Health and Mental Treatment (Amendment) Bill, 1965: Second and Subsequent Stages.

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

Minister for Health (Mr. O'Malley)

The object of this Bill is to make some adjustments in the categories of persons who are entitled under the Health Acts to avail themselves of general and mental hospital services and of the Maternity and Infant Care Scheme. I should explain that there are three categories of persons who, with their dependants, are entitled to use these services. These are:

(i) Persons insured under the Social Welfare Acts; (ii) other persons over 16 years of age whose yearly means, as defined in the Health Acts, is less than £800, and their dependants; and (iii) farmers where the rateable valuation of the land and the buildings thereon is £50 or less.

Before going on to discuss the changes made recently, or now proposed, in these categories, I should mention, to complete the picture, that a person who is not in any of them can still be regarded as entitled to the services if he can show that it would cause him undue hardship to make private arrangements for the necessary medical care.

In regard to the first category of persons I have mentioned, those insured under the Social Welfare Acts, under section 6 of the Social Welfare (Miscellaneous Provisions) Act, 1965, which came into effect on 6th September last, the income limit for the inclusion of non-manual workers in the social insurance scheme was raised from £800 to £1,200 a year. Therefore, except for some categories exempted by the nature of their employment from social welfare insurance, as well as all manual employees, irrespective of income, all non-manual employees up to the new limit of £1,200 a year are, with their dependants, entitled to use the health services which I have mentioned. This change was a direct consequence of last year's amendment of the Social Welfare Acts and no supplemental health legislation was necessary to give effect to this change. Therefore, the Bill now before the House does not purport to deal in any way with the change in eligibility for health services for insured persons. It is concerned solely with the other categories of eligible persons which I have mentioned.

The second category can conveniently, if perhaps a little inaccurately, be described as the self-employed. In it are included persons, other than farmers, not insured under the Social Welfare Acts with yearly means under £800. Seeing that the corresponding limit for employees is now £1,200 a year, it is clearly equitable that the limit for the self-employed should be raised to the same figure. This is all the more justifiable, seeing that the formula for assessing eligibility for the self-employed is considerably more comprehensive than for the insured.

In assessing whether a self-employed person comes within the prescribed limit under the Health Acts, there is taken into account not only the yearly means of the person concerned but also the means of the husband or wife and subject to some deductions, the mean of any unmarried sons or daughters resident in the household. It is proposed, by subsection (3) of section 1 of the Bill, to change this, so that, in future, only the means of the applicant and of the husband or wife, if any, will be taken into account. This change was particularly welcomed in the Dáil and I am sure this House will agree that it is more realistic to accept that most unmarried sons and daughters do not, for reasons which are often very sound, contribute their entire income, or most of it, to the household budget.

The changes, then, for the self-employed are that the limit will be raised from £800 to £1,200 a year, so as to bring that category back into line with the insured persons, and that this desirable easing will be made in the formula for assessing their eligibility. These changes, coupled with the extension of the social welfare limit, which, as I have mentioned, has already become effective, will restore entitlement to these health services to a considerable number of people who have lost it through betterment of their incomes and will confer such entitlement on a number who did not previously have it. I shall later discuss the justification for this extension of eligibility.

First, however, I should like to explain its implications for the third category mentioned, that is, the farmers, and what it is proposed to do for them in the Bill. The valuation limit of £50 for farmers has been the same since 1953, when this way of defining eligibility for health services was first introduced. In 1958, the income limit for the other categories was raised from £600 to £800 a year, but no change was then thought necessary for the farmers as the change in the income levels was such as merely to make a rough compensation for the fall in the value of money between 1953 and 1958. The present Bill goes somewhat further than this. If the income limit were to be raised only to a figure sufficient to compensate for the fall in the value of money since 1958, this figure would be £1,000 a year. Therefore, the change to £1,200 a year represents an increase, as against 1958, of about 20 per cent in the real value of the limit and to keep the farmers in line, an increase of 20 per cent in their limit, that is from £50 to £60 valuation, is justifiable. Hence, section 1 of the Bill provides for this increase.

The House will appreciate that we cannot calculate exactly what the effect of this Bill will be on the numbers eligible for these services, but it is thought that, coupled with the change already made as respects insured persons, the proportion eligible for the hospital services and the maternity and infant care services will be raised from about 85 per cent to something over 90 per cent of the population. This may seem a considerable increase but I should point out that, as the general level of incomes changes, so does this percentage. Therefore, each change in the prescribed limits for eligibility brings the percentage to a peak from which, in the normal course, it falls over the years as more people become better off and ineligible for the services.

This factor does not apply directly to farmers as valuations do not change with improving incomes. However, with the diminution in the numbers of small farms, the long-term tendency is for the proportion of farmers eligible for these services to decrease. Thus, in 1951 about 87.5 per cent of all the farmers in the country were under the £50 valuation limit. The 1961 census shows, however, that in that year only 85 per cent of all the farmers in the country were under this limit. The number, according to that Census, under the new limit of £60 was about 89 per cent. The net effect, therefore, of the changes since 1953 in relation to the farmers is that, instead of 87.5 per cent being eligible, 89 per cent will be eligible under the present Bill.

The Irish Medical Association and the Medical Union, with which I have discussed the Bill, are opposed to the extension of eligibility to the figure of £1,200 a year and to the change in the farmers' limit. The Irish Medical Association asked me to bring its views on this matter before the Dáil and I did so. I think it desirable that I should repeat in this House what I said in the Dáil. This was:

The Irish Medical Association has told me that it was opposed to a comprehensive medical service on the principle that the profession would be expected to give free service to individuals who are capable of making provision for themselves without significant hardship and that this opposition applies equally to the extension as now proposed. It is as well that this statement of the policy of the Association should be on the records of the House. I agree with the views of the Association in regard to the giving of free service to those able to provide it for themselves without hardship, but I disagree with them that this principle is violated by the changing of the income limits proposed in the present Bill.

To supplement this statement which I made in the Dáil, I should mention that the Irish Medical Association had earlier suggested to me that the income limit should be raised from £800 to £1,000 a year, so that the net point of difference between the Association and myself is the further increase to £1,200 a year, in the form proposed in the Bill, and the proposed raising of the limit for farmers. I should say, too, that in discussion with the Association, I conceded that if, as a consequence of the operation of the new Bill, they can show that any of their members suffer financially to a substantial extent, I will be prepared to consider some compensation by way of adjustment in their remuneration from public funds.

The objections of the representatives of the medical profession are based on the fact that the proposals go further than merely compensating for the fall in the value in money. The reason why it is proposed to go further than this and make some increase in the real limits for eligibility is that the cost of hospital services has in recent years increased very substantially. For example, while six guineas a week was charged for a bed in a public ward in a Dublin teaching hospital in 1961, £17 10s. a week is now charged for such a bed. I am satisfied that these increases have meant that only a comparatively small percentage of the population have the resources to arrange hospital services privately, either directly or through Voluntary Health Insurance. Therefore the changes poposed by this Bill do not represent an unnecessary extension of the scope of eligibility for these services, or an unnecessary intrusion by public authorities on the private practice of the doctors. I commend the Bill to the House for Second Reading.

