Health and Mental Treatment (Amendment) Bill, 1958—Second Stage.

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

This Bill involves no departure in principle from legislation which has already had the approval of both Houses of the Oireachtas. Its main object is to amend the definition of some of the classes eligible under the Health Act, 1953, for general institutional and specialist services, maternity and infant care services and mental hospital services. The passage of time has made it desirable to introduce the amendments now proposed in the categories of eligible persons if real effect is to continue to be given to the intentions of the Legislature in passing the principal Act.

Section 15 of the Health Act, 1953 specified the classes who with their dependents are eligible for the services. These classes are, broadly speaking, persons insured under the Social Welfare Act, 1952; other adult persons whose yearly means are less than £600; farmers the rateable valuation of whose holdings is £50 or less; and persons outside these three categories who cannot without undue hardship, provide the services for themselves. Dependents of persons in each of these categories are also included.

The first amendment we are making in this Bill provides that the reference in Section 15 to the Social Welfare Act, 1952, will be read as a reference to that Act as amended. At present, when it is desired to confirm the eligibility for health services of an insured person, it is necessary only to establish that the person has paid an insurance contribution within the specified period. As the insured were accepteden bloc in 1953 as a class which should be given the benefit of the new and extended services then introduced, it is equitable that insurability, as newly-defined now, should continue to be one of the criteria for entitlement to these health services.

The second category of persons eligible for institutional and specialist services is adult persons whose yearly means (including the means of certain relatives) are less than £600. The Bill proposes that this limit should be increased from £600 to £800. It would obviously be inequitable that, while insured persons earning up to £800 a year would be eligible for the services, the income limit should be £600 for others.

The Bill relates only to two of the classes entitled to the services and does not affect the present basis for determining the eligibility of farmers. The reason is, of course, that land valuations are, to all practical intents, immutable and that the proportion of the farming community entitled to the services has not altered since they were introduced. A farmer who would have been entitled to the services in 1953 is still entitled to them, unless he has been fortunate enough to acquire extra acres since, bringing the total valuation of his holdings over £50.

Apart from the matters to which I have referred, it is proposed in the Bill to make one small but important change in the determination of eligibility. I have had representations to the effect that it is onerous to include, in the yearly means of an applicant, the full yearly means of any unmarried son, daughter, step-son or step-daughter living with the applicant. I think it is generally agreed that in most cases the full income of an unmarried son or daughter is not available to supplement the parents' income nor is it realistic to expect that it should be. It is accordingly provided that, in calculating yearly means, the first £100 of the income of any son or daughter resident with an applicant shall be disregarded, subject to an overriding limit of £300 on the amount to be so disregarded.

It is difficult to arrive accurately at the number of persons who will be affected by the provisions of this Bill and of the extra cost which will be incurred. It is, however, estimated that very roughly 80,000 additional persons will be brought within the scope of the institutional and specialist services and the maternity and child health services. The annual cost, half of which will be met by the rates and the other half out of the Exchequer, is of the order of £120,000.

I recommend the Bill to the House for Second Reading.

The Minister has made a fair case for the Bill and there are only two points I should like to make on it. It is, of course, desirable in the light of the falling value of money to raise the point at which a person becomes eligible for health benefits from £600 to £800. I understand that under sub-section (4) of Section 1 that £800 may, in certain cases, be increased by £300. So that we are in the position now that a person may be eligible for health benefits when he has £1,100 a year, whereas he is also subject to surtax at £1,500 a year. Therefore, we have this rather curious position that here the falling value of the £ is taken into account, whereas the State and various Ministers for Finance stubbornly regard the £ for the purpose of income-tax and surtax, not only as falling in its value in 1958 but as having the value it had in 1914, which surely portrays a rather curious example of double thinking. If some Minister does not take it up soon, we will reach the point where people who are eligible for surtax will also be eligible for health benefits, which, in the words of Euclid, would be absurd.

A great many more people are eligible for benefits under this Bill and as far as Dublin City is concerned, it will certainly mean greater crowding in the Dublin hospital clinics. There are in Dublin a great many clinics. I think there are over 200. It is complained that in the case of a considerable number of people who go to them, and particularly the poorer people, their position now is worse than when the Health Act came into operation. Before the Health Act came into operation, they went to a clinic, sent very often by a general practitioner without filling up a form, or sent by a specialist and they got in the clinic itself the medicines prescribed by the specialist.

The position now is quite different. They cannot be treated unless they have a ticket and as well as that, they must fill in forms. I have been given, by various people, rather harrowing descriptions of women with a baby in one arm and parcels in the other, not well educated, endeavouring to fill up forms which asked a variety of questions such as what is their husband's income, which sometimes they do not know. The whole work of the hospital is slowed up by all this form filling and it is adding to the expenses. They have found it necessary to give assistance to people filling in these forms. It sometimes happens that one woman will fill in a form rather summarily for another which one doctor said was the best thing that could happen because all that he wanted was to see the patient.

The charges now are 2/6 for attendance and 7/6 for an X-ray. There are no provisions at all for the use of certain machinery for the examination of heart or brain trouble and no provision at all for physiotherapy. I am not sure what the extra cost of that would be, but the extra cost of this Bill, according to the Minister, will be £120,000. It will benefit certain people but it will also aggravate the position in the dispensaries in Dublin City. One of the curious things about the present position is that whereas a patient before the Health Act, could get medicine in the actual hospital or clinic which he was attending, the same patient has now to get the prescription, and take it to his dispensary area where the doctor may, I think, refuse to make it up or have it made up for him.

