Vol. 48 No. 7
I move amendment No. 1: —
To delete paragraph (a), lines 11 and 12, and substitute: —
(a) by the substitution in sub-section (4) of ‘ten shillings for each day of the first six months and six shillings a day thereafter' for ‘six shillings for each day'."
I wonder if the House would be agreeable to take amendments Nos. 1 and 2 together? Separate decisions may be had on each, if required. Perhaps we could take amendment No. 3 also with the first two amendments?
I am afraid that the arguments on amendment No. 3 will be different from those on the other two. We could take the first two together and take amendment No. 3 separately. On amendments Nos. 1 and 2, any Senator who has construed them in relation to the Bill will realise what their purpose is. We all know there will be cases in which some degree of hardship will occur through the enactment of this Bill. I thought I might make an effort at drawing a line at a certain point and, following discussions with members of my own Party, particularly those who are members of local authorities, I came to the conclusion that a period of six months at the full rate, during which a person would have paid a bill of £100, would be a reasonable point at which to draw a line and make some concessions.
Thirteen weeks at £3 10s. a week would amount to about £50, if you include medical treatment. If you took 26 weeks, the cost would be about £100, which would be a heavy enough burden on many persons in the middle income group. I must admit I have taken it that this provision applies to the middle income group — people who have an income of about £500 a year. I feel that in their case a hospital bill of £100 in any period of six months would be quite a sufficient figure.
There will also be the matter of two guineas a week subsequently so that the total figure which such a person would pay in a full year, if my amendments are accepted, would be in the region of £140 against the £180 for which provision is made in the Bill. That would mean a saving of £40 a year in the case of the person unfortunate enough to spend a year in hospital. It would be double that sum, £80, in the case of an unfortunate person who had to spend two years in hospital. That is my case for the amendments. Other people might have thought the line should be drawn at three months. On the Second Stage, it was said that county managers and hospital managers are reasonable people. The answer to that argument is that this is legislation. Even if nine out of ten acted reasonably, you could always get the tenth who was not reasonable.
I would ask the Seanad to reject these amendments. There is not, in fact, any need for them. The Senator has based them on highly exceptional cases. He has referred not merely to persons who are likely to be in general hospitals for terms of six months and of 12 months but, allowing his imagination to go further into the future, has spoken of persons being there for two years.
These examples have no contact with the generality of cases. Very few people are in hospital nowadays for longer than two or three weeks, and six, seven or eight in the case of major operations, because the whole trend of medical and surgical treatment is to get people out of hospital as quickly as possible. But we are asked to consider these amendments seriously on the basis, as I have said, of these highly improbable examples. I suggest that is not how we should deal with the matter at all. We are not legislating for particular cases but for the general condition. In these circumstances, I think we should have regard to the general condition.
There is one satisfactory feature of the amendment, and that is, that it now appears that Senator O'Donovan is convinced that for a period of six months at least, the county managers will act in a humane and reasonable way towards those who have to avail themselves of Section 15 of the Health Act. That is a very considerable advance on the attitude which the Senator adopted here when the Bill was before the Seanad for Second Reading. It is a pity that, having been converted to this reasonable view of the Bill, he should have attempted to put in amendments in which quite obviously, I think, in view of the tenuous arguments which he had to adduce, he himself does not believe.
My case against the amendments is that there is no need for them. Why should we assume that a person who, even in Senator O'Donovan's view, will act reasonably and humanely for a period of six months will, when the six months have elapsed, change his whole character and disposition, and in the case of a person who is suffering a hardship and disability, will proceed to exact the maximum amount which he may take from a patient if, and only if, the local authority is prepared to disregard the fundamental principle upon which Section 15 is based, that is, that no man will be asked to contribute more towards his treatment and maintenance in a general hospital than he is able to afford?
I do not think there is any reason whatever, anything in our past experience of the administration of the Health Acts, which would support such a suggestion as permeates these amendments. On the contrary, I think everybody will admit that the county managers in whose hands the immediate administration of the Act will be, and the members of the local authority to whom they are responsible and by whom they are surrounded, would not for a moment permit a person to act in the inhuman way in which Senator O'Donovan suggests they would act.
I have said there is no need for the amendments. In all cases, when fixing the contribution required from the patient, the local authority takes into account, and, in my view, must necessarily take into account, the duration of the illness and take that factor into account with a view to mitigating the hardship arising out of the illness. Senator O'Donovan suggests that local authorities will disregard that and will act in a contrary and perverse way, and, instead of mitigating the burden, will propose to increase it. It is more than probable — I think it is almost a certainty — that in over 99 per cent. of Section 15 cases, this amendment would not effect anything.
Whether the amendment is justified or not, it would be futile for the purpose for which Senator O'Donovan professes to have put it down because, as I have already pointed out, the vast majority of patients do not remain in general hospitals for six months. The bed occupancy in most of our hospitals is very much less than that period and, therefore, as I have said, over 99 per cent. of the patients would not be affected in any way by this amendment. I am not saying for a moment that the remaining 1 per cent., or that the whole of the remaining 1 per cent. would be, in any way, benefited by the amendment. I want to make that point quite clear. I am saying that 99 per cent. of the cases will not come within the scope of the amendment at all, and that, of the remaining 1 per cent., I am perfectly certain that it would be an exceedingly minute fraction whom the amendment would touch in any way.
What we have to concern ourselves about is whether, in respect of that minute fraction, we will be justified in limiting — for that is what the amendment seeks to do — the right of the authority to charge more than 6/- a week, to ask for a contribution of up to 10/- a week, if, in the opinion of the local authority, the means of the patient justify it. That is the net principle that is involved here. If the means of the patient do not justify a contribution of 10/-, the patient will not be asked to contribute 10/-. What Senator O'Donovan wishes the Oireachtas to prescribe is that even if the means of the patient would justify the local authority asking for the full contribution of 10/- per day, the local authority may not do that.