Mr. O'Quigley

I commend the Minister for the wisdom he has shown in consulting the Irish Medical Association and the Medical Union. However, I shall have more to say about that later. I regret to say that the people who have to bear the brunt of the operation of the medical services are not satisfied with what the Minister is doing now but perhaps the Minister may be able to give some further information on that at a later stage.

I welcome this Bill in so far as it brings the existing health services to a wider number of people but it is very regrettable, at this stage, that the health services which cost as much as they do are so unsatisfactory. This represents another small accretion of people within the ambit of the health services. I hope the Minister, with the passage of time, will find himself in the position to provide a comprehensive health service for the entire community.

Senators

Hear, hear.

Mr. O'Quigley

It is time we had health services based on the principle that when people are well, they should have to pay for ill-health and that when they are ill, they should not have to pay for ill-health. That principle would be much better than the present principle. It is a sad reflection on the capacity of our administrators and the Minister that, at this stage and in this day and generation, when a man gets sick, say, a labourer or a self-employed person such as myself, who is eligible for the health services, and goes into hospital he is annoyed by questions about what he is earning, not when he is ill, but when he was well. There is no consideration given to the fact that he has no income when he is ill, and in fact, may be unemployed. This is a completely wrong principle and the sooner the Minister does something about it the better.

I must confess I am disappointed that the Minister in his speech had no word whatever to say about the White Paper which was promised before Christmas. In fact, in the Dáil the Minister said he was dreaming of this White Paper. I gathered from that it would be a pleasant kind of thing which he intended to publish, even though a White Paper is a long way from the necessary legislation and the reorganisation of the health services. The Minister had no word at all about this White Paper. This has been going on for far too long.

The Minister's predecessor was not satisfied with the health services. It was some concession on his part that the health services were not all they should be. A Select Committee was established by the Dáil to inquire into the health services but nothing at all was done and no report was made by the Minister. A proposal was made by Deputy T.F. O'Higgins to the Committee but before they got time to consider it, the Committee wound up for one reason or another.

I regret that the Bill contains the limitations of £1,200 per annum and the £60 valuation. When people are sick in hospital, they cannot understand when almoners and nurses come around prying into their private affairs. They inquire from a woman what is her husband's income. When people are ill, they should not be concerned with that kind of thing. They should be concerned only with getting better. It is most regrettable that our health services are based on that kind of annoyance to people who are sick.

I do not know whether the Minister has ever been very ill. If he has, he would know that women who are ill are not in the mood to have people coming around checking on what her husband is doing, what his income is, how many children are earning, what are their ages and things of that kind. That is what is being continued in this Bill. The average person who has not been in hospital becomes very shocked when he has to go into hospital. He finds that what he has to pay is based on whatever rates, not exceeding 10/-per day, the county manager decides. It seems to me to be a hopeless way of financing the health services to say that when you are ill and have no income, a calculation is made, and you are asked to pay perhaps 10/- a day. That is a hopeless system, and the sooner it is got away from the better. It seems to me that the only way that system can be got away from is by having a system based upon some form of insurance, under which you pay for when you are ill when you are earning, not when you are not earning.

The Minister told us—and I welcome it—that this measure will bring the number of persons within the scope of the Health Acts from 80 per cent of the population to 90 per cent. That is all right from the point of view of the health services, and from the point of view of the people who will benefit from them, but we must also consider —and I do not know what view or what information the Minister will have on this—what effect it will have upon the rates. When we talk about the rates, we should remember that, unlike income tax or any other tax related to income and earning capacity, the rates hit people irrespective of their income. There may be the case of a widow with a house valued at £20 in the suburbs, who is now supporting seven or eight children on a small income, and she pays exactly the same amount of rates as her next door neighbour with an income of £1,500 a year. Every increase in rates imposed upon a person like her is an additional and unbearable burden, and she cannot get rid of it. If she does not pay, the sheriff will be in on her.

Dr. Sheehy Skeffington

How would she pay for insurance?

Mr. O'Quigley

If there were an insurance scheme, she is the kind of person who would not be called upon to pay any insurance. That could be decided beforehand. This is the kind of thing that is increasing the rates, and the sooner it is taken off the rates, the better it will be for that kind of person, and for the old age pensioners and people in those categories. The value of an insurance scheme is that these matters are dealt with beforehand, and those who cannot pay anything will be automatically insured and be within the scheme. Our health services being such as they are—and apparently as they are likely to continue for some time—I should like the Minister to direct his mind towards making some improvements in the existing services within the limitations imposed by law.

One constantly regrets the interminable delays which unfortunate people who have to attend outpatients' departments have to undergo. There seems to be no reason, financial or otherwise, why people who have to attend outpatients' departments should not attend at different hours. I have had the experience of attending at one of the children's hospitals in Dublin, and I know that if you are not in by 9 o'clock, you can stay out. Everyone must be in by 9 o'clock, and inevitably some people will not be reached until 1 o'clock. I can see no reason why a busy housewife who has to attend to her household duties, to get dinner for her husband, or be home to collect the other young children, must be in the outpatients' department at 9 o'clock and sit there hour after hour until 1 o'clock. This involves no cost, and the Minister should take it up with the hospitals concerned. The same thing applies to X-ray departments.

I have often felt a great deal of sympathy for these people. I have had the experience of attending the outpatients' department of a children's hospital and I thought it was quite absurd that people should have to sit in those places. I would not mind if the places where these people have to sit were comfortable—and this applies not only to the children's hospitals but to the general hospitals also—but they are supplied with straightbacked chairs, and they are asked to sit on them for three or four hours. These people are ill. It is time we woke up and had some regard to the fact that people who are ill are entitled to more consideration than being asked to sit on the straightbacked, hardbottomed chairs which are to be found in the outpatients' departments of quite a number of our hospitals.

There has been a great deal of criticism and agitation in one of the Sunday papers about our ambulance services. It is all very well for the county managers who are the judges in their own cause to say that they have investigated all the complaints, and everything is in order. The truth is that our health services, in my experience, do not provide proper ambulance services. I once sent for an ambulance for an unfortunate person who was involved in a motor accident in one of the suburbs. The ambulance came to the area but the people in it did not know the road. That was partly the responsibility of the local authority who had not put a name on the road, and partly the responsibility of the ambulance service whose business it should be to know precisely where the roads are, and to have them marked on a map. It is altogether too regrettable that people who are injured, and in urgent need of being brought to hospital, should be placed in that position. To my mind, that is a matter which calls for organisation and for the proper use of the resources we have.

I hope I am not going beyond the scope of the Bill, but I should like to say that in legislation of this kind something ought to be done to provide the necessary money to inaugurate some kind of a crash course in firstaid treatment for people involved in road accidents. I read recently that a great number of people who die while being brought to hospital die from suffocation, perhaps due to the way they are put into a car. Whatever the cause, if some fundamental rules were known to people who want to help in the case of accidents, perhaps these deaths could be avoided. I appeal to the Minister, in consultation with the Minister for Local Government and the Road Safety Organisation, to institute some kind of crash course— if I may use that expression—in first-aid treatment for victims of road accidents.

