the person is right in believing that, according to his means, he is entitled to help, he will get it.
The position of the doctor who attends him is in no way different from what it was, except that he will be able to get free treatment for his patients in certain cases where he was not able to get it before. I do not see that his position is in any way changed.
Senators must remember that it is only the family doctor who will recommend hospital treatment or specialist treatment. Nobody else can recommend it. The family doctor is, therefore, in complete charge of his patient and will look after the patient as always and will, if he thinks fit, recommend this person to go to a specialist or a hospital as the case may be. The position of the great majority of doctors in this country, therefore, those who are dispensary doctors, those in general practice and family doctors, is not in any way changed as far as this Bill is concerned except they undertake to engage in maternity on behalf of the local authority. In other words, if the doctor puts his name on the list and if a patient chooses him in regard to maternity, he will be paid by the local authority instead of by the patient. In that way I should say he would be more sure of getting paid which should be of advantage to any doctor.
A doctor is free to put his name on the local authority panel. If he likes he need not do so. All he is asked to do is say to the local authority that he is prepared to take on maternity on behalf of the local authority if any person should accept his treatment for that purpose. The woman concerned can just name the doctor she likes who is on this panel.
The next point is that of the choice of hospital. If a person in the lower income group is at the moment recommended by his doctor to have hospital treatment he is dealt with by the local authority. He is sent to the county hospital or if the county hospital authorities think that he should go further to some other hospital, then he goes further. I should like to tell Senators, because there seems to be some confusion on this point, that the person who decides whether the patient should go to a county hospital or to, let us say, a voluntary hospital in Dublin is the medical man in the county hospital. If a dispensary patient at the moment is recommended by the dispensary doctor to have treatment in hospital and if he is a surgical case, he is sent to the county surgeon. If he is a medical case, he is sent to the county physician. The county surgeon will make up his own mind whether he will keep that man in the county hospital and look after him or whether he is more properly a case for some specialised hospital. If the latter, he decides to have this man sent to a more specialised hospital. I want to assure Senators that from the time the person thinks there is something wrong with him at the moment he is guided entirely by medical opinion and by nobody else.
As far as the lay staff of the county local authority are concerned their only job is to make arrangements for the person's admission to hospital and pay the bill when treatment is over. Every decision that is taken about where the person should go or how he should be treated is entirely in the hands of the medical staffs. The same will apply to the middle income group who may claim hospital or specialised service as a result of this Bill. Therefore, there is no danger of any kind that there will be any change in the situation. Therefore, there is no danger that any layman will decide whether a person will go to a hospital or not or what hospital he will go to.
There is this, if you like, that the local authority makes contracts with certain hospitals, and to that extent, if the county surgeon or physician decides that a person must be sent, let us say, to a Dublin hospital, the choice is limited to one or two voluntary hospitals, but I think it would be unreasonable to expect that the local authority should make a contract with every voluntary hospital in the country so as to give a complete choice to the county surgeon or physician when sending a patient on from the county hospital for further treatment.
I mentioned that the local authority may charge a person in the middle income group a certain amount for maintenance. In no case can it be more than 6/- a day or two guineas a week. The local authority hospitals are at the moment paying the voluntary hospitals in Dublin £5 12s. per week for any patients they send them. The two guineas is only a portion of that. The local authority pays the remainder. If a person in the middle income group, or, indeed, in the lower income group, says that he would prefer to choose his own hospital he has power to do so, but he will not do so well financially if he makes that choice.
If he says he wants to choose his own hospital he can go to any hospital he likes that is a recognised hospital. We had, and have, a method under the social welfare legislation where the National Health Insurance Society have a list of recognised hospitals. It covers every hospital on that list who applied to get on the list and who kept at least one ward of four beds. That was not a very stringent test, but that was the test, and there will be some such test in regard to this scheme, too. In any event, if the person says he wants to choose his own hospital he can consult with his own family doctor in regard to what hospital he will go to, and he can go to any hospital and the local authority will pay a subvention. That is the usual fee which they pay. It is £5 12s. less two guineas. That would be £3 10s. at the moment.
If this Bill were in operation just now and a person wanted to choose his own hospital, he would go along to his own local authority and it would pay £3 10s. for his maintenance. He would be responsible for anything over and above the £3 10s. a week that hospital would charge and he would also be responsible for any fees otherwise that might have to be paid either to medical staffs or anybody else. It is just that the subvention of £3 10s. per week is paid. I should say that nursing homes will also rank as eligible for the reception of such cases..