I think that is all done under regulations and I suggest that these regulations could be simplified and that we could reduce the amount of form filling. If one abandoned the form filling and left it to the discretion of the hospitals or medical practitioners and made a bulk payment, I am not sure that it would cost a great deal more. I know of one case where the bill of 10/- a day at a hospital was the cause of considerable anxiety and considerably retarded the patient's progress. I know you cannot give these things out quite freely, but it is a curious commentary on the State's welfare operations that a great many people should find themselves worse off now in the City of Dublin, from the point of view of attendance at clinics, than before these Acts came into operation.

I wonder if the Minister could make an inquiry, with a view to seeing if all this form filling, which is very difficult for certain people, could be lessened. I am fairly expert myself in filling up forms, but I find them very repulsive and difficult and people not accustomed to using a pen find them still more difficult. I wonder if some improvement could not be made in Dublin, particularly so that a patient who went to a clinic could be attended there and get at the clinic whatever medicines were prescribed for him rather than that he should have to go to a clinic in one place, then go to another place, wait in a queue and perhaps fill in another form to get medicine. Granted the principal Acts are there and that the processes being followed in this Act would seem to be inevitable, but as I said in the beginning, while the Minister for Health is pursuing the £ upwards, the Minister for Finance is holding the £ for tax purposes on the basis it had in 1914.

I want to make first a few points, some of which I thought relevant to an earlier Bill. The two Bills are linked together, and one may be forgiven perhaps for making similar points about both. The Minister, in justifying the introduction of this Bill, said that the rise in the remuneration limit from £600 to £800 is justified on the grounds of the changed value of the £. I notice, as Senator Hayes has pointed out, in certain cases the limit can be raised from £600 to £1,100, that is to say, nearly doubled.

I would like to make to the Minister for Health the point I made to the Parliamentary Secretary to the Minister for Social Welfare. I should like to see some evidence of a similar Government realisation of the rise in the cost of living when we come to give increases to pensioners——

The Senator is now going outside the scope of the Bill.

I shall return immediately inside the scope by saying I was glad to note the figure, that an extra 80,000 persons are being brought in.

That leads me to a related question to which the Minister might give a reply. I think I am right in saying that his predecessor told us that some 5/6ths of the community are covered under the health scheme as it was before this present amendment. I should like to know what is the new proportion? Is it some 7/8ths of the community which will now be covered by the scheme? If this is so would it not be better, as Senator Professor Hayes has suggested, or half suggested, to abolish all the form-filling in the simplest possible way, by going all the way, and making it 8/8ths of the community, by getting rid of the means test? Most of the complications in the administration are related to finding out whether you had £600 now, or will have £800 a year, or £1,100 a year or more, with dependents.

I should like to ask whether the Minister has had any representations from the voluntary health insurance scheme, arising out of the fact that their potential market will be reduced by the provisions of this Bill. It seems obvious that a pretty large section of people—some 80,000 persons in fact— who were potential subscribers to the voluntary health insurance scheme will now almost automatically cease to constitute a part of that potential market. I should like to know if the Minister has had any representations, and if so whether this is a matter of concern to him, and whether he has any opinion as to whether the loss of this potential market may not jeopardise the scheme.

Finally, I should like to ask a question about the doctors—whether the doctors were consulted on this. I take it that the Bill means in fact that a number of paying patients will now be treated either free or partly free— patients who previously would have to pay either directly or through a voluntary health insurance scheme. I take it that the doctors under this scheme are being asked to take free or semi-free an extra 80,000 people. I do not know whether it is considered that the doctors' fees should therefore be increased, or the number of doctors be increased, but I would like to know whether consultation with the doctors has been entered into by the Minister. It would seem that courtesy would demand that. The doctors pretty well must comply with the terms of this Bill when it becomes an Act, and my feeling is that they deserve at least to be consulted in the matter. I should like to know if they were consulted, and if so, what is their general attitude towards this change.

This Bill extending the limit from £600 to £800 is, as Senator Hayes has said, a very logical extension of the Health Act of 1953, in view of the fall in the value of money in the past five years. It is also, of course, a corollary to the Bill the Second Stage of which we have just passed, the Social Welfare (Amendment) Bill. It should therefore commend itself to the Seanad. I have only one point to make in regard to the matter, and it is a legal point, arising out of the interpretation by the courts of certain sections of the Health Act, 1953, which should be brought to the notice of the Minister and his Department. It concerns a defence which is of late being entered in the courts by insurance companies where they operate for defendants in road accident and other negligence cases.

It has now become a practice for insurance companies to plead as a defence against the plaintiff's claim that the plaintiff, in regard to his medical and hospital expenses, is not a liability of the defendant, as being a holder of a medical card, or, in the middle income group, and a liability of the defendant or defendants in the case of contributions which have to be paid by him to the local authority. That view has been pushed by insurance companies in their pleadings, and their defence in these cases has been upheld in some courts. It has not yet been decided finally by the Supreme Court. This I think is a matter which should be brought to the notice of the Minister for Health, because the effect of insurance companies setting up the Health Act and saying that they are not liable to pay the plaintiff's hospital and medical expenses because of the Act, and that the plaintiff in the particular case must look to his local authority to pay for his medical and hospital expenses of course, would, if universally held, shift a certain burden on to the local authorities and to the Exchequer which heretofore has been borne by insurance companies.