There is another matter which I think cries out for attention. In my experience, there is far too little communication between the hospital authorities and the next-of-kin of patients. My experience is—I do not know whether it is shared by other Senators—that country people very often are diffident about asking nurses or doctors or matrons what progress their next-of-kin is making, and my experience is that a lot of people just do not know what is wrong with their relatives. When they ask, they are given very little information and are left in a state of doubt and anxiety. They get a reply from the nurse which is as vague as the nurse thinks suitable to give, a nurse who, perhaps, has not sufficient authority to communicate to the relatives the condition of the patient. You have unfortunate people in the country ringing up the county hospital to find out how the patient is and told that he is doing nicely today, or is as comfortable as can be expected, or doing as well as can be expected. These unfortunate people may have travelled two or three miles, perhaps on a bicycle, to the local post office and this is the only information they can get.

I heard of a case recently of a child of two or three years of age who was in a hospital in Dublin, which I do not wish to identify, and the only information the parents ever got concerning the child's progress was what they could get from people who went in to see the child. If a person hands over the custody of a child to a hospital, there should be somebody there who will write to the parents once a week or once a fortnight, or perhaps once a month—this particular child was in hospital for months—to say how the child is progressing. If we are paying millions of pounds per annum from public funds, and people are paying 10/- a day, we are entitled to much better services than those being provided. Once inside the hospital doors, people do not become prisoners in a concentration camp. They are people whose next-of-kin, whether a husband or wife, or a father or mother, are entitled to know what is going on and to know that with as much precision as possible. Now that apparently he Minister for some time to come will not have enough money to inaugurate the type of amendment and improvement that he would wish in our health services, this is the kind of thing that I should like to see tackled. I should like to see this kind of thing being done as a prelude to the better things which we hope will come at some stage.

The people who are being brought in under this Bill will of course be liable to pay hospital maintenance up to a maximum of 10/- per day. As I say, it is an utterly hopeless situation that when people are sick, that is the time they are called upon to make these payments. I am particularly concerned about people in mental hospitals, the people we were dealing with on the Electoral Bill. In my experience, these people are liable to pay some proportion of the 10/- per day for maintenance, which I think is an extremely heavy impost when taken over a whole year or over a period of years. The health authorities, certainly in the case of patients who are wards of court, never determine the amount to be charged until the patient is dead and then automatically the full 10/- is charged and the whole lot comes out of the estate. I venture to suggest that that is not the law. The law requires that the rate be charged from day to day. The local authority, when the patient goes into hospital, should make inquiries as to his means and then fix the amount. Having done that, that is the amount the patient is liable to pay, in the same way as if the patient in the mental hospital were a patient in the county hospital. There should be no distinction between the two types of patient.

In the case of patients who are wards of court, they have a committee to argue and if a charge of 10/- per day is made, they can say that that is impossible as the patient has only such and such property and that such a sum is all the patient should be liable to pay. In the same way the person going into an ordinary surgical hospital can get a Deputy or a county councillor to make representations to the hospital authorities, very often with success, to reduce an unwarranted charge. The same should be done in relation to mental hospital patients but that is not what is being done. I have never heard of a case where, when the patient has died, the charge has been less than 10/- a day. That is quite unfair to the patient's next-of-kin. The law as it stands requires the health authorities to measure the proportion of 10/- which the health service recipient, whether in a mental hospital or an ordinary medical hospital, is able to pay and that charge is payable from day to day. This is something which the Minister by an administrative act should correct and he should take up this matter with the health authorities.

The Minister has indicated in this Bill that the means of an unmarried son or daughter resident in a household are not to be taken into account in computing the sum up to £1,200. I agree entirely with that. The Minister is quite right when he says that, for good reasons or bad reasons, there are quite a number of sons or daughters who do not make any contribution and who sometimes are not in a position to make a contribution—they may perhaps be engaged in a business venture —and it is far better in the case of the husband and wife that the contributions of unmarried sons and daughters should not be taken into account.

On the whole, I must agree with the content of subsection (3) under which the Minister will now consider only the income of the husband and spouse, not taking into account the income of sons and daughters living with them. However, I think county councillors may be complaining the other way. We have had many complaints about young people living in a house whose income is taken into account. At the same time, we must think of this from the point of view of the ratepayers. You could have a council house with three or four sons and daughters bringing in £10 a week each. I have heard of a case where £70 a week was going into a council house. Now, apparently, the father and mother will be entitled to treatment at the lower income group rate.

This amending Bill will gradually bring us nearer a comprehensive health service. I am not quite sure, however, it is going to be a final answer to the health controversy. Subsection (2) of section 1 deals with a subject I have spoken about elsewhere. I do not know how a valuation of £50 can be equated with an income of £800. But now we come to the present figures and get a figure of £1,200 income—an increase of £400—equated with an increase of £10 in valuation. I fail to see where any statistics could be obtained to substantiate that.

Mr. P. O'Reilly

(Longford): It would be hard to satisfy you mathematically.

Mr. Cole

Or any other way. The difference between the income of a farmer of £50 valuation and £60 valuation is supposed to be £400. I do not think any figures we have could possibly substantiate that. I would point out to the Minister that £60 valuation represents an enormous difference in income in different parts of the country. Figures were given in the National Farm Survey a few years back. At that time the difference between the family farm income of the 30 to 50 acre farm in the southern area and in the north and north-west was £230. The figure for the southern area—Munster, and the better lands down there—was an average income of £570, while in the northern area it was £338. In the 50 to 100 acre farm category, there was a difference of £270 between the southern area and the northern and north-western areas. That is a matter that should be taken into account when dealing with the income of farmers in regard to paying hospital bills and so on. It appears that the poorer the people, the more of them in the north and north-west have to pay more for hospital treatment.

I cannot expect the Minister to look into these points on this Bill, but I hope he will bear them in mind in relation to future Bills. I would ask him particularly to consider this matter of equating £60 valuation with £1,200 income. This is considering actual income only and not taking into account the number of hours worked. On that basis, it should be a great deal more. In Cavan County Council, we estimated it should be £75 and £800, and that is a county council which is not 50 per cent farmers. It is a matter that should be examined more fully. It is unfair treatment of farmers.

Dr. Alton

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 agree with one point Senator O'Quigley made, that is, that public relations in the hospitals could be improved. We are, I think, all agreed on that. He was on sound ground there, but otherwise, I think he was travelling in reverse. This is a very dangerous thing to do, even within the precincts of this House. It seemed to me that, on the case he made, the answer was a comprehensive medical scheme, but, as it turned out, the arguments he had been putting seemed to him to lead to a less comprehensive scheme than the present one. He talked about the unpleasantness, for instance, of prying into incomes and so on. This is only necessary, of course, because we have a means test, and there is no question that a great amount—I should not like to guess what proportion, but the Minister may be able to—of the administrative cost of working our present scheme resides in trying to find out the means of the patient. I remember at one time —I do not know how many questions there are now on the questionnaire— that before they got the benefit of the scheme, over half the questions asked of patients dealt with their income and not their malady. I suggest that a great deal of the administrative cost in the application of our present scheme derives from the retention of a means test.