It could happen by reason of the provisions of Section 15 that a single, unmarried person, without dependents of any sort, could have a continuing assured income of £599 19s. 11¾d. He could have a continuing income just touching on the £600 limit, with no financial fears as to the future. Yet, if we accepted Senator O'Donovan's amendment, the local authority would not be entitled to ask this person, with an income of all but £600 a year, to contribute more than 6/- or, as he put it himself, more than two guineas a week towards his maintenance and treatment in hospital.
Even if he were outside the hospital and living with his family, it would cost more than two guineas a week to maintain him. If he were living in a normal way, it would cost considerably more than two guineas to maintain him. But Senator O'Donovan says that merely because this man is taking advantage of the public services which are provided to assist him through illness, we are not to be entitled to charge him more than two guineas a week, notwithstanding the fact that he will have a surplus of almost £500 a year after that to spend.
I think that is absurd. It is not reasonable to ask anyone in this community to contribute towards the support of such a person. It is not reasonable to ask anyone in this community to contribute anything towards the treatment in hospital of a person who can afford to contribute 10/- a day. That is the net principle. No matter how long he is in hospital, whether for six months, 12 months or two years, if the person can contribute without undue hardship or serious inconvenience up to 10/- a day, then I think, in justice to the community as a whole and in justice indeed to the least well circumstanced of the community, we are not entitled, as Senator O'Donovan asked us to do, to deprive the local authority of the right and power to ask him to contribute up to 10/-.
There is another aspect of this into which we should look. It shows the folly of drafting these catch-penny political amendments. The implication which may be read into these amendments is serious. It is that, in the opinion of the Oireachtas, the local authority should aim at getting 10/- a day, unless the patient is in hospital for more than six weeks; and only if and when he is in hospital for more than six weeks is the target to be lowered to 6/- a day. Indeed, that is what most people would read out of these amendments — that we regarded the 10/- as reasonable in all cases for the first six months and that at the end of that period, the local authority might be justified in reducing its target to 6/-.
I think, having regard to the situation in the country, it is much better to leave the sub-section as it stands and to emphasise that, while it will be permissible for the local authority in appropriate cases to charge up to 10/- a day, nevertheless, they are expected to continue as they have been doing in the past and to exercise their power in this matter humanely and reasonably. I submit, therefore, that in these circumstances the Seanad ought to reject the amendment.
There is more to these two amendments than the Minister is pretending. If there was as little in them as he made out, he would not have needed to make such a long and fanciful statement about them. He referred in his opening sentence to the imagination I brought to bear. It is only trotting after the poetic imagination the Minister brought to bear on the matter.
There was a considerable volume of opinion here that the Bill was too severe in certain cases. I attempted to find out in my own mind what the most severe cases were. If there are so few cases to which this applies, the Minister is giving away nothing. Why does he make such a song and dance about giving away nothing? Remember he introduced this Bill to balance the Budget. Two-thirds of one-tenth of 1 per cent. of accuracy — a rather fanciful and poetic piece of finance. The Minister used words like "highly improbable" and "minute fraction", and then took a case of a single man with £599 a year——
To show the absurdity of the amendments.
It shows the absurdity of the Minister's mind in dealing with this matter. The Minister made a point, in which there is something, that I voted against the Bill and that I was prepared now to discuss the Bill. Why would I not? The Bill was passed by the House. Why would I not attempt to amend it and bring it into accord with my ideas of what should be in it?
It does not matter what the Minister says to me or anybody else about the reasonableness of the local authorities or of the managers. What we have got to put into the Bill is reason; and it is not reasonable to ask a person with £500 a year, being about the mean of the group, to pay a bill of £180 a year if he is in hospital for 12 months. It is not reasonable to put a person in the position that such a sum can be demanded of him.
To refer to these amendments as "catch-penny political amendments" is just in line with the Minister's whole attitude towards the matter. Having made his speech, the Minister asked the House to reject the amendments. If he had not done so, I was going to ask him whether he was accepting them, because his arguments against them were so extreme and on the verge of the whole case that I thought he was merely referring to the quiet way I put them before the House.
The Minister says there is no need for the amendments. Of course, there is need for them. If there was only one case of extreme hardship arising out of this Bill, there would be a case for making that amendment. Everybody knows there would. The suggestion that I believed the local authority would act humanely for six months and would then act inhumanely afterwards is not in accordance at all with what I had in mind when putting down the amendments. I simply wanted to try to reduce the burden on cases which do occur. The Minister gave us no figures as to how many cases there are longer than six months in hospital. They do occur.
This was an effort by me to meet the more extreme cases of hardship. They do arise in relation to people who act, as the Minister says, in a contrary and perverse way. On occasion, officials do act in a contrary and perverse way. There is no obligation on this House to give them an opportunity to act in "a contrary and perverse way". If the Minister had said that my amendments, as put down, were going to cost him even £10,000 out of his £90,000, I might have said he had some case for it; but he did not suggest it would cost him £10,000 out of the amount he is going to save — this magical figure of two-thirds of one-tenth of 1 per cent. of the total State expenditure this year, which he is able to estimate with this degree of accuracy. If he would be prepared to give away even this two-thirds of one-tenth of 1 per cent., I would be prepared to say he had some case for sticking to his principle as laid down in the Bill, assuming that there is really any principle worth talking about in the Bill.