Is this before the Supreme Court?

No. It is a matter which has not been finally decided by the Supreme Court, but it has been held in various High Court and numerous Circuit Court decisions in cases where the insurance companies have used in their defence Sections 14 and 15 of the Health Act, 1953, as an escape clause. I think it is a most undesirable practice, shifting a burden to the local authorities and the State which has not heretofore existed. Where this plea has been entered, the insurance companies are claiming to be free from the burden of paying the plaintiff's medical and hospital expenses. It is a very undesirable development, and should be settled one way or another by the Supreme Court, or the Minister could very easily consider an amendment of this Bill for the Committee Stage. If that is not possible, certainly in the next six or nine months if the position has not been clarified, a Bill should be introduced covering this point.

It would be a simple matter to exclude all liabilities arising out of negligence actions by the provisions of Section 14 and 15. A simple sub-section could quite easily be brought in excluding local authorities from any liability arising out of hospital and medical expenses incurred in any civil action. The shifting of a burden arising out of a legal technicality being utilised by insurance companies to the detriment of the finances of our local authorities would appear to be a very undesirable development.

We welcome the raising of the means ceiling from £600 to £800 and also the modification which leaves out of the reckoning the first £100 of the yearly earnings of an unmarried son or daughter residing with the family. The charges for institutional treatment, however, still give rise to much hardship because of the general tendency to treat the 10/- per day as the minimum and not the maximum charge.

I have been asked to direct the Minister's attention to the case of victims of occupational accidents where the persons may be hospitalised for long periods during which the only payment they receive is workmen's compensation of 90/- per week. The number of non-fatal occupational accidents in the course of a year is very considerable and many such cases require hospital treatment for some time at least. I am informed that the majority of these institutional cases are charged at the full 70/- per week, although the workmen's compensation payment of 90/- would be insufficient for the maintenance of the family during the breadwinner's stay in hospital. The procedure adopted is that the hospital bill is not served by the local authority until the man is back at work again, when, though he may be in a difficult position trying to clear off debts which inevitably accumulated when he was in hospital, he is pressed to clear off the hospital debt at the full rate of 10/- per day.

On a previous occasion, the Minister informed me that if a person's income ceased when he entered hospital, he would, in the absence of other means, be treated as in the lower income group and so receive free institutional treatment. In the case of injured workmen in receipt of workmen's compensation, the same treatment should apply and it is reasonable to ask that the means be assessed as they are when a man is in hospital and not when he is back at work earning full wages. I would ask the Minister to consider this point in view of his previous statement and that he would advise county managers to follow the procedure mentioned.

There are two points I should like to raise, one of which deals with those who contribute towards maintenance. In the explanatory memorandum which the Minister sent us with the Bill we have the statement:—

"Under the Mental Treatment Act, 1945 (as amended by the Health Act, 1953), the classes eligible for the mental health service are the same as those eligible for the general institutional and specialist services."

There is one exception to that and I should like the Minister to look into it. There are people who are liable to contribute towards a patient in a mental hospital who are apparently not liable to contribute under the general health services.

I should like to refer the Minister to Section 230 of the Mental Treatment Act, 1945:—

"For the purposes of this Act and without prejudice to any obligation for the time being imposed by law otherwise than by or for the purposes of this Act, the following provisions shall have effect:—

(a) every legitimate person shall be liable to maintain his or her father and mother;

(b) every illegitimate person shall be liable to maintain his or her mother;

(c) every man shall be liable to maintain such of his legitimate children as are for the time being under the age of 16 years;

(d) every woman shall be liable to maintain such of her children, whether legitimate or illegitimate as are for the time being under the age of 16 years;

(e) every married man shall be liable to maintain his wife and shall also be liable to maintain every child, whether legitimate or illegitimate, of his wife who was born before her marriage to him and is for the time being under the age of 16 years.

Under that section apparently, a married illegitimate child would be liable to maintain his or her mother, even though I presume the clause about hardship would come into it. There are instances which I should like the Minister to look into. I know it is a difficulty with which mental hospital authorities are confronted. They are bound by that to claim against people who perhaps would prefer to forget all about it.

The other point I wish to raise is the question of the £50 valuation as opposed to the £600 or £800 limit. Circumstances have arisen apparently since 1953 that entail the giving by the State or employers of anything up to £800 salary where previously £600 had been sufficient. In other words, either because of the cost of living or some other consideration, it was necessary for a person who previously earned £600 to get a great increase in his salary.

Surely the cost of living has been equally hard on the farmer, who has to meet his own cost of living. He has had to meet an increase in the price of fertilisers and seeds and so on. The agricultural price index figure is perhaps the only indication I can give the Minister. It has not risen very much since 1953 until 1956, the last year I have figures for, 1956 was the last year in which it was above the 1953 figure, which would indicate that the farmer's income has not increased, whereas his cost of living and the prices he must pay for seeds and fertilisers have increased. To my mind, there is no comparison between the man with £600 salary and the farmer with the £50 valuation and I suggest to the Minister that he should raise that figure to £60 under this Bill. To my mind, £600 was always far in excess of what the £50 valuation farmer could earn from his farm in 5½ days in the week. In the first instance, £600 far exceeded the average income of the farmer with a valuation of £50 and I think any figures the Minister can procure will bear out that point. I hope the Minister will look into that point and then decide to change that £50 to £60.