Senator O'Quigley talked, too, about the widow, etc., who would apparently not be included in his insurance scheme, or would not be asked to pay, unless she wished to; but she, too, would be subject to a means test presumably, because there are wealthy widows as well as poor ones. Therefore, I feel, the retention of the means test is a bad thing and I am glad to see that the Minister is in this Bill moving towards a more fully comprehensive scheme.

Senator Cole dwelt on valuation and so on. Quite clearly this whole question would be greatly simplified if we had a comprehensive scheme. I remember Deputy T.F. O'Higgins, when he was Minister for Health, introducing his Voluntary Health Insurance Scheme, and he boasted that only one-sixth of the population was left uncovered, which meant that the scheme then covered about 83 per cent. He claimed that we Irish are rugged individualists and love paying medical bills, and that more than 17 per cent, therefore, would feel aggrieved if brought in. I am glad the present Minister does not suffer from that superstition and has gone beyond the 90 per cent mark.

I listened carefully to Senator Alton's excellent speech. He made a balanced critique of the situation. He mentioned the fact that there has been a great increase in the number of patients. I think the reason should be pointed out: in the past five, six or ten years, perhaps, it has been financially easier for the average patient to get access to the necessary medical attention. The number of cases has, therefore, increased.

The Minister is fully aware of the fact that the answer to most of our problems is finance. He is also, I think, fully capable of fighting for the finance he requires. Senator Alton made the point, very judiciously, I think, and well. I think, however, he is a bit afraid of free medical services. Now I do not think they should be referred to as such. If you have a State comprehensive scheme, the services are, in fact, paid for by the community according to the community's capacity to pay, and they are placed at the disposal of patients according to their medical needs. This is in fact a principle applied by the vast majority of private doctors to their patients. They treat them according to their needs and they charge them according to their capacity to pay. That is an excellent socialist principle: from each according to his capacity, to each according to his need.

What about the consultants then whom Senator Alton mentioned? It is easy to make fun of consultants. Some are doing very well. I feel that their trade union is as strong as any other, and I am sure they would be well able to fight their corner. We should not forget that the consultant's connection with a hospital is part of his prestige and part even of his sales value in the market. The fact that he is attached to a hospital is certainly part of his sales value. If he gains less from his hospital work, as is quite possible under the present system, than might theoretically be his due, I do not think very many could, if one applied a means test to them, prove that they were actually suffering from hardship. What is required, in my opinion, is more money equitably applied. The Minister is moving now in the right direction towards a full, comprehensive scheme. This Bill constitutes a big advance towards that happy state. It is a step forward towards that particular goal, and I say to the Minister: good work, keep it up.

Business suspended at 6.10 p.m. and resumed at 7.30 p.m.

Mr. Nash

In this Bill the Minister has made very far-reaching changes, much more far-reaching than would appear at first glance. All members of the agricultural community will, when this Bill comes into force, if their poor law valuation does not exceed £60, be entitled to free institutional treatment both in the ordinary hospitals and in mental homes, free specialist services, free maternity medical attention and free children care. In my view, that would cover approximately 90 per cent of the agricultural community. Already everyone engaged in manual labour, irrespective of his income, is entitled, free of charge, to those services. Under the Bill, by reason of the new social service scheme, all persons engaged in non-manual labour whose income does not exceed £1,200 will be affected, as also will all self-employed people whose income does not exceed £1,200.

In introducing the provision that the incomes of children living in the house will not be added to the incomes of the parents, the Minister has very much extended the scope of free medical services. Heretofore, if, for example, a clerk, married, earning £700 had with him a son or daughter who was earning £300 or £400, he was not entitled to the free institutional and specialist services now provided.

Senator Alton explained the services which are being given to this country by the voluntary hospitals and by specialists attending those voluntary hospitals. The religious orders running those hospitals are entitled to the greatest credit. To them nursing is not a service but a vocation. To many of the specialists attending those hospitals also their work is a vocation. They work with their heads and their hearts but primarily with their hearts. The Minister, therefore, was faced with finding a happy medium whereby he could give to the country a medical service which, on the one hand, would not entail a severe impost on anyone who was ill and, on the other hand, would reasonably meet the views of the medical profession. He has told us of his interview with the Irish Medical Association.

Senator O'Quigley indicated that the Bill should go much further and that it should include everybody, irrespective of income and irrespective of poor law valuation. Senator Sheehy Skeffington said likewise. I believe that the Minister's approach of in-between is by far the most satisfactory one. However, it may impose a very big burden on the rates. At present 50 per cent of the health services are paid out of the rates. The people for whom I have most sympathy in the payment of those rates are not the agricultural community, because already they have various allowances, various credits, not the wealthy businesses and factories, because they get back practically 50 per cent of what they pay in rates by way of allowances in income tax— their rates go down as the business expands; between income tax and corporation tax they are re-allowed 9/4d. in the £. The persons for whom I have the greatest sympathy if their rates are to be increased by reason of extra medical services are the ordinary middle income groups in our villages and towns and cities.

As Senator Alton pointed out, this Bill brings into the category of free institutional and specialist services approximately 200,000 of our population. I realise from statements the Minister made in the Dáil, and repeatedly in the public Press, that this is only the first part of a much wider programme which, quite obviously, the Minister has in mind. I can visualise that if 50 per cent of the extra increased expenditure has to be met by the ordinary ratepayers, the ordinary middle income group living in houses with poor law valuations of between £15 and £25, it will impose on them a burden which they will find very hard to meet.

Many of those people who married eight, nine or ten years ago and built their houses, until now had the benefit of rate remission. Many of them today are perhaps buying houses already built. Not only will they have to pay the higher interest rates charged by building societies and county councils on loans for houses but if this Bill and these medical services mean a higher impost on the rates, they will have to meet these imposts. I can sympathise with members of local authorities who will be faced with the task of collecting those rates. If, however—I do not know how it will be possible—some method could be devised whereby these extra imposts because of medical services would not increase the rates, if the Minister, young, intelligent and enthusiastic, can persuade the Government to introduce some scheme, some method whereby he could marry his ideals in respect of improved medical services to some form of expenditure that would not increase the impost on these people, then he would produce a child which all of us could take to our hearts.

I realise that is a herculean task. Senator Alton pointed out the difficulties in no uncertain terms. If the Minister could do this he would ensure to some extent that those middle income groups already paying voluntary health insurance will not, in addition, have to pay again in their rates the entire cost of the scheme. I should like to ask the Minister whether he and the Government have anything in mind which will enable this to be done. If he has, then he has produced a Bill we can all welcome with open arms.

Mr. Rooney

It seems to me that this Bill, which provides an improvement on existing services, is a stopgap measure, an extension of the existing services while we await comprehensive medical services. I believe this is the last step towards the comprehensive medical services which have been pressed on the Minister and his Government for so long. It is obvious this extension has become necessary because of the substantially increased cost of living and the drop in money values.

