This appears to be a very simple and straightforward Bill and very praiseworthy in some ways. I must say I think the removal of married sons and daughters from the means test part is particularly good. As this Bill works in tandem with the Social Welfare Bill, I do not think there is any doubt about its going through. Otherwise, we would have the injustice of two neighbours, both earning the same amount, one self-employed and one employed, one of whom would be able to get free treatment and the other unable to get it, so I do not think there is any doubt about its going through; but, on the other hand, it must be thought about a bit because, under this present scheme, we shall have 93 per cent of the population of Ireland under a State medical service and this perhaps is very close to the percentage in England who use the English health services. Therefore, we are entering an era of complete socialised medicine, one might say, because the remaining seven per cent are unlikely, in any event, to use it. Furthermore, not only are we entering this era but we are attempting to do it on the present medical framework. This is the point that worries me.
There are some questions which we shall have to think about. The first question we must ask ourselves is whether the country needs it and wants it. If we want socialised medicine, is this the kind of medical service we want? Is this framework good enough or will this Bill look better on paper than in practice? Lastly, we must ask ourselves if this framework is sufficiently good to take another 200,000 people. I think this latter question is the important one because there is no use in building on an insecure foundation.
At the present moment, we are spending 2.9 per cent of our gross national product on health. Since 1953, no other country in Western Europe has been spending less than 3.6 per cent. We are spending £27 million and, on this calculation, it looks as if we should be somewhere around £35 million at the least. I do not think we are that smart in this country that we can be saving that amount of money and doing a good job. Are there any comparisons nearer home that would bring this out?
The hospital service in Northern Ireland is spending £19½ million on 1.4 million people whereas we are spending £19 million—a shade less—on 2.8 million people. So, on that count, we are spending a little less for twice as many people. Now, this may not be a true comparison because nobody is quite sure of the Imperial contribution to Northern Ireland and how much the subsidy there is. Let us take Scotland, where conditions are very similar to those in Ireland. They are spending £73 million each year on their hospital services for 5 million people. Even allowing, at the present moment, for only 86 per cent under State benefit, it looks, once again, as if we should be spending around £35 million a year on our hospitals. So, on a comparison with other countries, it looks as if we shall have to accept that a lot more money must be contributed to be used on health purposes.
But even this is not the key point. How do we fare with this distribution? This Bill deals with specialist services and, in this country, if one excludes the 1,800 medical and surgical beds in the district hospitals which give competent but not specialist medical services, we have approximately 7,300 beds devoted to acute medical and surgical cases of a specialist type. Of these, 3,800 are in the voluntary hospitals and the remainder under the local authorities. So it will be seen that we have, give and take, roughly half and half because some hospitals seem to be under almost a mixed type of control.
The voluntary hospitals are almost entirely confined to Dublin, Cork and Limerick and these are looking after 1¼ million people in their areas—so they have approximately half again of the population to deal with. But, in 1963, which is the last year for which I can get accurate figures, 45,000 people came in from outside these counties as patients to the voluntary hospitals in these counties. That means that 45,000, out of a total of 130,000 patients, were dealt with by these voluntary hospitals so that one patient in three in the voluntary hospitals in Dublin, Cork and Limerick came from outside the borders of these counties. Now, they had plenty to look after already in their own areas so what I really mean is that I do not think any patients came in because of overcrowding in the local authority hospitals in the other counties.
Some small percentage may have been sent up as requiring super-specialist care but it boils down to the fact that the 45,000 people were sent to the voluntary hospitals, either because they or their doctors thought that the care they received in the local authority hospital was not adequate or else because treatment in the local authority hospital had failed. This is worrying and it gets more worrying when we consider that seven years earlier there were 13,000 fewer cases coming into the voluntary hospitals. In the years 1958 to 1963, more patients than ever were coming away from the local authority hospitals into the voluntary hospitals. I feel that the Minister will not know that the local authority hospitals are reaching an adequate standard of treatment unless and until that tendency is reversed.