Senator Cole has just mentioned the point I was about to raise. My problem is why the farming community are to get no benefit under this Bill. I do not see any reason why farmers whose valuation was £50 or under when the Bill was introduced in 1953 should not benefit under this Bill. They are no better off to-day than they were in 1953, and, as a matter of fact, in my opinion, after the disastrous year we have just had, they are much worse off than the salaried people whose incomes are not less than £600 or £800. I should like to join with Senator Cole in asking the Minister to consider the farming community in this regard.

There is another aspect which was mentioned by Senator Sheehy Skeffington, that is, the detrimental effect this Bill will have on the voluntary health scheme. In my opinion, it will make impossible the working of that scheme. I understand that when the Voluntary Health Insurance Bill was introduced, the then Minister for Health, Deputy O'Higgins, gave an undertaking that there would be no change in the social welfare legislation without consultation with the voluntary health scheme authorities. That obviously is not the case.

There is no doubt that 70 per cent. or 80 per cent. of the population of this country will be covered by this Bill, which leaves only 20 per cent. who ordinarily would not be interested in either voluntary health or national health insurance, so it seems to me that this voluntary health scheme will fall through. I understand that none of the staffs in our voluntary hospitals even as present constituted have been consulted about this Bill. In my opinion, the present extension of the Act will have a detrimental effect on Section 14 of the Health Act, 1953. Therefore, I would ask the Minister to reconsider this Bill and to put it in a more workable form than it is in at the moment.

May I, partly from a professional standpoint, respectfully raise four points for the Minister's consideration? We contemplate the extension of a very important Act to provide for certain people. There has been a great deal of talk about incomes under £600 and under £800 per annum. May I stress another side of the matter?

We are extending a service. What does that extension exactly mean? The extension of the service will involve, I think, the consideration of four points. Firstly, for want of a better term, we must consider what I can only call "leakage". It is current gossip that a certain number of persons are benefiting themselves though they are not financially entitled to do so. Those of us in medicine say that they are benefiting themselves anyhow, even if we are paying for it. Even if there is some leakage going on, which I think will increase by raising the ceiling from £600 to £800 per annum, I should be interested to hear the Minister on the subject of the number of persons availing themselves of a service to which they are not financially entitled.

Secondly, we must consider the question of the local authority. The extension of the Act will increase the responsibilities of the local authorities. As far as we can judge, the local authorities have in many ways shown themselves to be in a bit of a difficulty. For example, speaking from the point of view of the medical profession, we get the impression that they are trying to clamp it down on outpatient departments. If this Bill is passed and if the Act is extended to certain people, I think outpatient departments will suffer a bit more.

If we extend the application of the Act, we must realise that in the past three or four years not only has the outpatient department been extending itself enormously but it has developed in the past two or three years in ways which were not heard of when the Act started. I have in mind psychiatric treatment in the outpatient department. It is now possible for a person in a neurotic condition to go to an outpatient department and have things talked over by a sympathetic expert. His troubles can be solved. He may be given a sedative. Everything may be set right. Most valuable work has been done in that respect. Sometimes these troubles are not permanent but are just like the oscillations of a barometer, really. In extending the services of this valuable Act, it is very important to make the local authorities recognise the importance of the outpatient psychiatric department and psychiatric treatment.

Thirdly, this will be an additional strain on hospital resources, hospital staff and hospital facilities. A figure of 80,000 patients has been mentioned. Is that not a minimum figure? Would that not include the families?

Yes, it is a comprehensive figure.

An increase of 80,000 will increase the strain on hospitals. Every year, they are getting more strain because of better diagnosis and increased laboratory work. What can be done now is almost unbelievable to those of us who were medical students 40 years ago. We realise the importance of modern biochemical tests, and so on. If we extend the Health Act, we shall have to extend the treatment we are giving.

Point number four has already been raised efficiently by Senator Sheehy Skeffington and others, that is, the relationship of the general practitioner and how far the medical profession has been consulted in this regard. If I were embroiled in medical practice, I would say: "The cost of living has been rising for these people and for me, too. I will get only 2/8 for each patient treated. My share for my services, such as they may be, is certainly nearer to 3/6 than to 2/8." What is sauce for the goose should also be sauce for the goslings. I hope the Minister will consider the points I have made.

I have not very much to say on this Bill because I do not think it a measure that lends itself to too much discussion. A few red herrings have, I think, been brought into the debate. The approach by certain Senators has been rather unrealistic. For instance, certain Senators tried to convince us that the reason for the introduction of this measure is the alleged increase in the cost of living and also the alleged diminution in the value of the £. I think the leader of the opposite side of the House started on that note. I want to point out that these considerations have no bearing whatever on the Bill.

This Bill has been brought in because it has been discovered that certain deserving sections of the people have been put outside the scope of the 1952 Act by reason of certain increases in remuneration, salaries and wages that have been given to those sections of the community. The real purpose of this Bill is to bring those people back again within the scope of the 1952 Act. I think nobody here can deny that that is the fundamental purpose of the Bill and its introduction has no bearing on the cost of living or on the value of the £.