One dramatic example has been the fact revealed by the Minister that one hospital which charged less than £7 per week only a few years ago now finds it necessary to charge £17 per week for the services provided. It is obvious also that this extension of the health services will increase the rates by about 3/- in the £ all over the country. Already the ratepayers are complaining about the heavy burden of the health services. Health service charges are now the highest item chargeable on local rates, having displaced the road charges. Three shillings in the £ is a very substantial increase for many people, particularly the farming community who already find it difficult to pay their rates. We have seen rates agitation, we have heard farmers say they find it difficult to bear the burdens and we have had statistics comparing farmers' incomes with those of other sections of the community. The painful part is that many of the people who pay very high rates cannot benefit from the health services towards which they contribute so substantially.

When the Minister announced some months ago that he proposed to publish a White Paper on health services, we believed it was the final move towards comprehensive health services. The Minister said he was dreaming of a White Paper and it gladdened the hearts of people who felt the Minister had grasped the nettle and was dealing with the burning question of health services, a live issue at all times with not alone those who were paying for them but with those who expect to benefit under a health service scheme which they complained is piecemeal or lacking altogether at the moment.

Whether this Bill extends the health services to an increased number of people, let us not forget that the charge of 10/- per day still remains. The Minister knows that in many cases this charge of 10/- per day can cause great hardship. The charge is applied after people have answered many questions in relation to means. It is charged during the time a person is in hospital. He may come out to find he is unemployed, he will get a bill from the hospital and a letter later threatening action for the recovery of the charge of 10/- per day. There is a lot to be said against application of the means test while a person is in hospital.

In moving towards comprehensive medical services, the Minister will find it necessary to ensure that the conditions in which the dispensary services are being provided will be improved. Any of us who has experience of the dispensary services knows how unfortunate people are crowded into cold rooms with bad atmospheres to sit on hard chairs until their turn comes. They are people who are going there for some kind of medical treatment in the course of getting the medical services to which they are entitled.

With regard to hospital costs, I think the time has come when hospital costs should be broken down in order to see whether the very high cost of a bed at £17 per week could be reduced. I know that the average is somewhere about £15 or more. It should be possible, at this stage, to break down the cost of that bed, to put these costs and charges under the miscroscope, first of all, in order to assure the public that it is not possible to provide the services for less than £15 per bed per week and, secondly, with a view to co-ordinating and improving the services which go into the provision of this bed service in the form of medical treatment for people in hospital. I know that, owing to the financial condition of the country at the present time, it is not possible for the Minister to implement a fully comprehensive medical service. I feel that even at this stage he should set about planning it and publishing it. If he publishes it a considerable time before it is implemented, he will have the benefit of the views of various organisations likely to be affected. He will also have the benefit of advice in relation to the various services which will be operated and co-ordinated within the scheme.

The day has come when the Minister should cease to look to the ratepayers to make such a substantial contribution towards the operation of this scheme. He should find a scheme which will encourage people to value their health and make a contribution towards it, particularly in the days when they are enjoying good health. They should realise that they have a personal responsibility to themselves to ensure, by contributing during their days of good health, that, in the event of sudden illness or eventual bad health, they will have provided for themselves, instead of looking to one section or another of the community to do so.

The costs at the moment are divided, first of all, amongst the ratepayers, and secondly, the taxpayers, and in some cases by contributions from their own pockets. The citizens, in general, should be encouraged to contribute towards their own health services so far as they can. A contributory scheme of one kind or another should be brought in. I know that the Labour policy is to have this scheme financed from the Central Fund, probably from general taxation. However, that might not be a satisfactory way to finance our medical services in the long run. It might be better to have some kind of contributory scheme which would make the citizens realise that they are making a contribution towards their own health services. Nobody will dispute that, in these modern times, having regard to the high standard of living which people enjoy, and expect to enjoy, and having regard to the high standard of medical services which they also expect and demand, they should be encouraged to make a substantial contribution towards the services, in the ordinary way, while they can, and so far as they can.

Professor Quinlan

We are deeply indebted in discussing this measure to Senator Alton for the very comprehensive survey he has given. We all look forward to reading it in print and to seeing the difficulties of the medical profession as explained by one of their most eminent members. It will do a good deal to clarify thinking on this issue.

The difficulties in medicine are just like the difficulties in education and everywhere else. They all seem to come back to more money. We are acutely aware of the difficulties of producing comprehensive health services but we should at least try to make the best use we can of our available resources. The Minister seems to be adopting the right approach in this matter in trying to get the best possible teamwork out of our existing system, combining the voluntary hospitals and the local authority hospitals. Of course, that has to be the foundation because as a nation we owe a tremendous amount to voluntary effort and, in the medical field, to the work done by the voluntary hospitals. No tribute would be too great to pay to the self-sacrificing work they have done at all times for the sick. Any comprehensive system will have to be based firmly and squarely on a recognition of the vital and essential role of the voluntary hospitals.

The Minister in this regard might look at some European practices where you have the parallel system, with the State doing some work, through its own organisations, and with voluntary bodies doing like work in competition. You will find, especially in Holland, where that has been most successful, that the State is always very scrupulous in estimating the cost of doing a particular service through its own organition. The State is fair minded enough to pay others doing that job on that basis. I know that, if that were put into practice here, the voluntary hospitals would certainly have their incomes quadrupled and quintupled if they were paid on the basis of what it costs the State to do the work.

I believe any system will have to recognise the fact that the voluntary hospitals will have to get greater support than they have got in the past. Senator Alton mentioned the real problem about staff, their scarcity and so on. We all recognise that but the Government must take a great deal of the blame for the way in which the medical schools have been left. If we contrast the treatment given to the veterinary college for animals with that given to our medical schools, we find, in the current Estimates, on page 187, that the total provision for the training of veterinary surgeons in the Veterinary College is £102,000, in University College, Dublin, £102,000, and in Trinity College, £46,000, making a total of £250,000. Speaking for the college which I know best, University College, Cork, I can say that on a grant which is only about ten per cent of that, we are expected to provide for six times the number of students in the Veterinary College. In fact, out of our resources, we are expected to man a medical faculty that has a greater number than are at present in the Veterinary College; yet all we can afford to allocate from our resources to that is about one quarter of the total given for the training of veterinary surgeons. In other words, it costs four times as much to train a veterinary surgeon as it does to train a medical doctor. There is something wrong when we see those figures.

I was glad to hear Senator Cole advert to the still highly exaggerated notion that prevails about what farmers can afford. We find that a farmer with a £60 valuation is being equated in this Bill with a man with an income of £1,200 per annum. That is not a proper equation in any sense, because if you take the average gross output as somewhere in the region of £18 per acre of reasonably good land, the average type of land has a value of the order of £1 per acre. So, taking the national figure, the output of a farm with a valuation of £60 certainly would not exceed £1,200 gross, and the amount which would remain with the farmer, on average, for all his labour on the 60 acres would be about 60 per cent, or £700. That is the measure of his income, so obviously this is not giving fair play to the small farmer or the medium farmer, compared with the worker with a salary of £1,200. In fact, to have £1,200 left for family income the farmer would need an income of at least £2,000 gross, and that would be very difficult to produce today on a valuation of £60.