If we look at some of the statistics concerning local authority hospitals, we come across some things that are rather disturbing. I have a note of some of them here. We see that Mayo has a population of 123,000 people and has specialist surgical and medical beds to the number of 135. Monaghan, with 47,000 people, has specialist surgical and medical beds to the number of 151. Tipperary, with a population of 109,000 people, has 266 beds in the same category and Waterford, with 28,000 people, has 282 such beds. Therefore, we have Mayo with roughly one bed per 1,000 of the population while Waterford has one bed per 100 of the population and we cannot even credit Waterford with draining the neighbouring counties because Kilkenny, Wexford and Cork have very good services of their own.
Furthermore, there are two counties without county surgeons, three counties without county physicians, four counties without radiologists and I cannot trace more than two full-time paediatricians under local authority employment in the whole country and, as members of the Seanad know, Ireland has a very high child population. Over and above that, there is quite a shortage of ancillary medical staff at the house officer and registrar levels in the local authority hospitals. This is a very uneconomic state of affairs because county surgeons and county physicians are doing work that would normally be left to minor medical personnel and it is very much as if you employed a general manager and gave him the duties of the office boy.
Therefore we suspect that the voluntary hospitals are carrying a very big load. I went into this and I have taken North Dublin to illustrate it because it is the area I know best, but I can assure the Seanad that pretty much the same conditions exist everywhere. In North Dublin, there are three general voluntary hospitals, one children's hospital and one maternity hospital. In the three general voluntary hospitals 11 beds have been added between 1958 and 1963. At the same time, we have very big housing schemes opening up in Finglas, a huge one in Coolock and Ballymun on its way. If this Bill becomes law, as I know it will, we will have a further 25,000 potential patients coming into this area. What will be the result of this? The result is indicated by the fact that the out-patients of these three general hospitals the outpatients' session of the years 1958 and 1963. In one of them alone, it increased by 15,000 in 1964 and the 1965 figures look like going up correspondingly. It is just not possible to cope with these numbers.
At the present moment in these hospitals the out-patients' session of three and a half hours may cover up to 80 patients, all of whom, under the terms of the Act, are entitled to see the consultant. More than that, it is the Minister's wish and the consultants agree, that these patients should not only be treated well but courteously and kindly. Senator O'Quigley was looking for an appointments system. We have this in operation but it does not work out that way. You cannot say to a patient: "Come in at 9.03" or "You must come in at 9.06", because at the present moment these are the figures we are trying to cope with. After allowing for four new patients per session, the average for a three and a half hour session should be 18 to 20 patients.
Now on the in-patient side, it is pretty grim as well. These three general hospitals turned over 2,000 more cases in 1963 than in 1958. The numbers are still increasing. Their bed occupancy increased to 91 per cent of the available beds and this is rather above the level recommended in the USA. In concrete terms, this can mean there might be a two-year wait for a tonsillectomy, one year for a squint operation and a two-year wait for a gynaecological operation. If the condition becomes acute, this could always be hurried and the patient can be got in, but we have no means of knowing how many cases of children awaiting a tonsils operation develop rheumatic fever during this waiting period and whether any heart damage can be attributed to it. Nor does the fact that a gynaecological operation is not a lifesaving procedure mean that someone will not have any difficulty waiting for her turn to come. We have operating theatres built 25 years ago which coped with 1,000 patients in 1955 and which in 1965 had to cope with 4,500 patients. I might mention in passing that there is a maternity hospital in Dublin whose bed occupancy runs at 108 per cent, that is, 14 or 15 stretcher beds every night to cope with the situation.
It is a rather frightening set of figures which does, I assure you, make for bad medicine, for a considerable amount of diagnostic error and not the best type of treatment one could wish for. One of the problems of this country is that Ireland has on paper a very high percentage of hospital beds. This gives a rather wrong impression. A hospital bed which is occupied by a chronically ill geriatric patient is of no use for the acute medical or surgical case. Equally so a bed which is empty is no good unless there is adequate medical and para-medical services to back it up. It is indeed rather worrying, and I speak for my profession at the present moment, as we are wondering where we are going from here. I realise, as does every doctor, the difficulties of dealing with the medical profession and services. I know the Department of Health has many factors to deal with: there is the public; there are the doctors, there is the matter of finance; and there are small groups who ride hobby horses—they are rather vested interests. All these lead to a system for which nobody really is to be blamed but it can go a little off the right track. The present worry is where are we going to put these 200,000 people, where are we making provision for them and where are we making provision financially to deal with them.