This Bill is somewhat difficult to reconcile with the Act which was passed by the Oireachtas last year. Under that Act, the contributions which might be demanded by a local authority from a person in the middle income group who was entitled, under Section 15, to hospital treatment were increased from 6/- to 10/- per day. The case then made by the Minister was that persons under £600 per annum were well able to pay up to a maximum of 10/- per day and that they should be compelled to pay that, if the local authority decided they were able to pay that sum.

I find it hard to reconcile that point of view expressed by the Minister when he was increasing those charges with the extension of the limit from £600 to £800 per annum. I should have thought that people under £800 would be in as good a position, at any rate, to pay for their hospital expenses as the people under £600, perhaps— say, somebody on £400—would be able to pay the increased charges which the Minister enabled the local authorities to charge under the Act which was passed last year.

It seems a logical conclusion of the introduction of the Social Welfare (Amendment) Bill to adjust the charges as set out in Section 1 of this Bill. It is a fair indication of the value of money at the present time that a family with an income of £1,100 is now entitled to the benefits of Section 15 of the Health Act, 1953.

What disturbs me about this Bill is what has disturbed a number of other Senators. Many thinking people have come to regard the establishment and functioning of the Voluntary Health Insurance Board as a hopeful sign of the direction in which we might travel in regard to social legislation. That board is the nucleus of a sound social policy which might be enlarged and expanded. Instead of drawing people upwards into the health services, it might have been a far better thing if people were given the opportunity, through some slight degree of subsidisation of the Voluntary Health Insurance Board, of being brought downwards into the voluntary health insurance scheme. Under the Voluntary Health Act, no subsidy is payable to the board. If some small subsidy were payable, perhaps the necessity for extending the income limit from £600 to £800 might not arise at all. We would have more and more people availing themselves of the benefits of the voluntary health insurance scheme instead of casting a further burden upon the local authorities and the Exchequer by the extension of the income limit.

As Senator Sheehy Skeffington has said, the potential market for the Voluntary Health Insurance Board is being contracted. It is very regrettable at this stage of the development of the board that it should be faced with the serious competition presented by this Bill. As far as my knowledge goes, the board has functioned in a way that has won the admiration of anybody who has taken out insurance with it. It is a great pity that anything should be done under this Bill to endanger the successful functioning of that very desirable body or which would prevent the development of that aspect of social policy I have referred to.

As regards the functioning of the health services, I am sure the Minister is well aware of the many complaints being made about the method of operation. In his statement, the Minister said that the insurability of people under the Social Welfare Act was intended to be and would continue to be the criterion of eligibility for benefits under the Health Act.

No, not quite that. Only in relation to Section 15 (2b).

Yes, that is what I mean; that insurability would continue to be the criterion of eligibility for these people. I understand that a voluntary contributor under the Health Act is a person who is insured or is regarded as being an insured person to the same extent as a compulsorily insured person under the Social Welfare Act. I should have thought that immediately a person established he was a voluntary contributor, the local authority was not obliged to look into his means or the means of his dependents—that the voluntary contributor was entitled immediately to the benefits of the Health Act. That does not seem to be so. Perhaps the Minister might indicate whether local authorities are being unduly meticulous in the discharge of their functions in making these inquiries from voluntary contributors?

The point raised by Senator Lenihan deserves the attention of the Minister. I do not know whether the necessary amendment to oblige an unsuccessful defendant to pay hospital costs should be brought under the Health Acts or the Road Traffic Act, 1933. Section 174 of the Road Traffic Act did oblige persons liable to pay damages to an injured person to pay the hospital costs incurred by that person as a result of injuries sustained in a road accident. Whatever sum was recovered under a judgement against a defaulting person provided for the payment direct to the hospital authority of expenses as laid down in the Road Traffic Act.

I would disagree with Senator Lenihan that we should await some final decision in this matter by the Supreme Court. Take the case of a negligent motorist injuring a person. It is quite clear it was never intended that that person's insurance company should benefit by the health legislation that has to be financed out of public funds. I would prefer that before there is any decision in the matter by the Supreme Court, rather than have the Oireachtas as it were override a decision of the Supreme Court, the Oireachtas should decide the matter now while it is in doubt. The Oireachtas can meet the case by an amendment. If an amendment is not possible under this legislation, I suggest that the Minister, in conjunction with the Minister for Local Government, consider an amendment under the Road Traffic Act.

I wish to answer a question asked by Senator Sheehy Skeffington. No doubt the Minister will answer the question but I am in a position to answer it also. He asked the Minister how far the medical profession was consulted in the drafting of this Bill. The answer is that the medical profession was not consulted at all in regard to the drafting of this Bill. So I am informed.

The 1953 Health Bill was pushed through in the teeth of the strong opposition of the profession. The profession was opposed to State medicine, to the absence of proper planning in regard to the facilities offered in the Bill and to the absence of reasonable compensation, particularly in the case of the medical staffs of the voluntary hospitals. In spite of that, the medical profession co-operated in the implementation of the 1953 Act, and made a success of it.