I was taken by the figure given by Senator Alton. He said that 93 per cent of the population will now be brought within the ambit of the services provided, mainly free, by this Bill, leaving seven per cent to pay for their medical services and for specialist services. This is an amazing burden on that seven per cent, and that seven per cent should be entitled at least to consideration for remission of income tax on medical bills over a certain amount, because £1,200 is not a princely salary today. Many persons earning above that salary have to incur heavy medical bills which should be allowed for income tax.

It seems that any service that will provide medical services on the scale regarded as necessary today will have to expect a contribution from the individual concerned. I think we have gone too far with the idea of non-contributory services. The people themselves would value the services much more, and be much more selective in their use, if they had to make a small contribution. On the one hand, it would ease the burden on the rates and on the Exchequer, and on the other, would ensure that our medical practitioners are not called out unnecessarily. We must realise that we are a small country with financial difficulties and with a relatively low national income, so, in planning for these services we must expect some contribution from individuals.

I should like to say how gratified I am at the better relations that now prevail between the Minister and the Irish Medical Association. We are all glad of that, and we may say that perhaps an engineer has brought conciliation and arbitration into what looked to be a very difficult field. We wish the Minister well in his task, and we hope he will continue to expand the area of co-operation and consultation between the profession and himself and his Department. If he does, the medical profession, like any other profession, will not be found wanting—when they are treated as they should be treated by a Minister who realises the dignity of the profession.

Mr. McDonald

I should like to welcome the improvement in this Bill. The increases in income and rateable valuation are welcome, but I agree with Senator Quinlan when he points out the injustice of equating a poor law valuation of £60 with an income of £1,200 per year, taking present farm prices into consideration.

There are many inadequacies in the present health services, and it is difficult to visualise a vast improvement in a small measure of this kind. In our local authorities the greatest cause of discontent seems to be the allocation of medical cards. It is extraordinary that the same Health Act can be interpreted in so many different ways as between one county and another. It is regrettable that while some families can apparently succeed in gaining registration on the general medical services register, we still find people, especially old age pensioners. without medical cards. Amongst the older members of our community, we find people who have enjoyed a certain amount of independence all their lives, who very often deny themselves services to which they are entitled because they feel that if they applied for a medical card they would be turned down. That is very wrong. The Minister should insist that the Health Act is administered uniformly in every county in the State.

I should like to support Senator O'Quigley's plea that there should be an improvement in the system in regard to patients waiting at clinics and X-ray departments. Surely it is unnecessary to expect people to be in at 9 o'clock or 10 o'clock in the morning and to wait for several hours for attention. Surely there could easily be some form of appointments system that would take some hours off the time some patients have to wait. I find in my county, Laois, that patients who have to come in their own mode of conveyance are perhaps kept waiting for hours. That may be all right for some but I think that with a little thought and a little bit of extra work, many of these difficulties could be ironed out. Our voluntary hospitals and the people working in them merit well-earned praise for the great work they have been doing down through the years and I feel that the State should be fairer to them. In many parts of the country improvements are needed and the Department should lead the way in this regard.

The Minister some time ago promised a White Paper on Health and all of us who are interested in this, such as members of county councils and those interested in health treatment generally, have been eagerly awaiting this White Paper. We find that the cost of maintaining patients in extern hospitals, by the county councils, has been increasing every year for the past few years and it is now very expensive. There should be a more economic way of providing the specialist services we need and of making them available in the country. There should be a better way of organising the transport of patients. In by own county, which is pretty convenient to Dublin, the transport of patients cost up to £10,000 last year—an enormous sum for a comparatively small county. If we had more centralised services we could perhaps provide centres in the midlands where some of the specialists could attend and thereby save having to transport the patients to Dublin. This would be easier on the patients themselves and would be cheaper on the ratepayers. I do not advocate that we should tackle this problem from a completely economic point of view but, at the same time, with the services as they are we should explore every avenue in order to endeavour to meet the situation.

Finally, I should like to comment on the increase in hospital charges over the past year. They are a definite burden on quite a large section of our people and I hope when the Minister is bringing in his new Bill he will bear in mind people in the middle income group. I have in mind particularly the farmer who is up to the £75 valuation and who has a very heavy outlay on rates. The number of such people is very small; they are caught here. I feel that the increase in valuation up to £60 is not a just figure in view of the fact that the Minister has allowed other sections an income limit of £1,200 a year.

Mr. Murphy

This is a simple Bill and I thought it would go through the Seanad easily and quickly. Quite frankly, I am interested in it going through quickly because I think we are all agreed that it is a good Bill in that it provides an extension which perhaps is not very much but is still a good thing. The Bill will come into operation when the Minister appoints by order and, therefore, the quicker the Bill goes through the sooner, we hope, will the Minister make the necessary order. When he is replying to the debate, I hope he will give us some indication as to what he has in mind about making the order for the operation of this legislation.

As I said, it is a relatively simple Bill but we seem to be having a debate on a White Paper which has not appeared. I do not propose to follow in any great detail that sort of debate. I would much prefer to see the White Paper before we attempt to debate it. I hope we will see the White Paper pretty soon and I also hope the Minister will take his courage in his hands and propose the introduction of a comprehensive health service for the whole community. I know that when you mention a comprehensive health service people raise the bogey of the cost. Quite frankly, I can never understand this argument because I think we have to regard not merely the existing cost and what we pay in rates and what we pay from central funds, but what we as individuals also pay. If we say that a comprehensive health service, free to the whole community, will cost much more than the sum total of what we as a community spend at present, that means in effect that we are not providing a proper service, that we are depriving sections of the community of a proper health service. That seems to me to be the sort of argument that we cannot afford to do it, that we cannot afford to treat a section of our community in a proper way. The people who have the money can have a proper health service and a section who cannot afford it must have it doled out to them—I was going to say meagrely, but that would not be quite just in view of what the Minister is doing—cannot have what is appropriate or just for them. As I said, I want to see this Bill going through as quickly as possible but I do suggest to the Minister that he should take his courage in his hands and propose the introduction of a comprehensive medical scheme for the whole community. It would be a fitting monument, in 1966, to the patriots who died 50 years ago.

Mr. McAuliffe

I should like to welcome this Bill which I think is a step in the right direction although we in the Labour Party were really looking for a health scheme on an insurance basis. The fact that it covers 90 per cent of our people is gratifying, and it should not take much more to cover the whole population. I believe there will have to be an insurance scheme before we can reach that stage. If we take the increase in the numbers covered, most of it came from persons insured under the Social Welfare Acts. One of the other two categories is self-employed people. Any member of a local authority has a fair idea how self-employed people get on under the Health Act. They have not been doing too badly. It is rather difficult to assess the income of self-employed persons. Small shopkeepers or contractors do not keep audited accounts and books. Then, there are cattle dealers and various other people. It is impossible to assess their income. When they get sick, they get the benefit of the Health Act as it stands.