Because of the value of money decreasing and the increasing cost of hospitalisation, something will have to be done but I do not think we are going the right way about it. Is it possible to improve these services? I think it is. I think it is perhaps easier to improve the local authority hospital services than the voluntary hospital services because they are more unified and easier to deal with. A number of very highly qualified specialists have come home over the past few years from abroad and have taken up appointments here. Initially, they took up these appointments at very low salaries but their salaries have been revised since then as a result of an agreement negotiated, and their new salaries are much more in keeping with their positions. But one snag is that they come back from where they have been working, in high-class units, and suddenly discover that they have not got all the facilities they need or the facilities they are used to and in some ways they feel like fish out of water trying to do a lot of small jobs with deficiencies in medical staff, equipment, diagnostic facilities, and, in general, without most of those components which go to make up a highly efficient unit. I think this could be helped relatively easily.
Recently a very worrying case came to my notice. In fact it was only a few days ago. It concerned a young man who came back from England to take up a job as an assistant pathologist in a local authority hospital. He was very highly qualified, holding his M.D., M.Sc., and M.D. in pathology. He and his family were anxious to come back to Ireland to live and, consequently, he took the position at a salary of £1,600, rising to £1,800. Even though this salary was less than could be paid to a registrar in Ireland after four years' experience, he relinquished a consultant's post in England which was bringing him in £2,900 per year. A condition of his employment was that if he got a job in a nearby university, his salary scale could be from £2,000 to £2,200. He was appointed to the university—indeed, they were very glad to get him—and he has now been made a statutory lecturer.
When he was first appointed, he received a salary of £730 per annum, whereupon the county council abated his hospital salary, so that the total salary was £2,000. That was fair enough because they were losing his services for a certain amount of time each day. The next thing that happened was the university raised his salary to £970, whereupon the county council abated his salary again so that it was again reduced to their standards. Now, no more time than before was taken from the county council and it seems difficult to believe that this should warrant a further abatement. Now it has reached the stage when the university is only too anxious to pay him a full lecturer's salary but sees no purpose in so doing as it would mean further abatements. This certainly does not make for good relationships.
With the voluntary hospitals, the story is quite different and it may be a very much more difficult situation. Unfortunately, previous Ministers for Health never permitted themselves to realise that this country is dependent on the voluntary hospitals as the backbone of its specialist services. The policy, therefore, has always been to build up other units. The policy in fact has always been to build up local authority units. I do not think this is wrong; I think the idea was understandable. They were building up their own units under their own control and they hoped to make these very good and important units. In some cases they have succeeded and there are some such very important units throughout the country but the trouble is that in most cases the same factors that I have already mentioned have upset the units —they could not get co-operation with staff such as teaching staff and university staff and they could not get what is necessary to make a unit really great. Many of these units never really paid off in the terms they were designed for and for which everybody gave them full credit.
On the other hand, this trend to build up these good departmental units had the effect that the voluntary hospitals gradually began to be treated like poor relations. A teaching hospital I know has in the last five years put out £100,000 on units it thought necessary and which have since worked up and become very important. This £100,000 was collected in shillings throughout Ireland. I know that these voluntary hospitals are difficult; they are independent, sort of irresponsible and hard to control but nevertheless these are the factors that have kept them important. It is in these that the tradition is that the patient is more important than rules and regulations and consequently they have always done their best by the patients.
Really, they must get more support and there must be a different orientation in future towards the relative places of voluntary hospitals and local hospitals. It is quite a tragedy so far as medical students are concerned— and these are the important people of the future—that neither the Department of Health, the universities nor the Department of Education will accept responsibility for their teaching and recreational facilities in a teaching hospital. None of these bodies will accept responsibility and who is to do so? The voluntary hospitals of this country have a great tradition. Originally, they were charitable institutions and the doctors there gave their services free and in return they got experience and a connection which afterwards gave them paying patients. You treated rich and poor, paying and free, and you averaged out. This freely-given voluntary service plays an important part in present problems. The implementation of the Health Act in 1956 changed all that. Many patients who by those standards could pay were then made free and were in the 86 per cent who were taken into the State scheme. At that time the Minister said that because of a possible loss of income to the doctors he was prepared to pay compensation and amounts were fixed for intern and extern patients and, in almost the same words the present Minister used, the consultants were told that the Minister did not think they would be out of pocket but if they were adjustments would be made in the future and frequent consultations would be held and furthermore no change would be made in the level at which free hospital service would be available to the population without full discussion with the IMA.