This Bill has been drafted without any consultation with the medical profession, the voluntary hospitals or the local health services. The result of this Bill, when it is enacted, will be to place a great additional pressure on the already inadequate facilities of the hospitals of this country. The staffs are inadequate; finance is inadequate; the hospitals are all running on deficits. This Bill will add a very large number of additional patients who will press on these already overloaded facilities. As Senator Hayes has already said, the people who will probably suffer most in this will be the very poor—the people who are not able in any circumstances to pay for their medical attention. These people rely entirely upon the services of the voluntary hospitals, and if those hospitals are overtaxed, as this Bill tends to overtax them, then the people who will suffer most are the very poor sections of the community.

As already stated in this debate, many of the facilities for treatment at clinics by the local authorities are inadequate. I am informed that in the cities of Dublin and Cork, owing to either real or alleged financial stringency on the part of the public authorities, there has been considerable ill-advised retrenchment with regard to outpatient clinics particularly, as has been pointed out by Senator Fearon, in relation to psychiatric treatment. I am informed that the local authorities are unwilling to institute new types of clinic which are called for by the new developments in medical science.

It is well known that there has been great development in other countries in the out-patient treatment of psychiatric diseases. As Senator Fearon said, many of these diseases yield to intelligent treatment. I am informed that in Dublin and Cork, owing to an alleged financial stringency, the necessary facilities are not available in this country.

One point which has been raised in this debate several times and one which I make no apology for repeating, is the effect of this Bill on the incomes of the medical profession. I would have thought that 80,000 families and, therefore, over 300,000 persons would be added to the people entitled to get specialist treatment in hospitals without extra payment. The Minister interrupted a previous speaker to dispel that illusion. Apparently the total number of people affected by the Bill is 80,000.

The addition of so many to those entitled to get specialist treatment in hospital without extra payment will undoubtedly have an extremely depressing effect on the incomes of the medical profession. Doctors at present get 2/8 per patient per day in hospital for specialist treatment. This Bill will add very greatly to the number of people who are getting treatment at that very moderate rate of pay, many of whom could very well afford to have a certain amount of treatment at the hands of their own doctors.

I am merely repeating earlier points in the debate but sometimes it is no harm to say a thing twice. Doctors have to live as well as everybody else. It has been said that the justification for raising the limit from £600 to £800 is the rise in the cost of living. There is a quite unanswerable case for an equivalent rise in doctor's fees. The professional classes in this country are penalised at every turn. They are the last people to get rises in money incomes. They are taxed to their absolute capacity.

The £600-£800 group who have been brought within the scope of this Bill for hospital treatment are amongst the people who provide incomes for doctors. Now they are being included in a category which will get specialist treatment from doctors who are paid quite inadequate fees. It is an unfortunate fact but we know it is true from income-tax statistics, that the number of people with over £800 per annum is rather small and that the number of people with over £1,100 per annum is even smaller. If this Bill comes into operation the doctors will be confined for their professional incomes to the demand of this very small section of the population.

Speaking as a university representative and as a person who has the interests of the medical profession at heart, I cannot help feeling that the Bill is a very serious threat to the prosperity of the medical profession in this country. Already we export from our universities a very large percentage of our medical graduates and, if the earning capacity of the medical profession in Ireland is still further reduced by measures of this kind, we will export more doctors. The attraction abroad is very great where incomes are higher. We are exporting a very large number of our medical graduates in University College and other colleges throughout the country. If the result of this legislation is gradually to whittle away the incomes of the Irish medical profession, then I am afraid that more and more of our best graduates will emigrate. The effect of that will be serious from the public health point of view. I think it is an extremely serious step for the Government to enact any measure, however desirable it may be for other reasons, which may have the effect of impoverishing the medical profession and driving more of our graduates away and depriving us of the best medical practitioners.

Therefore, I suggest to the Minister that, in legislation of this kind where the medical profession are asked to make all the sacrifices and to do all the work, they are at least entitled to some consideration at the hands of the Minister.

I should like to correct a misapprehension under which, I think, Senator Hayes and, perhaps, other Senators may have been when the Senator asked me if it were possible that an income of £1,100 a year would still not debar a person from benefiting under paragraph (b) of sub-section 2 of Section 15 of the Health Act, 1953. I said "yes". I want to qualify that and point out that that is a family income. It is not the personal income of any one person. It is the amount which the family as a whole may enjoy as an income. As you know, in computing the family income under this Act, the local health authority is bound to take into consideration not only the earnings of the head of the family and his wife, but also the earnings of the children of the family and the stepchildren of the family. All this section does is to exclude the first £100 of each child's earning up to a total of £300 in all. It is not, as the Senator tried to equate it, the same as personal income.

The Senator also complained that the people were very much worse off nowadays in regard to clinics than they were before the Health Act of 1953 was introduced. That is a strange thing because I think that, before the Health Act of 1953, the specialists holding these clinics recieved no remuneration. Nowadays the position is different. They are paid on a sessional basis. It is rather strange to find that, according to Senator Hayes, experience is now supporting an argument which I have often heard advanced by a medical practitioner who happens to be a member of the Dáil that if you want to get good service then it must be a free service and that a person who does not pay does not get the same sort of service as he would if he were paying. We are paying——

I may be stupid but I did not say that.

We are now paying for service in the clinics and Professor Hayes says that because we have made arrangements under the 1953 Act to pay people for these services they are now giving worse service to their patients. I do not believe that.

I did not say doctors were giving worse service. The Minister will not get away with that. I did not arrive here yesterday.