The number of people in the second category—self-employed people—who will be included will be very small indeed. I would be surprised if the number is as much as a half per cent of the population. I am very interested in the third category, farmers under £50 valuation. I always considered that the £50 valuation was too low. Other people whose incomes had gone up to £800 were included, but a man with a valuation of £50 would find it hard to make £800 a year. I do not think the Minister has gone far enough in increasing the valuation figure from £50 to £60. He is now calculating that a man earns £20 per £1 valuation. That does not include land valuation alone but the value of the whole holding, including buildings.

If you went into a county manager under the old Act in connection with hospital beds, he would take this down on his bit of paper and multiply by 16. He is encouraged by what the Minister has done now to multiply by 20. The Minister could have gone to over £70 to put these people on a par with people earning £1,200 a year. I do not think the number of extra people included in respect of self-employed people and farmers under £60 valuation will make any difference whatever in the rates in any county. A number of these people are already covered under the Voluntary Health Insurance Scheme and they are hardly likely to withdraw from it. If they withdrew, they would have to get into the queue to see a specialist or would have to go into a public ward. By continuing to pay their Voluntary Health Insurance Scheme contributions, they would have the advantage of going into a private or semi-private ward, according to the number of units they have.

I know the Minister has done something for hardship cases. He mentioned hardship cases in his statement here today. However, there is very little he can do. How hardship cases are treated is in the hands of the county managers. Some of them are quite good; some are not. It is laid down in the Health Act that the manager can give only certain concessions as far as hardship is concerned. A person may be in hospital for three months paying full fees. The manager may put him on threequarters of the rate. If the illness is prolonged, the manager has power to allow a person off at half the rate. But I think that is the greatest concession I have seen given. I have seen some grave cases of hardship with people barely over the £50 mark.

The doctors seem to be worried that the inclusion of this 1.5 per cent of the population will seriously interfere with their incomes. It will not take a penny from the pockets of the dispensary doctors, because not one person in the two categories dealt with here—self-employed people up to £1,200 and farmers up to £60 valuation —has the slightest chance of getting a medical card. Therefore, it is obvious that the dispensary doctors will lose no income because of their inclusion. Consultants, surgeons and so on may possibly lose. I do not know how the Minister could compensate them if they could show they had lost income as a result of the Act. They are not tied up in the same way as dispensary doctors and doctors attached to local authorities. In that case the Minister could easily see whether they were losing income and deal with them. But he would not find it so easy dealing with the incomes of people in private practice.

Mr. McQuillan

Supposing they produced their incomes for a change.

Mr. McAuliffe

I am also pleased with the way family income was dealt with in the Bill. A few days ago we got a circular in Westmeath County Council telling us that all old age pensioners were to be issued with medical cards. I should like to congratulate the Minister on that.

Mr. O'Quigley

And Deputy T.F. O'Higgins, who prodded the Minister into it.

Mr. McAuliffe

It was as a result of a statement made by the Minister in the House. I do not know who brought it about. I would be glad to compliment Deputy T.F. O'Higgins if he got the Minister to make that statement. However, the Minister made the statement and, more important, implemented it. It was very much appreciated by the people in the country. I do not think old age pensioners should be annoyed by people trying to find out what their sons and daughters earn. I compliment the Minister on following the same principle here. The head of the house is the person who will be answerable for the income of the house, and his son or daughter cannot be approached to find out how much they are contributing towards the maintenance of the people in the house. That is a move in the right direction, a move to stop lies and everything else. It only brought about lies told to try to avoid hospital bills, which really hit people hard.

It is gratifying that 90 per cent of the people are covered by the Health Act and it should not be too difficult to get a scheme, contributory or otherwise, to cover the full 100 per cent. The sooner this is done, the better.

Mr. Garret FitzGerald

I had not intended to speak, but the Minister looked so invitingly at me when I entered the Chamber that I could not resist it; although in fairness I shall not keep him more than a few minutes.

I do not agree with Senator Murphy that it is inappropriate for us to take this opportunity of adverting to some general principles in regard to the health services which may be of some value to the Minister in guiding him in the preparation of the White Paper, the delay in the issue of which is perhaps not entirely his fault. I should like to suggest tentatively a few principles which I think should be borne in mind in devising any radical review of the health services, such as is overdue and as the Minister is contemplating.

First, I am convinced that the present system of financing the health services is the wrong method of financing them and is an inadequate method. Any system of finance that depends for half of the finance on a tax as unjust as rates and for the other half, on general taxation, where there is always pressure on the Government, is one which is bound to lead to an unstable and inadequate service. Our difficulties in regard to health services derive in large degree from this and from the persistent reluctance of the Government to face up to the need for drawing on the alternative method of raising money for this purpose which is used elsewhere and which is appropriate for this purpose, namely, some form of contributions from the people concerned — insurance contributions or whatever you may like to call them.

As it happens, in this country, the burden of such contributions on employees is relatively light, compared with its incidence in other countries, even though there have been significant increases in the social contributions in recent years. However, the burden of other taxes is by no means so light. While our income tax is not so very high, it still is by no means low and increases in it are liable to have a disincentive effect. This is not true of the kind of insurance contribution we talk about. Until the Government are prepared to draw on this additional source of finance, we shall not have adequate health services here.

One almost regrets that Fine Gael introduced a scheme with this proposal of insurance contributions because though there are many other Fine Gael policies which the Government adopted with remarkable celerity after the last elections, this one became controversial and the Government almost committed themselves not to accept it. I hope they will not persist in that attitude. I hope that the Minister will take a broader view because this is a matter of fundamental importance to any radical improvements.

Secondly, all patients should be treated equally and that is something which does not apply under the present system. There is a marked disparity in the application of criteria in the different counties for medical card holders.

I think that in any new system all the patients should be on the same footing with the doctor. The doctor should not be in a position to distinguish between the man paying for himself and the man being paid for by the taxpayer through some social mechanism or other. How the patient pays for it is a matter between the patient and the public authority. The doctor should not be in a position to distinguish between patients or faced with distinctions of that kind

In determining the method of contribution, it seems to me that some form of contribution to provide a supplementary source of finance is important. That type of contribution is one from which it would be proper to exempt people of straitened means. We must try to avoid the means test which, in its historical application here, has been unfortunate. As far as possible, the exemption of such people should be based on some categorisation — those in receipt of social benefits or social assistance at the time and perhaps other special classes such as widows. It should be possible to avoid a scheme based on asking people to disclose their income because it gives rise to abuses, to controversy and to the general unpleasantness associated with the actual application of a means test in this country—not that the means test principle is unsound. It is proper that the poor should benefit and that the rich should pay the full cost but the application of the means test here should be such as to try to move away from the methods applied heretofore.