The Minister says everyone will admit this and that. I do not admit in relation to this Bill, and I do not think any other Senator would admit, that there is any obligation on us to do otherwise than put into legislation a proper provision to deal with cases of extreme hardship.
Is the amendment being pressed?
No, Sir. We will take amendment No. 3, I think, and press it.
I should like to make two points on Section 1, in relation to the figure of 10/- and the proposed increase to 10/- from 6/-. These points are related to two questions which I put to the Minister on the Second Stage and to which, it seems to me, he did not give a full answer. As reported at column 149 of Volume 48, the first question I asked was in relation to the basis upon which he calculated that £180,000 would be saved by this Bill. I should like to ask him again at what rate he made the calculation. The point I was making on the Second Stage was that, in relation to the number of people involved, I wanted to know had he calculated that they would be paying on an average an increase of 2/- per head, the mean between the present 6/- and the future 10/-; or did he calculate it on the basis that they would all be paying 10/-.
He had assured us previously that 10/- was a maximum, and would not by any means apply in a large number of cases. Therefore, I asked the Minister the specific question as to the basis upon which he reached this figure of £180,000. His answer to that, as given at column 188, was that I had referred mistakenly — as I did — to 17,000 persons being involved. As he pointed out quite rightly, he had made it clear, on the Fifth Stage of the Bill in the Dáil, that there would be another 14,000 people involved, and in fact there would be some others under "specialist charges" and so on, and that consequently when I put the question, mentioning the number 17,000 people, I was not stating the full figure.
The Minister then, apparently feeling that he had answered my question satisfactorily, passed on to other things. All that he had indicated, however, was that there are more people involved in this than was realised. I accept that as being true, but that does not answer my question at all, which was: what was the basis of his calculation when he said that this number of people, no matter what number of people is involved, will bring in an extra £180,000 a year — £90,000 to the Central Fund and £90,000 to local rates? As to the basis of his calculation, is the Minister calculating that they will each be paying, on the average, an extra 4/- or 3/- or 2/-? What is the basis of his calculation? I am afraid that if one examines the record, it will be seen that the Minister, probably inadvertently, did not answer that question at all.
This question is related to this first section because I want to know whether the 10/- is in fact in the back of the Minister's mind as the rate which will be charged in the vast majority of these cases. I think it might be demonstrated, if we were to be shown the calculation he made, that in fact he has been thinking of a payment of 10/- and not, as he asked us to believe in another connection, of a payment of 7/-, 8/- or 9/-.
The second point I want to make is in relation to another question which the Minister failed to answer. As given at column 152, I asked him whether his figure of 31/5 was correct. I quoted him as saying in the Dáil: —
"The simple arithmetic average of the daily average costs in 1955 — the last year for which figures are available — in the nine Dublin general hospitals works out at 31/5, so that persons paying 10/- a day will be paying less than a third of what the service for them is costing."
I asked him whether that was not a faulty average figure, because of the fact that, as I understood it, that average figure relates to the cost on the average number of occupied beds per day in these nine Dublin general hospitals and fails entirely to take into account that in establishing that "average cost" per bed all the costs of the out-patients' department are included as a charge on the in-patients, and consequently this figure of 31/5 does not represent the cost of the hospital service to the in-patients but represents a totally faulty average, worked out on the total cost of the hospital in relation not merely to in-patients but to out-patients.
I was disappointed to notice that the Minister in his reply, as given at column 189, did not answer that. I am not quite sure whether he really was replying at all to my question, but his remarks at column 189 were the nearest I could get to it. He says: —
"Senator Sheehy Skeffington put a similar question to me. I do not think that these questions properly arise on this comparatively minor measure. Perhaps on another occasion, if I am in the Seanad and if I have some notice of such questions, I will have the archives and the accounts examined and may be able to give a specific answer to them, in so far as such an answer could be specific."
It is very questionable whether some of these questions arise on this section.
This is specifically related to the sum of 10/- which was justified by the Minister on the grounds that it represents less than one-third of the average cost of the hospital treatment given those patients. I am making the point that this amount of 10/-, if it is based upon such a consideration as that, is faultily calculated, if the Minister has thought of it as being less than one-third, as he said, of the cost of the service to these patients; and if this figure of 31/5 is a faulty figure, then similarly the 10/- which is mentioned in this section is a faulty amount.
It was in an endeavour to find out the validity of this figure that I put the question to the Minister. He tells me he would have to go into archives and make up accounts to justify a figure which he himself used in his argument. I find that startling. I am convinced that the figure is a defective one. I cite the case of a Dublin hospital of roughly 150 beds where the patient-occupied bed-days in a year amounted to 42,000 and where the out-patient attendances in a year amounted to 98,000. Even if the cost of an out-patient-attendance is taken as being equal only to about one-fifth of the cost of one in-patient day, it still would be apparent that the out-patient costs in such a hospital would represent roughly one-third of the total costs of that hospital.
Therefore, on the Minister's figure, if we take that as an average daily cost figure of 31/5 per day, I suggest the real fact is that, of that 31/5, 10/- at least is the cost of out-patient attendances. That is a guess, but I think it is a reasonably accurate one and that, consequently, the in-patient cost per day would not be very much over 21/-. Therefore, if the Minister says we must charge 10/- because that is "less than one-third of the actual cost" of the treatment given these in-patients, he is misleading the House because, in fact, the one-third of what the in-patients really cost would be only 7/-, by reason, as I say, of the fact that all the out-patient costs are at present misleadingly included for these nine general hospitals in calculating this average figure quoted by the Minister, and for which apparently he has no justification whatever, without, as he says, examining archives and going into accounts. I am not satisfied when he says he is prepared to come back on some future occasion and justify a figure upon which to some extent apparently the 10/- in this first section is based.