This story did not work out so well. Frictions developed; frequent consultations were not held and the adjustments were minimal. In the whole ten years with the cost of in-patients rising from four guineas to about £17 10s the consultants got an extra 2/4d per day per patient. As late as last night Dublin Corporation were trying to work out their new rate and told that £330,000 was the increase due to health. Of course, under this new rise which we got recently about £30,000 will go to the consultants and of that only £20,000 will be paid by Dublin Corporation; the remainder is coming from corporations and county councils throughout the country.
The real snag in the system, however, is that consultants were put on a scheme whereby they were getting compensation and not salary and this means no pension rights, no holiday pay, no sick pay, no study leave pay, no cost of living rises and nothing like that. In 1956 the situation was very critical. There were then only 400,000 people left in the country to provide patients who would maintain the consultant services. A very wonderful organisation started, the Voluntary Health Insurance, and this literally came to the rescue. It spread the load and over the years provided the increases necessary truly to compensate the consultants for their low incomes under the Health Acts. The Minister was literally steeped in luck. He had 400,000 people who, under the Voluntary Health Scheme, kept the corps of consultants going so that these consultants could keep the Health Act going and further keep it going and be paid cheaply for it. In actual fact, the present payment is about 25 per cent of what consultants get in similar conditions in England. Can I drive this point home by saying that in 1963, the entire corps of consultants attached to the voluntary general hospitals in this country looked after 3,800 beds for seven days and nights every week of the year for a little more than twice the total yearly remuneration of Senators?
But the balance was very tight and as the load in the voluntary hospitals increased, a peculiar situation arose which I would like to illustrate for you. I asked two surgeons of about 40 years of age, one in each of the two main voluntary hospitals in Dublin what income they were getting from the public services and how much time they were spending on this work. I picked surgeons because they are the better paid. In each case, the figure was around £1,000 per year and the work was about 30 hours a week. Now, at the present moment £1,000 per year would not even pay for their consulting rooms and their secretary—so that these men having worked 30 hours a week have not even cleared their basic expenses and have literally not commenced to earn money for themselves and their dependants.
Their car and phone, their rates and taxes, their postage and equipment expenses have all yet to be met and they have used up 30 hours of their working week. It was self-evident that they could not spend any more time doing hospital work or dealing with this increasing load of patients. Otherwise, they would be left without an adequate number of hours for private patients from whom they must earn their living. In fact, it would pay them better to give up their out-patients sessions and only a strong sense of duty compels them to continue.
As far as inpatients are concerned, we are in a rather similar position. The consultant staff of a hospital are paid by the number of beds occupied. This means that you cannot increase the income of your hospital as long as the payment per patient per day remains the same. Over the past ten years a line of new specialists has arisen. A lot of bright young men have been away being trained. These are brought back and we put them on our staffs. What happens? The more you take on, the further the income must be divided and the less there is for each. Although there has been this increase of 2/4d per patient per day, the average income of consultants has increased, not to the estimated extent, but by very much less because of new young consultants taken on.
The situation is aggravated by two factors. First of all, one would have thought that these new consultants would take on extra outpatients' sessions and shed the load a little but this is not all the time possible because the health authorities are rather against new outpatients' sessions and have been tending to restrict them. There is a maternity hospital in Dublin which, for three years, has been looking for a psychiatric session because it maintains that the strains of pregnancy and the first few months after a birth are very likely to produce psychiatric trouble and, for this reason, the hospital felt that they needed one psychiatric session a week. So far, this has not been allowed.
The other aggravating factor, which is an even more frustrating one, is that it is very annoying to be on an out-patients' session and, depending on the number of patients, getting perhaps a few shillings—perhaps 1/- to 5/—a patient and finding, when you get a patient coming to Dublin from, say, Kildare, that the Dublin Health Authority are getting £1 1s 0d for this patient and are paying the consultant who sees him only one-fourth or one-tenth of the amount they are receiving in respect of the patient. It is galling because you know that there are clinics operating in the city which are almost paying for themselves by reason of the number of patients coming from outside the county.