I do not know what the Senator really intended to say and I do not want to misinterpret him, but, after all, it is the sort of conclusion one could reasonably deduce.

It certainly is not what I said.

The Senator also complained that previously the patients could get medicines at the clinics. That is true, but what sort of medicines? They could not get the very expensive drugs they are now entitled to get and which are provided for under the Act. The cost of drugs has gone up so much and the cost of the health services has gone up so much that by regulation we have to try and keep control over the manner in which these very expensive medicines are dispensed. That is why we have a certain amount of form filling and why certain medicines are no longer free on demand at these clinics. Those who see the cost of health services rise year after year and who complain very bitterly about the burden imposed on the taxpayers should support us in endeavouring to control expenditure under the Act rather than seek to loosen the control and thereby result in an increase in the cost of the services, perhaps without any real benefits to the people.

Senator Sheehy Skeffington asked me how many people were going to benefit. He asked me what percentage of the population would now come within the scope of the Health Act. I should say exactly the same proportion of the people would be entitled to the benefits of this amending Act as when the Act of 1953 was first introduced. All we are doing in this Bill is to give renewed entitlement to benefit to persons who were excluded from the scope of the Act by reason of the increases which have taken place from time to time in their money incomes. We are merely restoring thestatus quo as it existed in 1953.

Would the Minister say what is that percentage now? I accept the statement that there is no change.

It will be about 85 per cent. About 85 per cent. of the population will now be covered by the Health Act.

Would the Minister further clarify that point? When he says 85 per cent. will be able to benefit, they will not benefit completely. They will not enjoy all the specialist services.

Oh, no. They are not all going to be provided with treatment altogether gratuitously and free of charge. A very large number of people, of course, will have to contribute but the assumption is that they are in a position to contribute. The free services are provided only for those who cannot provide them for themselves. The Senator also raised the question of how the voluntary health insurance scheme would be affected by this Bill. I have received no representations from the Voluntary Health Insurance Board that the board's schemes will be adversely affected by the Bill. I am advised that they will not be affected at all and therefore the long and sometimes protracted speeches which we heard about the baneful effects of this amendment upon the future of the Voluntary Health Board are without foundation.

The question was put to me by Senator Sheehy Skeffington, and repeated by a number of other: "Have the doctors been consulted?" The doctors have not been consulted because we are merely restoring the position as it was understood to be at the time when the introduction of the services concerned was being considered. We are merely bringing back into eligibility the persons who it was anticipated would be eligible in the first instance.

Senator Davidson mentioned the position of patients who have been the victims of occupational accidents and in that connection cited what I understood she believed to be the practice of Dublin Corporation. Her reference was in relation to such persons who have to undergo hospitalisation because of the fact they have met with an industrial accident and who, during the time they are in hospital, are in receipt only of the statutory amount payable under the Workmen's Compensation Acts. It has been the practice, with certain health authorities at any rate, in cases where they have reason to believe a person has an income, and is not entered on the General Medical Service Register, to bill him in the first instance for the hospital services at the rate of 10/- a day. Within the last five or six weeks I have taken steps to indicate to the local authorities concerned that I do not think that this is a proper practice and that unless an applicant appears,prima facie, to be in a position to pay the maximum charge, then a reduced charge related to his readily ascertainable income should be charged. That perhaps would cover the main grievance to which Senator Davidson referred. I shall, however, look into the matter further to see if there is anything else we could reasonably do to meet a case of that sort.

Senator Cole said there were some inconsistencies between charges made under the Mental Treatment Act, 1945—under Section 230—and under the Health Act of 1953. In fact, there is no inconsistency. In the case of both Acts persons are required to pay charges made on their immediate dependents where such charges are leviable and the person on whom the charge is made is not in a position to pay it. That is the fundamental principle of the Public Assistance Act, 1939. The Senator also mentioned the position under the Mental Treatment Act of 1945. There is no discrimination as between persons who have dependents and who have immediate relatives whom they are in a position to maintain. There is no difference in their treatment under the two Acts. Perhaps I did not get the Senator's point quite clearly. If I did not, I will have a chance of looking at the official report——

There is the section which refers to illegitimate children, but I do not think you can compel them under the Health Act to support their mothers.

No; it is in the Public Assistance Act, 1939.

That will still be the position.

I will verify that, but it is my recollection that it does not appear in those terms in the Health Act of 1953 but it is by reference ascribed to the Public Assistance Act of 1939.

The Senator argued that because we were increasing the income limit for entitlement under the Health Act from £600 to £800 we should do something more for the farmers. First of all I have made the case that the real purpose of this Bill is to bring back within the scope of the Health Act those extruded from it by reason of the increases which have taken place from time to time in their money incomes. There has been no change in the valuation of farms. The same number of people on the farms are entitled to the benefits of the Acts as were entitled when the Act was first passed, and in fact I may say that it is very difficult to see what more one could do in the remaining cases. I have mentioned that the general average for the country of the number of people who will be within the scope of the Act as amended will be about 85 per cent. At the present moment the number of farmers under £50 valuation in Connacht is 97.4 per cent. of the farming population of Connacht. In the three counties of Ulster the percentage is 94.9. In Munster it is 82.7 and in Leinster 74.3. It seems to me that there cannot be any great hardship among those who do not come within those very comprehensive fractions.