I rise to oppose any increase in hospital charges. I should like to stress again that any increase would be more than the ordinary wage-earner could meet. The Minister stated his belief that the maximum charge of 10/- per day would be enforced in comparatively few instances. He gave figures for the City of Dublin which showed that in 75 per cent. of the cases, nothing was charged; in 11 per cent. of the cases, the people were asked to pay less than 6/-; and in 14 per cent. of the cases, they were charged the maximum figure. I think the Minister was wise to choose Dublin where there is an enlightened administration, but I should be grateful if he would get the figures from other health authorities throughout the country. I do not think it will be easy for a wage-earner to face up to the increased hospital charges.
In spite of what the Minister says, I am of the opinion that insured workers have had a raw deal and I should like to hear from him if my way of looking at the position is wrong. I do not wish to be unfair, but I see it this way. Previously, a qualified insured person — a bread-winner — when he became ill, had his hospital charges met through his national health insurance and his family had his sickness benefit with which to maintain themselves to some degree. I am aware, of course, that there was a limit of six weeks' hospital benefit, but that was subject to an extension, if such were deemed necessary, and there generally followed two weeks in a convalescent home, also subject to an extension. I think, too, it is right to say that if a patient were discharged and if, after a week or so, it was felt he still needed hospital benefit, he could go back again and remain in the hospital for another six weeks. The comparative freedom from worry aided the recovery of patients under this scheme. I think, too, that a six weeks' stay in hospital would be a rare occurrence—the new voluntary health insurance scheme budgets for ten weeks as a maximum.
If the person requiring hospital treatment was not the insured person himself but a member of his family, that person would not be covered under the previous scheme but here the bread-winner's wages would be available and, with some economies and aided in some cases by benefit from his contributory trade union hospital scheme, he would be able to meet necessary charges under this head. Under the new legislation, if the bread-winner becomes ill, he will have no wages. He will most likely have to pay for his treatment the sum of £3 10s. weekly from his social welfare benefit of £3 1s., which will leave his family with a deficit of 9/- weekly and no income of any kind on which to maintain themselves. I think such a domestic situation will not help a patient along the road to recovery but will rather drive him to leave hospital and return to work before he has fully recovered.
Here is another point which has struck me. Could the Minister say if, when an insured worker becomes ill, receives no wages but is entitled to the maximum benefit under this legislation, he becomes a member of the lower income group and immediately entitled to a medical service card entitling him to free treatment?
I am sure the Minister would not look to me to pull his chestnuts out of the fire for him. He is quite confident he is able to do that himself and perhaps anything I might say in his support in regard to this section might not be welcome, as he might wonder at the reason for my support.
I have some experience of local administration and I am not alone on this side of the House in regard to that experience. I should like to say this in reply to Senator Sheehy Skeffington. At our second last county council meeting — my colleague, Senator Cole can bear me out in this—we were told that the cost of the hospital was 30/- a day per person. When we are presented with our estimates at the beginning of the year, the estimates are sub-divided. A certain amount is put aside for dispensaries. "Dispensaries" involve not only attendance in dispensaries but also the treatment — what Senator Sheehy Skeffington would understand as the dispensary service.
We were given this figure of 30/- a day. That is the ascertained cost in a county hospital. I am quite satisfied that that is probably the average cost of every county hospital in the country. Dublin hospitals, as far as we understand them, are more expensive. Certainly, when a county health authority has to send a patient to any of the Dublin hospitals, it is very alarmed. There is an urgency in the matter of building or reconstructing hospitals down the country as far as county health authorities are concerned because costs in Dublin hospitals, as interpreted to us, are higher than they would be with ourselves.
If it costs us the sum I have mentioned in one of the county hospitals and if all we are in a position to take from a patient in a hospital is 6/- a day, obviously someone has to make up the balance. Those of us who have come to the conclusion and who have for a very long time been of the frame of mind that we do not want to see people who can pay their way leaning back and being carried by the community say the Minister is doing the right thing here. If one could have analysed the payments made by all the patients who go through any of our county hospitals in the year, one would see such a variety of charges as would convince one that there is no hard and fast rule. There is a sense of equity about what is taken from the patients. If patients can pay, they do pay. They are expected to pay and they ought to pay because it is their duty to pay. It is a duty to themselves and to the ratepayers that they should carry their own burdens. If they are unable fully to discharge their responsibility to the hospital, then the local authority must pay. We have gone too far along that road and we cannot survive unless people adopt a proper spirit in regard to bearing their fair share of responsibility in every field.
The figure has been raised to 10/- and a limited number of people will pay the 10/-. Even still there will be people who will pay less than 5/-, less than 4/- and less than 3/-. The examination which is carried out by the inspector, under the manager, is an exacting examination. If an aggrieved patient has a bill submitted to him which he regards as being beyond his ability to pay, he will speak out to some of the local representatives and they will listen to him. They have very good means of discovering whether he is telling the truth or not. Members of local authorities in these days sit down in a frame of mind which is full of anguish about how they are to levy this huge burden at the beginning of every financial year and they are going to be discriminating when somebody comes to them with a story. We have, throughout the country, a great number of honourable, fair and straight dealing people in our local authorities who want to do the right thing and they realise the difficulties in levying the rates. On the other hand, there are a number of us who know about suffering and hospital treatment and we cannot but sympathise with those who have to bear the worry and the scars left after hospital treatment. Members of local authorities have to balance in regard to who is to pay for what.
I merely rose to emphasise the point to Senator Sheehy Skeffington that the actual cost of maintaining a patient in a local hospital in Cavan is not less than the cost in one of the Dublin hospitals. I would like to see the position where a patient could go home from hospital, knowing that he did not have to pay anything, but many patients go home dismayed by the future difficulties they have to face and it would be a splendid thing if we could bear the burden, but we cannot go through life bearing all the burdens for other people.