Another matter dealt with in this Bill is the rehabilitation of those who are deformed or disabled or who are recovering from very serious illness such as T.B. or some other long drawn out diseases. Where a person is not in a position to go back to his old occupation or perhaps is a person who never had any occupation having been ill since his youth, the local authorities will provide this rehabilitation service and will try to train people in certain occupations according to their physical capacity. In addition to that, the local authorities will pay maintenance allowance to incapacitated adults over 16 years of age who have no means and whose families are not in a position to look after them. These are new services as far as we are concerned here and it will take some little time to work out the necessary details of administration. These will be covered by regulations which will be submitted in due course.
All services under the Bill will, of course, be provided by the health authority. The health authority is the county council or the county borough council, as the case may be. All costs of this service, as in the case of other health services which are now in operation, will be recouped to the extent of 50 per cent. by the Department of Health. The powers at present exercised by public assistance authorities will, as a result of this Bill, be exercised by health authorities, and public assistance authorities will disappear.
In the county council area there is no change—it is the one authority in any case—except that it will no longer be necessary to call the county council the public assistance authority when they are dealing with, let us say, dispensary doctors, and call it the health authority when they are dealing with T.B. They will deal with all health matters as the health authority.
There will be some complications about Dublin, Cork and Waterford, because in these three places we still have public assistance authorities left which are not the same body as the health authority. It will be necessary to bring in, as soon as we can, a Bill to regularise these three areas and we have had a good deal of negotiation with these various bodies in connection with this Bill we have in mind. As soon as we get the agreement of the various bodies concerned, we will be able to produce the Bill.
Perhaps I should have mentioned at the outset the necessity for this Bill, although I do not think it makes very much difference where the point is made. The principal reason for this is that health services are costing a great deal more than they did. The cost of hospitals has gone up enormously in the last four or five years and the cost of the maintenance of a patient in a hospital has increased almost threefold. In 1947, when I was previously Minister for Health, I think local authorities were paying two guineas and later £2 10s. a week for their patients. There have been several increases since then and now it is £5 12s. That gives an idea of the enormous cost of hospitalisation of the private individual; in fact, so costly have hospitals become that those who are described here as being in the middle income group find it difficult to meet not only the cost of prolonged sickness but even the cost of a rather short illness.
Apart from that, I think people are becoming very much more health-minded. People are inclined to go to hospital more than they did. Some 30 or 40 years ago it was difficult to get a person to go to hospital even though he badly needed hospital treatment. There is no great difficulty now in getting a person to go to hospital provided he can pay or can get somebody else to pay for him. It would be a great pity, indeed, if people who were in need of hospital treatment and who were anxious to accept treatment were debarred from getting it through lack of means. That is a principle to which, I think, every Party has subscribed; that is, that no person should be denied the best possible medical treatment through lack of means. That is the principle upon which this Health Bill was largely based.
Maternity is also a problem for a great many people in the middle income group, in particular for people living in the cities and towns. Very often when a young pair get married in the city or town they have the expense of furnishing a flat or house; many of them cannot secure a flat and have to buy a house and, of course, they borrow the money to buy it. They have to pay the cost of purchasing the house over their first 15 or 20 years of married life. The young man who is trying to do this is not at the top of the salary scale of whatever occupation he may be in. He finds it hard enough to pay for his house, perhaps pay instalments on the furniture and, if he is in a certain type of occupation, he may have to pay for a car on the instalment system, too. When babies appear rather regularly in a case like that it becomes almost impossible for this young couple to meet the cost, and it is necessary that something should be done at that time of married life.
I had an experience some five or six years ago which made me very keen on providing facilities for the middle income group. I met two farmers, both of whom told me the same story. When I asked them how they were, they said that they were not too well. They had been told to undergo an operation, and when I inquired why they had not done so, they said that they could not afford it. That did apply to many people in the middle income group. They could not afford either the time or the cost of an operation, and if they could at all postpone it they did so. I need hardly tell the Seanad that there was great danger in postponing a matter of that kind.
From every point of view there is a necessity for such legislation. Whether we can all agree upon the particular measure or not is another matter. I know the Irish Medical Association felt the necessity for a measure of this kind.
They had proposed an insurance scheme to cover people in this group. There was no reason why they should propose such a scheme, unless they felt those people needed some help to cover the expenses of medical treatment.
The insurance scheme which they put up may be referred to and I would like to give my objections to it. I am not against the scheme in principle at all, but it does not cover just what we are up against at the moment in this country. First of all, an insurance scheme must be either voluntary or compulsory. If it is voluntary, at least quite a number of people will not adopt it. It is just likely that the improvident person will not adopt it and will not have money to pay for his operation when up against a crisis. Someone must look after him, as we cannot let him die. Therefore, even if the insurance scheme were put into operation by the Irish Medical Association, there would be a residual problem there with which I or someone else would have to deal. In that case, if I have to set up this elaborate machinery to deal with people of that kind, it would be just as well to deal with the lot.