A person who owns a farm of £50 valuation has a very valuable property, whereas another person has perhaps a more or less precarious existence; in so far as he depends on the general state of the economy and on another individual or corporation for the day-to-day employment which gives him his livelihood. In those circumstances we are not doing any injustice to the farmers when we are merely trying to redress in relation to wage earners and persons in similar circumstances the position in which they now find themselves, and restore them to the position in which they were in 1953 in relation to the Act.

Senator Fearon seemed to think that we were breaking entirely new ground. That has been the basis of the objections raised on behalf of the medical profession; but we are merely endeavouring to recover lost ground or to bring back and reinstate on the original ground the people who were driven off it.

I have no doubt that the services have been readily and easily available, and therefore some people are perhaps getting benefits under the Acts to which they are not entitled; but I do not think there is a very significant number of such people. It is no greater now than it ever was, and in fact if anything I should be surprised if it is not significantly less, because I have taken the line that these services are costing so much and are now so highly developed and highly specialised that no person should get them free if he can make a reasonable contribution to the cost of them. The complaint I generally receive is not that somebody is getting the services who is not entitled to them, but that persons entitled are not getting them. It would seem, taking these latter representations, that it is unlikely that there is any very substantial number of persons getting the services who are not entitled to them.

The suggestion has been made— Senator Fearon mentioned it too —that one of the consequences of raising the income limit under the Act will be that local authorities will tend to clamp down on outpatient departments. That is not my experience of local authorities. They behave responsibly and try to give the benefit of the Health Acts as widely as possible. Their tendency is rather to look for greater expenditure than to try to cut it down. I do not think there is any very great danger that they will reduce the scope of the services now available.

We should of course like to see these services extended to the maximum extent that would be useful, but again we have to consider in this connection the overall cost. The cost of the services now runs in the order of £16,000,000 a year. I have tried to keep it to that figure. Whether I can succeed in doing it this year I do not know, but if I do not do that and if the Minister for Finance has to increase the standard rate of tax I shall hear a great deal of moaning and gnashing of teeth in this House when I come along, if I should happen to come along, with another Bill to increase the medical benefits which might be provided.

I do not know that the Bill is going to impose any very great strain upon the existing hospital facilities. I gather that when the Act of 1953 was going through the House it was represented that its provisions would strain the resources of all the hospitals—public authority and voluntary hospitals—to breaking point. I do not think it can be contended that this is being done. Indeed, so far from there being any undue pressure upon certain classes of hospitals, we have reached a stage at which we have some hospital institutions vacant for want of patients, and our difficulty has been to find some use for them. That of course does not apply to general hospitals in Dublin, but I do not think it can be contended by any person going through the hospitals and looking at the conditions and the manner in which patients are treated now that the Health Act of 1953 imposed any undue strain upon their resources or their staff.

In any event, the raising of the income limit from £600 to £800 surely is not going to increase the incidence of sickness and illness among us. We will still have the same number of persons falling ill, I suppose, year after year, or approximately the same number. The only difference will be that if they do fall ill they will receive a certain amount of help to make themselves well. The voluntary hospitals will, to that extent, perhaps, benefit by the provisions of the Bill.

Senator O'Quigley was one of the Senators who raised a number of questions and were disturbed about the effect this Bill might have on the voluntary health insurance scheme. I have dealt with that and I do not think I need repeat what I said. Another question which he asked was whether the officers of local authorities are unduly meticulous in inquiring into the means of voluntary contributors under the social insurance scheme. I do not know. I do not think they are. Naturally they must satisfy themselves —they must do their duty to the ratepayers—that these voluntary contributors are entitled to secure services which are provided for them, either free of charge, or for the rather nominal charge which is provided for in the amending Act of last year.

Senator O'Brien said that the Act of 1953 was put through in the teeth of opposition from the medical profession. I do not know whether or not that is an exaggeration, but I do know that despite that opposition, the Government which in 1954 succeeded the Government which put the Act through in 1953—our immediate predecessors in office—put the whole Act into operation. They must have done that presumably by some sort of agreement or arrangement with the medical profession. In any event, since then, we have had another general election. The Health Act of 1953 happened to be one of the issues in that election, particularly in my own constituency, and the people have endorsed the provisions or the principles of the Health Act of 1953. It is too late to argue whether we are for or against the Act. The people have spoken in regard to it and we have just got to make the best of it and the medical profession must make the best of it.

The Senator also adopted an unaccustomed role. As a rule, he is one of those who plead for greater and greater retrenchment in relation to Government services and expenditure. To-night, he told us the health facilities are inadequate at the moment and he spoke of the real or alleged need for retrenchment. I think our general financial position may be somewhat better now than it was last year. The need for retrenchment, however, where it can be secured without affecting the efficiency of the services has not passed and, needless to say, it is still very real. To the extent that we can make these services more economical without impairing their efficacy, I shall try to do so; but I must say I cannot see that we will be in a better position greatly to increase the amount of money which can be provided for the health services, while still trying to meet the long term commitments of the Hospitals Trust Fund. The community as a whole is still bearing a very substantial burden in taxation. There are other sources of revenue which appear at the moment to be tending to dry up. In these circumstances we shall have to face the position realistically and see what can be done. We have done a great deal within the past five or six years and until the situation has considerably improved we cannot do very much more.

Question put and agreed to.
Committee Stage ordered for Wednesday, 17th December, 1958.