I entered public life at a very young age, in 1925, and I have been in public life since. I have served on every public body in my county and I am familiar with all the facts. I was very impressed by the statement made by Senator Baxter. I know that everything he has said is only too true. Even before the Health Act came into force, the board of health, as we knew it, had very large bills every year to pay for sending patients to Dublin and Cork for extern treatment. I should like to say that no patient who was ever recommended to that local authority was ever denied the treatment he required. Now we come to the question of cost. Senator Baxter has given figures and I can corroborate what he has said. We like to hold the scales of justice evenly between everybody, but we can see the alarming increase in rates every year when we bring our local budget to the ratepayers.
Some of us have experience of the Dublin hospitals; some have been in them and had to pay for their own treatment and they know the cost. Any man who is able to contribute the amount of money demanded from him should do so. The amount of money demanded is a very reasonable sum — in this case, the maximum is 10/- and it goes down to 4/-. I think, as Senator Baxter said, that people should have some civic spirit and should pay something. This idea of getting everything for nothing is an idea which should be discarded. I have met people from every part of my county and any time there was a case of hardship presented to us, irrespective of who the person was or to what Party he belonged, we always brought it before the county manager and in no case did he disregard our recommendations or our advice. I am whole-heartedly behind this Bill which I think is very reasonable.
I should like to reply to a question put to me by Senator Miss Davidson because I know it is of general importance. If an insured person becomes ill and loses his income, he is eligible for a medical service card, provided the county manager, after taking all the circumstances into consideration, so decides, but he must be satisfied that the circumstances are as the Senator has described them.
With regard to a query put by Senator Sheehy Skeffington as to the basis on which the 31/5 per day has been calculated as the cost of maintaining a person in a Dublin hospital, it is quite true that I was not able to segregate the cost of maintaining and treating the in-patients in the Dublin hospitals from the cost of treating only the out-patients. Therefore, all these patients have been grouped together and the average has been arrived at. By spreading the total cost over the whole body of patients, whether in-patients or out-patients, the effect, of course, has been to reduce the average cost per patient because the out-patients do not receive any maintenance, but merely treatment. The in-patients do, of course, receive maintenance and consequently the average cost of maintaining and treating the in-patient is very much higher.
Sub-section (1) of the Bill, however, is concerned only with the cost of an in-patient. Therefore, in giving the figure of 31/5, I have probably very considerably overstated the cost of maintenance and treatment in a Dublin hospital towards which an in-patient is asked to contribute. I do not see how that fact helps Senator Sheehy Skeffington's argument against the Bill. He would have some point if I had overstated the average in order to overstate at the same time the relative reasonableness and modesty of the contribution the in-patient was asked to pay, but, when I have understated the average, then I am certainly not weighting the case in favour of the Bill. I think that is the suggestion which Senator Sheehy Skeffington wished to convey.
The other point which the Senator put to me was: how did I arrive at this figure of £160,000 to £180,000? It is spread over a fairly good variety of circumstances and services and in large part it might be said to be conjectural as we have not immediately available in the Department sufficient records in regard to the extent to which specialist services and institutional services are availed of, including, in particular, the bed occupancy. We have not those for every hospital in the country — at least not up to date because there are delays in furnishing the necessary data. I am quite satisfied that our estimate does not err on the side of being too low. If anything, we have perhaps overstated by 10 or 15 per cent. the possible recoupment to the local authority which will eventuate as a result of the passage of the Bill, but it is somewhere in the region of £160,000 to £180,000. So far as we can reasonably assess the situation, it is not likely that it will fall outside either of these figures.
I want to make it clear that we have not just made a shot in the dark. It is not just a case of think of a number and do what you like with it afterwards. There are some reasonably reliable statistics available to us and one of them is the number of persons in mental hospitals who contribute under Section 71 of the Health Act, 1953. We assume that there are about 14,000 of those, in round figures. We believe, as a result of the data available, that the contribution which they make towards the cost of their maintenance in the mental hospital brings in an income of between £30,000 and £35,000 a year. If one divides £30,000 a year by 14,000 one gets a total average contribution per contributing patient of about 43/- a year — substantially less than 1/- a week. If one takes £35,000 a year as being the amount of contribution—again assuming there are 14,000 persons who make a contribution — then the average charge per annum is in the order of about 50/-, again slightly less than 1/- a week.
These are average figures, but it is quite clear from the average that by far the greater portion of contributing patients pay substantially less than 6/- per week and it is the exception rather than the rule — I will not say the rare exception — for patients to contribute up to 6/- per week. That is admittedly the case in regard to the mental hospital. We have not got the figures readily available for the voluntary hospitals.
I gave examples, I think, on the last day in regard to the Dublin general hospitals. I indicated that, as a result of the check which we had made of the Dublin general hospitals, it was clear that 75 out of every 100 persons who qualified for treatment in the Dublin general hospitals under Section 15 pay nothing. If they pay nothing, when the permissive maximum is 6/- a day, it is not likely that they will be asked to contribute anything merely because the permissive maximum has been increased to 10/-.
Eleven out of 100 are asked to pay less than 6/- a week. That leaves a balance of 14 out of 100 patients who are asked — because their circumstances justify the request — to contribute 6/- a day. That is the position. I think in all those circumstances we are not doing any injustice to any person. So far as the mental hospitals are concerned, we have exceedingly modest contributions, no doubt dictated by the circumstances of those who contribute. In no case do I think that any one of these is likely to be affected. In the case of the Dublin hospitals, there are 14 out of every 100 people who may be called upon to contribute as much as 6/- a day. Because they are asked to contribute up to 6/- per day in present circumstances does not necessitate their being asked, even as to that 14 per cent., to contribute more.