I do not think it would be feasible for the State to bring in an insurance scheme as well as this scheme. I have no objection whatever to the Irish Medical Association bringing in an insurance scheme if they so wish. Not only do I not object, but I have even said to the Irish Medical Association that I would help them in every way possible to implement such a scheme if legislation is necessary.
Someone may say that the insurance scheme should not be voluntary but should be compulsory. When drawing up the Social Welfare Bill more than a year ago, we naturally gave a great deal of consideration to the point whether we should make everyone insure, that is, self-employed as well as employee, as has been done in England. We came to the conclusion that it would be impossible in this country. In England 80 per cent. of those gainfully employed work for another person and only 20 per cent. for themselves. In this country, as you know from the census, 50 per cent. are self-employed and 50 per cent. are employed by another person. It is very difficult to work an insurance scheme by going to every individual: it is comparatively easy to work it if you collect contributions through the employer, as we do on the social welfare side.
The self-employed cannot be dealt with in that way. It would be a matter of going to every individual and collecting the premium from him. That would be extremely costly and probably would not be successful. On the social welfare side we had to drop the idea of bringing the self-employed in; and I think that on the health side we will have to do the same. That is why I think compulsory insurance would be impossible. As I have said already, voluntary insurance probably would not cover the whole problem. Therefore, I had to reject insurance as a complete remedy for the present situation; but I repeat that if the Irish Medical Association wish to go on with an insurance scheme as well, they will get every help from me.
Since 1945, the effort to implement a health scheme of this kind has been pressed by the Minister for Health, whoever he may be, and opposed by certain other interests. Since the White Paper on this scheme was issued 12 months ago, giving an outline of what the Government had in mind, it has met with fairly vigorous criticism from some quarters, particularly the Irish Medical Association, and opposition generally from various interests. The Irish Medical Association gave certain points which I might as well anticipate, as it is almost certain they will be raised in this debate. One thing they have talked about in particular is what they call the "doctor-patient relationship". I have never been able to get a complete picture of what that relationship is, but evidently it is a type of relationship where doctor and patient get to understand each other and trust each other. Undoubtedly, it would be a great pity to upset that relationship in any way. I could never see, however, how this scheme would interfere with that relationship.
Everyone in this country will still go to the same doctor as they went to before. They can trust one another as they did before. If the doctor trusted his patient before to pay the bill, he can trust him still, as he will have to pay the bill. There is no change as far as that is concerned. When that doctor sends the patient on for further treatment to hospital or for specialist treatment, it is said there is some change in this doctor-patient relationship. I do not see what it is. If the patient is in the lower income group, there is no change. If he is in the higher income group and chooses his own hospital, there is no change. If he does not choose his own hospital, he will go to the county hospital or, if the medical authorities at the county hospital say the patient would be better in another hospital, he will go there.
A lot of people have to go to hospitals of that kind for treatment and it depends on what bed they are put in as to what doctor attends to them. There is no great complaint about the doctor-patient relationship in a voluntary hospital. I wonder what the change in relationship is there. I remember, some 40 years ago, being a resident student in a hospital under a very famous surgeon. He would come to the door in the morning, saying: "When did that fellow over there come in?" I would say: "Last night." He would ask: "What is wrong with him?" When he would have been told, he would say: "I will operate on him in the morning; bring him down to the table in the morning." Is that the doctor-patient relationship that we are going to destroy? I think the county surgeon will establish just as good relationship with these patients brought in, as would the doctors in any other hospital. I cannot see what the change is in the relationship there.
I was accused several times of Fabianism. I believe there was a famous general in Rome called Fabius Cunctator. He was noted for his powers of defence, in defensive warfare against Hannibal. I do not know why I should be accused of adopting Fabianism: I suppose I am entitled to carry on defensive warfare if I so think fit. It appears that this man achieved success in particular by delay; he always took his time and eventually got Hannibal where he wanted him and finished him. I am not delaying: I want to get on with this Bill as quickly as possible.
The point has also been put that we are drifting towards State medicine. I want to make this reply, though some Senators may think it is not an important point. It is the local authorities that carry out all these schemes, providing the treatment for these various people who will benefit. They are elected representatives of the people. My own experience of local authorities is that if any State Department tries to interfere with them, they just do not take it, but go on in their own way. They will not take dictation from anyone, so I do not think there is any great case to be made that we are introducing State medicine.
I want to make it clear that I am very particular to preserve any voluntary effort we have in this country, and I have said over and over again myself to any body of people that came along to me and that wanted help in any way, that I have tried to help them in every way possible. I have always done that because I think that voluntary effort is very important and I do not know why our local authorities should be attacked as being imbued with set ideas, because they are voluntary bodies, too. They are not paid for their services, and they render very good services indeed in looking after their hospitals and their various institutions, and I think we ought not to be too hard on them but rather we should be grateful for the things they have done.