Another point the Minister should consider seriously is that the contribution payable under any insurance scheme or whatever it is called—the Minister might find it more tactful to describe it as something else as the expression "insurance scheme" is associated with the Fine Gael Party—should, I think, be creditable towards voluntary health insurance. If a man is paying out £10 or £15 a year in compulsory contributions of some kind or another, he should be permitted to have that money credited to the voluntary health insurance scheme, or part of it as may be appropriate, as part of his contribution so that he is not faced with the choice that has just been mentioned of opting out of the Voluntary Health Insurance Scheme for a less favourable arrangement.

Another matter to which the Minister has agreed in principle is that doctors should not suffer financially by the introduction of any scheme. Some, at least, of the opposition of many doctors to State medicine derives, I think it is fair to say, from very long and bitter experience in dealing with the Department of Health and the kind of treatment they have received, which has not led them to believe that they would be treated generously or even fairly in any State system and they fear being dependent for their entire livelihood on the State, which has shown itself, in this area, a consistently bad employer. The Minister has shown a willingness to make a fresh start and we must encourage him on that course. He has an opportunity to gain the confidence of doctors and, without such confidence, it would be difficult adequately to reform the health services.

Another point—it is hardly a principle but it is something to consider— is the present system under which general practitioners in many cases are subjected to the strain of a 24 hour, 7 day week service which they have to provide and anything that can be done to alleviate that situation will be good. The general practitioner service should not be overlooked. There is a tendency to leave it out of any system because the cost to the ordinary household is not great but it should be brought in and consideration should be given to methods of ensuring through the operation of panel arrangements of some kind or another that the burden and strain on general practitioners, which in many cases is intolerable, would be alleviated.

In devising any scheme, I would hope that the Minister, before producing the scheme and in preparing it, would endeavour to make it as good as possible by consulting the different parties involved. There are difficulties here because of the historical relationship and the well-known antipathy of many doctors to State medicine. Although it is not proper for the Minister to go cap in hand to the doctors and ask: "What will you accept?"—that is not the job of a Minister of State—his job is to determine the aims he wants to achieve—but, having stated them, it is proper for him to go to the medical profession and other interested parties and say: "I am going to bring in a scheme to introduce these provisions. You may not like it. However, I want your assistance in telling me how to do it in the way which will cause the least disruption to you, inter alia, while providing the greatest benefit to the public.” An approach of that kind, even to people ideologically opposed to the proposal, can produce the response and help required in devising a means of achieving an aim which personally they may find distasteful. The good start the Minister has made by way of consultation makes it possible for him to take such a step and to approach the problem in that way.

A final point I should like to put to the Minister is an appeal to look at the question of hospital catering. This is a much neglected matter. It is extremely difficult to provide good, hot food to people in a large institution. It is not insuperable but nearly so, and nothing has been done in this country to overcome the problem. I have some little personal knowledge of this. About three years ago I had to look into this question for a particular reason and I had very constructive discussions with the Departments of Health and Education, with the vocational education authorities, some of the hospital authorities and with the Hospitals Commission. I discovered an interest and a willingness on the part of all these bodies in relation to this problem. I also discovered a total unwillingness on the part of any of them to take any initiative and a rigid belief on the part of each that the initiative must lie somewhere else. They were not by any means disinterested. They welcomed any initiative in the matter: they would be glad to co-operate but each thought it was somebody else's job to start the ball rolling. There is a document somewhere in the Minister's Department containing some practical suggestions arising out of the consultations I had, because his Department, knowing I was making these inquiries, said they would be very glad to know the result and what conclusions I came to. This is something that could well be looked at. That is the only other point I wanted to make and I am sorry for detaining the Minister.

Mr. O'Malley

First of all, I should like to thank the Senators for the very constructive points they have made during this debate.

Senator O'Quigley who was the first speaker suggested that people who go into hospital were assessed on what they "were" earning, not what they "are" earning at the time they are in hospital. That is not so, of course. Such persons should be entitled to have no charge levied on them for the hospital costs. I should be very interested indeed—if the Senator is aware of such cases—if he would let me know, but there must be some misunderstanding.

The debate, of course, covered a much wider field than I had anticipated. It was like a speech on my Estimate in the Dáil.

Senator Alton went to the greatest trouble in preparing his speech and I should like to congratulate him on it. I will take heed of suggestions he has made and bear them in mind, as indeed I will consider all the proposals of the other Senators. I could not possibly reply to all the points made by Senator Alton but there were some I did jot down when he was speaking. He spoke of the increase in population in North Dublin but remember, nobody has had to be refused a hospital bed there. I am not aware of any complaints and perhaps one explanation is that in 1964 the average stay in a hospital was 17.6 days, as compared with 20.1 days in 1960.

I was dealing with the question of the comprehensive health scheme and the question of an insurance contribution. I have expressed myself as opposed personally to the system of insurance contributions. Senator FitzGerald has raised the matter. I have no objection to examining exhaustively this system of insurance contributions whereby the State would contribute possibly one-third, the insured person one-third, and the employer one-third. It appears to me to be unjust that an insured worker with, say, £8 a week should pay exactly the same contribution, whether that is 1/-, 2/- or 3/-, as a person with £1,100.

Mr. Garret FitzGerald

Does the Minister think the present Social Welfare scheme in this country is unfair?

Mr. O'Malley

I think many things but I am talking only about Health now. I do not see the justice of this. Senator Quinlan very wisely said that we must make the best possible use of our resources. In doing that, the first category of people we must think of are the poor. They come first with us; they cannot help themselves. The next category are what I might call the middle income group, those earning up to £1,200, the extended limit under the new Act.

Senator Murphy asked me about the commencement date of the Act. I shall have to make regulations which must first be referred to the National Health Council but the date I have in mind is April 1st next.

Mr. McQuillan

Fianna Fáil would take them over.

Mr. O'Malley

If Senator FitzGerald will look up the Oireachtas records he will see that this question of insurance contributions has been discussed time and again.

Senator Alton referred to 45,000 patients in the voluntary hospitals and said the figure was up by 13,000 on 1958. He suggested that this showed a drift from the county hospitals to the voluntary hospitals. That is not so. Admissions to all kinds of hospitals have been going up. In 1957, the total number of patients admitted to all acute hospitals was 219,390. In 1964, it was 282,931. I admit Senator Garret FitzGerald may make a point of this and say that after the Coalition went out of office and we came in more have had to go into hospital!

Mr. Murphy

They have sickened.

Mr. O'Malley

I was interested in Senator Alton's point and a little worried, too, but I am satisfied, as I think he will be, that the trend is for increased admissions all over. Whether that is good or bad I do not know, but the average duration of stay in hospital has dropped substantially.

In conclusion, I should like to thank the Senators for their constructive contributions to this debate.

Question put and agreed to.

Agreed to take remaining Stages today.

Bill put through Committee, reported without amendment, received for final consideration and passed.

Seanad Éireann debate - Wednesday, 12 Jan 1966

Health and Mental Treatment (Amendment) Bill, 1965: Second and Subsequent Stages.

Senators

An Leas-Chathaoirleach

An Leas-Chathaoirleach

An Leas-Chathaoirleach

An Leas-Chathaoirleach

Seanad Éireann debate -
Wednesday, 12 Jan 1966