I assume that the case of every individual who falls within the category and who is at the present moment paying the maximum of 6/- per day will be examined by the appropriate officers and whether he will be called upon the circumstances which the officers ascertain on investigation. We are not, therefore, compelling local authorities to charge up to 10/- per day in every case. What we are doing in the Bill is giving them the right to charge up to 10/- per day if they think — and that is the important consideration, "if they think"—the circumstances of the individual warrant it.
I wonder if I might ask the Minister two questions arising out of his reply? First of all, I understand the Minister to say that I am right in thinking that this 31/5, which is an average figure, includes both out-patients and in-patients. But I am not quite sure how the Minister has proceeded. He tells me that, if anything, the figure is in his favour rather than in favour of my contention. I do not quite know how the Minister proceeds in the case of a hospital which has a very large out-patient attendance in the year. Some of the Dublin hospitals have 80,000 to 90,000 out-patient attendances in the year, whereas the number of in-patients treated in the year might be as little as 2,000 to 3,000. I am not quite clear as to how the Minister establishes an average. I cannot believe that he just takes the 2,000 to 3,000, adds that to the 98,000 and strikes an average. Does he regard the out-patient attendance as being one-fifth of an in-patient bed day, or does he really simply equate the two? How is an average figure struck between an out-patient attendance of nearly 100,000 and in-patients treated of, say, some 2,500?
The second question I should like to ask is in relation to the charges. The Minister mentioned that the big majority of patients—I think he was referring to patients in mental homes —who contribute are now paying substantially less than the maximum 6/- per day. May we take the Minister then as saying that, if a person's circumstances on examination have shown already that he cannot pay the maximum of 6/- per day, he will not be asked to pay any increased amount now under this Bill? I can understand the increased amount in relation to those who have already been found capable of paying the maximum, but may we have the Minister's assurance that those whose circumstances do not now justify their being charged the maximum will not be charged anything extra under this Bill?
That is an assurance I quite obviously could not give. I am not responsible for the administration of local authority medical services. The responsibility for that rests upon the local authority. I cannot, by a declaration here in the Oireachtas, bind their hands in any way or deprive them of the responsibility they carry. If I could do that, then it might be much better to abolish them altogether and abandon the pretence that there is any such thing as local government here in relation to health services. I could not give that assurance and I do not think any reasonable person could give it. Indeed, I do not think the question was asked really seriously. I cannot conceive any person who is in any way acquainted with the principle upon which our local government and health services are administered asking a Minister to tie the hands of local authorities in relation to any obligation or responsibility they discharge.
The Senator also asked me a question in relation to the numbers treated in hospitals. Perhaps I am not stating the issue in the same words as the Senator, but I gathered that he was aware of a hospital in which 80,000 or 90,000 out-patients were treated in a year. He asked had I taken that into account in arriving at the average figure of 31/5 for the cost of maintaining and treating a patient in an institution? Of course I had not. I took the global figure for the whole City of Dublin. I have not one particular institution in mind. Why should I argue from the particular to the general? It is more logical to argue the other way round. I took the figures for all the patients in the Dublin hospitals, patients who had passed through the hospitals, without any segregation.
Including out-patients?
Including out-patients.
Each individual attendance?
Oh, no, not each individual attendance. I took them as they were and I divided the total into the number of patients. I do not think I erred in any way in doing that. In any event, it is quite certain that I did not weight the average against the patient. If anything, it is the other way around. As I have said, it is possible that we have not exceeded the cost of maintaining and treating patients in institutions.
I move amendment No. 3:—
To delete line 39 and substitute:—"sub-section (3) of ‘10/- for each day of the first six months and 6/- a day thereafter' for ‘6/- for each day'".
I take it from the Minister's remarks on the other two amendments that there are very few cases in which people are confined to hospital for longer than six months and it is very seldom an illness lasts longer than six months. We all know that many mental patients are required by society to be confined in a mental hospital. We all know that such patients are frequently confined for years. We all know that the former Minister for Health was concerned about conditions in mental hospitals. I see that the British Home Secretary stated recently that he is turning his mind to the same problem.
The Minister might have added on the general amendment that people who remain in hospital for a long period tend very often to become chronic, even though they are free to go home. That is so, but the mental patient is not free to go home because the law does not allow him to go home unless he is cured of his particular incapacity. If we take the case of a patient confined in a mental hospital for a period of two years the maximum charge, under my amendment, for that two years would be about £250. That is to say, an average of about 50/- a week, which is a fair and reasonable charge for local authority institutions. Under the Minister's Bill, the maximum charge is 70/- a week. The total charge for two years would be in the order of £368.
Again, I am concerned to limit the hardship but there is in this particular case the obligation provided by society that the person cannot leave the hospital. The Minister gave us a figure of 14,000 patients contributing £35,000 a year. Taking his top figure, 50/- a year or 1/- a week, when you get into that kind of average you are getting to statistical lunacy because a figure of 1/- a week is, I take it, a figure which is charged only by people with accountants' minds, taking the value of 1/- to-day. Dividing 14,000 into £35,000 and getting a figure of 50/- a year is just an absurdity.
As on the other two amendments, I am concerned about the fact that this is legislation and that we are making provision whereby hardship will arise. We now say that people with an income of between £450 and £600 a year in this country are in the middle income group. If we take it back to the pre-war value and call it £200 a year, it is a very modest middle income, to put it mildly.