We feel that there will have to be a revision of the present scheme. As I said before, the voluntary hospitals are doing over 60 per cent of the specialist work in the country and over 90 per cent of the super-specialities. They will have to be given a very considerate hand in every way. Young consultants who have come back will have to be properly paid and not forced out into the realm of competitive practice at a stage when they are very active and very energetic and could spend a lot of time working in the hospitals, to the ultimate good of the public patients. The poor compensation for hospital work forces them out of the hospitals into competitive private practice.
Our worry then is: is this new expansion really necessary? That is the core of the Bill as before us. There is no doubt that for persons up to £1,000 income per annum, it is necessary because of the devaluation of money. For persons whose incomes are from £1,000 to £1,200 help is also needed because the charge for hospital beds has gone up to £17 10s a week. There is no doubt that persons on these incomes must have some help or they could not cope with these expenses. They had a very efficient organisation in the Voluntary Health Insurance, which was dealing very well with them. A married man with four or five children could for £16 a year completely cover the £17 10s per week in the hospital. If looking for the lap of luxury, he could do it for £30 a year, which is roughly equivalent to the new social welfare contribution.
There is, I admit, a group of people who are in a very bad way. These are people with long-standing and recurrent illness, people above the age of 65, those who have had a lot of illness or who for one reason or another are uninsurable. There is no doubt that these people need help. They are caught. They cannot pay for Voluntary Health Insurance. They cannot be accepted by the Voluntary Health Insurance Board. These should be covered by the Minister's hardship clause. Furthermore, this hardship clause should apply to a much higher income level than £1,200. Indeed, any person up to £2,000 a year should never have to pay out more than ten per cent of his yearly income on drugs, hospitalisation or doctors. This clause should be applied.
One of the snags in this hardship clause is—and I think the Minister is in equal difficulty about this—that it varies from county to county. Even the assessment of 10/- a day seems to vary and it is not possible to get the tables on which the assessment is calculated or why the decisions are made. There are some counties, I am afraid, where you would want to be on the ground on a stretcher before you would be a hardship case whereas other counties are very soft.
I am afraid that none of the political Parties are approaching the Health Bill in the right way for the future. That may sound very presumptuous but I do not think that we are a rich enough country to adopt a fully socialised medical service which would cost about £60 million. This cannot be done. Furthermore, I feel that our present gently increasing socialisation is financially very attractive; you just creep into it; but, it is very dangerous —by its very economy it ultimately defeats its own purpose. So you cannot live too cheaply either. I feel convinced that a free service with compulsory insurance above a certain level, associated with State aid for those patients who are uninsurable by virtue of prolonged illness or age, must be the ideal. It will spread the load. It will not impose too much of a financial burden on the country but it will give adequate service. It will also allow the State to step in in case of need. The hardship rules should be very definitely laid down in the form of a Bill and there should be no room for individual interpretation in different counties.
We know this Bill will go through. Then 200,000 people will be removed from this group of 400,000 who are maintaining the consultant corps in this country. This leaves just seven per cent of the population to maintain the doctors who are going to look after the rest. Even more frightening is the fact that the 200,000 who are being removed constitute the major portion of the contributors to the Voluntary Health Insurance Scheme because it is reasonable to suppose that the more wealthy people will have least interest in taking out this insurance. Therefore, the very organisation which has kept the ball rolling up to now will be put in a very unsound financial position.
The Minister's hopes that some will carry on the voluntary health insurance as well as being in the social service scheme may not work out. If my income were about £1,200 a year, I would think twice before I would pay the rates for the social service scheme and pay for voluntary health insurance at the same time. Farmers are forever grousing about the amounts they pay in rates for the roads. If they get a bit of health treatment, they will be up like a shot; they will not join the Voluntary Health Insurance Scheme. I cannot see anything to compensate for the fact that the pool that supports the consultants will be reduced. I would strongly appeal to the Minister, who is very energetic, to ensure that the State will grow up and regard itself as a business organisation. The time has passed when services like health and education can be run on a charitable basis.