The main argument which the Minister made on the other amendments, was that it was highly improbable that there would be such cases and that the vast majority, over 99 per cent. of the cases, would be at home after three weeks or a month. As far as I could get any meat at all in the Minister's answer on the other two amendments, that was his argument. Since it does not apply here, I take it the Minister is accepting the amendment.
If the Minister did, I think he would fall into the category of those who were committed for the public safety, to whom Senator O'Donovan has referred. I think we should clear up one thing. People are committed to mental hospitals under different circumstances. In some cases they are sent to Dundrum Asylum and we know the circumstances which bring them there. In the other case some of them are committed to ordinary district mental hospitals on an order made by a district justice, or something like that, in which case they are paid for by the Department of Justice. We can rule out straight away the position of those who are committed on Court Order.
The only people, therefore, who are really concerned in this section are those who go in because they are mentally afflicted with, I presume, some hope of being cured or, at least, if not cured, of being properly attended to and looked after when their families find themselves unable to give them the necessary attention. In that case, as I have pointed out, we can proceed only on the average. Senator O'Donovan may describe it as statistical lunacy to mention that the average cost is so-and-so.
It is not the average cost; the average charge.
Sorry—the average charge.
I never suggested that the average cost was lunacy.
One second; please bottle up your indignation for a moment. The average charge upon those who are naturally responsible for the patient is less than 1/- a week. The average cost, again to those who are naturally responsible for looking after their relative, is again less than 1/- a week. Whichever term the Senator uses, it does not alter the position. It remains the same, as being less than 1/-. I did not say—I was very careful to point out to the Seanad—that that whole congregation of 14,000 patients were all paying less than 1/- a week. I merely said that that was the average and that, therefore, some of those who are under Section 15 may have been paying and probably were paying up to 6/- a week. Let us make the point, which I am going to make again, that if they were paying up to 6/- a week——
A day.
Sorry—6/- a day.
There is a big difference between 6/- a day and 6/- a week.
All right. The Senator can trip me up, if he wishes, but it is exceedingly difficult to follow the Senator and talk sense. I was saying, Sir, that, even if they are paying 6/- a day, they are paying it because those who have investigated the circumstances of those who are naturally responsible for the patient have decided that they can pay that 6/- a day without causing undue hardship. That is the argument for the 6/-; it is the argument for the 10/-, that if a person can make a contribution up to 10/- a week, the local authority, the State, the taxpayer, are quite entitled to ask them to make that payment. If they are not able to make the payment then, of course, we are not entitled to ask it, but no person is prescribing that it ought to be asked for if the circumstances of those naturally responsible for the patient in a mental hospital do not permit them to do so. The same freedom of action in relation to this matter will remain with the local authority as they have at the moment and the passage of the Bill will not interfere with their discretion in any way except that they will be entitled to charge more than 6/- if, as I said, and I have to keep on repeating it, the circumstances warrant it.
I wish to support this amendment. The reason I do so is that I think it is an attempt to foster the policy fostered in this country for some time back—that is to say, to encourage people who need mental treatment to seek it. Up to now a stigma has attached to mental illness and efforts have been made in different directions by different bodies from time to time to remove that stigma from mental illness and to have mental illness regarded in the same manner as any other kind of illness is regarded by the community. Anything which would discourage people from obtaining mental treatment at the earliest stage when they require it or that would prevent people who have charge of those who require such treatment from seeking it for them is going against the policy fostered for some years to remove the stigma attaching to mental illness.
I think this amendment goes some distance towards maintaining that policy. The cost of mental treatment will, at any time, be great by reason of the fact that mental treatment is usually prolonged. It is regrettable that the cost should be increased and, as a result of that increase, that people should be discouraged, by reason of the financial burden involved, from taking mental treatment, or availing themselves of the mental treatment they require.
Is the amendment being pressed?
Yes.
Vótáil.
I move amendment No. 4:—
To delete sub-section (4) and substitute a new sub-section as follows:—
(4) This Act shall come into operation on the 1st January, 1958, or, on the day on which a scheme under the Voluntary Health Insurance Act, 1957, comes into force, whichever is the earlier.
The purpose of this amendment is clear. It provides that the Bill shall not come into operation until people have had an opportunity to protect themselves by means of insurance against the expenses which may occur if they fall ill. I do not propose to speak at any great length on the amendment. It is obvious from what the Minister has said on the previous amendment that he has no intention of accepting any amendment to the Bill.
I should like to support this amendment because it is a reasonable one. Unless the Minister has very strong reasons to put up against it, I think he ought to accept it. A large section of the white collar class are at present precluded, under the terms of the Voluntary Health Insurance Act, which we passed here, from insuring themselves against the costs which will now be increased by this Bill. Until such time as these people have had the opportunity of insuring themselves against these costs, it would seem reasonable to ask that this Bill should not be implemented.
It is reasonable to anticipate that some kind of scheme for voluntary health insurance will be offered to the people very soon. Whatever reservations we may have about how tempting a scheme that will be, nevertheless some kind of scheme will be offered, and this amendment asks simply that this Act be not implemented until 1st January next or until "a scheme under the Voluntary Health Insurance Act, 1957, comes into force, whichever is the earlier." That simply asks the Minister to withhold the application of these increased maximum charges from this class until they have a chance to insure themselves. Previously they had some chance to insure themselves but we have prevented them from doing that under the Voluntary Health Insurance Act. A scheme under that Act has not yet come before the public so it does not seem unreasonable to withhold the application of the increased maxima under the present Bill until such time as the people concerned have the alternative of insuring themselves under the voluntary health insurance scheme which surely must be coming up soon.
I should like to support this amendment. It seems to be a matter of justice. On the Voluntary Health Insurance Bill, I argued at some length in the House that it was unfair to deprive people of the right to continue to enjoy benefit under certain mutual benefit associations. Amendments along that line were not successful, but I do think we should do something for the people who have this extra burden laid upon them before they can attempt to meet it by insurance. Therefore, I would urge the Minister to accept this amendment, which is a reasonable and a just one.
I also wish to support this amendment. On the Second Reading of the Bill, I gave reasons for my opposition to it in that I felt it should not have been introduced until such time as the voluntary health insurance scheme was in operation. I understand the position with regard to the voluntary health insurance scheme, which the Voluntary Health Insurance Board are obliged by Section 4 of the Voluntary Health Insurance Act to provide for the public, is that it will be ready some time in the autumn. It is not asking too much to request the Minister to defer the application of this Bill until the voluntary health insurance scheme has come into operation.
My understanding of the position with regard to the increased charges which may be made under Section 1 of the Bill is that these charges will come into operation on the date to be prescribed by Order to be made by the Minister. If I am right in that, the Minister might be able to see his way not to make the Order prescribing that these charges may be made until such time as the voluntary health insurance scheme has come into operation or until the 1st January, if it has not come into operation by that time. I can see certain difficulties in relation to this amendment if it is passed, in that the Dáil is now in recess, but the Minister might consider adopting that suggestion in order to give effect to the purpose of the amendment.
I also wish to support this amendment and I would ask the Minister if he would state, when he is replying to the debate, if it is not his intention to accept the amendment, why there has been a complete volte face in this respect. Those of us who were in the other House during the previous term will remember the occasions on which the Fianna Fáil Party, then in Opposition, voted against the Government on various provisions of the Health Act. Those of us who were there then will also remember the present Minister who was very verbose on that occasion, stating that we were depriving the people of something which Fianna Fáil had decided to give them—had, in fact, given them in the Health Act of 1953—and which we were taking from them. If the Minister is not prepared to accept this amendment until such time, as Senator O'Quigley and Senator Sheehy Skeffington have stated, as there has been a voluntary health insurance scheme implemented for the middle income group, will he tell us why?
There is a very serious matter of political honesty involved here. Nobody can say that things have become easier for the people. Nobody would have the political hardihood to say that, and if things have not become easier it is not valid for the Minister to say that the purse is empty, and so on, when we consider that while he was in Opposition he did not care how empty the purse was and said the previous Government was cutting slices off the Health Act.
I do not remember ever having used the argument Senator Donegan has ascribed to me. I do not remember ever talking about the Health Act as if it were a side of bacon, something from which the Government could cut slices. I wish that Senators supporting this amendment would be consistent and realise that, in itself, the amendment is inconsistent. There are two propositions in the amendment: one suggests that the Act shall come into operation on 1st January, 1958; and, alternatively, that it shall come into operation on the day on which a scheme under the Voluntary Health Insurance Act comes into force. There is then the overriding condition "whichever is the earlier".
Consequently, if the voluntary health insurance scheme is not in force on 1st January, 1958, this Act comes into operation and the poor little voluntary health scheme is abandoned, like a baby on a doorstep, by the supporters of this amendment. I know that those supporting the amendment have seized upon a good case. All they are asking is that people who are likely to be affected should be afforded some opportunity of making other provision for themselves. That is all very fine, but it is not carried through consistently. While there appears to be a good argument in the second part of this amendment for deferring the coming into operation of this section, nevertheless, once you examine it, you will find it has very little force. In the first place, there is not at the moment any voluntary health insurance scheme in operation. My information is that it will not be likely to be in operation for some little time to come. I emphasise the words "little time".
If a voluntary health insurance scheme is brought into operation within three or four months and if it is a well-conceived scheme, it will provide for a substantial waiting period of some months. I have become a little confused, a little Gladstonian. The main point is that it will be some months before any voluntary health insurance scheme comes into force and it will be some months later, if the scheme is well-conceived, before it will be effective in doing what those supporting the amendment wish to have done, because it will provide for a waiting period before any of those who join it can derive any benefit from the scheme.
Therefore, what we are asked to do in this amendment is to postpone the coming into operation of this section until January 1st, 1958. I have not heard any argument from Senator O'Donovan or the others who have spoken in favour of the amendment, as to why we should postpone the coming into operation of the section until next January. In fact, I can see a very good reason why we should not. The position of the Exchequer and of the local authorities is such that we should hasten to give them any reliefs possible. We should try to avoid postponing these reliefs. If the general financial condition of the country is as bad as Senator O'Donovan has described it, then it seems to me there is less justification than there ever was for conferring benefits on some at the expense of the community in general.
It would seem to me that if the economic circumstances are such that people are finding it difficult to make ends meet, any person who can contribute to lessening the burden on the community as a whole should be required to contribute. That is one of the reasons why I say that, instead of putting back the coming into operation of this measure, we should give the local authorities the necessary permission to increase the contributions payable by any patients whose circumstances, in the opinion of the health authorities, justify their being asked to pay a little more than they are now paying. For those reasons, I would ask the Seanad not to accept the amendment.
On this stage of the Bill, I should like to express my apologies to Senator Sheehy Skeffington. I did not follow his rather complicated argument in regard to the manner in which the average cost per patient was calculated. Not for the first time to-day, I am sorry to say. I became a little confused and I misdirected myself as to the effect which the inclusion of out-patients would have upon the general average cost per patient. I should like to say now that I am still not convinced it would make any really significant change in the average cost per patient since most of the charges arising from the treatment of out-patients would be charges on the institutions as a whole and would represent the cost of such medicines as would be supplied to them.
I thank the Minister for making the position clear.
