When this debate was adjourned on 12th May last, I was referring to what Senator Alton had said on capitation, as opposed to fee for service, basis for payment for general practitioners. He, of course, favoured the fee for service basis, and certainly came out of his corner fighting, on this round anyway. I am not going to argue with him. I want the issue to be the subject of cold appraisal, not hot war. I think Senator Alton would have done a much greater service had he allowed discussions to take place between me and the Irish Medical Association and the Medical Union as they have been taking place—and I have promised to continue these discussions—rather than coming out so specifically on one side, namely, fee for service. I may as well say it, I think it was most unfair. I do not think that was the time to do that. There are other criticisms of the health services and the White Paper which could have been made without going into this in such detail. I am quite aware of my responsibilities and my first consideration is always the patient.
Public Business. - White Paper on Health Services: Motion (Resumed).
Hear, hear.
I do not think this is the place to have taken—well, I had better leave it at that. In the Dáil, I made it clear that I did not nail my colours to the mast on this issue of payments, and that references in the White Paper to capitation being considered the most practical system did not mean, and does not mean, that the Government will consider no other method of payment. There seems to be—I might as well say it—a lobby working among the medical profession——
Not for the first time.
——about a certain method of payment. This will not influence me in the slightest. I shall advise the Government on the best method, as I see it, in the interests of the country, within the capacity of the country to pay and in accordance with justice, but I shall not be blackmailed into coming down on any particular side, and if the doctors are trying to influence me unduly, and trying to work up a hysterical lobby, they are dealing with the wrong man on this occasion. I can tell them that much. They will not frighten me with some of the threats I have heard and some of the methods which are being adopted.
I have had the happiest relations with the Irish Medical Association and with the Medical Union since I became Minister for Health. I have the greatest respect for them. I have got good co-operation from them; but if there are individual members of those bodies who are acting in this manner, the sooner they cop on to themselves the better. They are not going to bully me. I intend to see that the health services of this country, the improvements initiated by Senator Dr. Jim Ryan in the Act of 1947, the subsequent Act of 1953 and now the Bill I shall bring in in November next, will work. I realise it is only with co-operation from all parties they can work.
I am willing to sit down and discuss round a table any of the peculiarities or problems which exist, or which certain sections of the community— bodies, representatives or individuals —might think constitute an injustice. I do not want to use the big stick. I do not want to bring in legislation which, (a), will not work or (b), if it does work would constitute a hardship on anyone. This is not the spirit in which we want to get things done. I have a personal preference—and I want to repeat it is mine and that I am not a puppet of my Department in this, as evidently Senator Alton tried to imply —in favour of a capitation system, based not on a slavish imitation of Britain but on considerations arising from our own particular scheme.
I might say, in this connection, that we have heard here and in the Dáil people saying what takes place in Australia, New Zealand, the Scandinavian countries, Italy, France, Germany and Britain. This is all most interesting. We also have studied all those things. We can learn a lot too from them but there are problems peculiar to this country. The solution of those problems in other countries would not be appropriate for the solution of them here, just as the health services in Ireland, no matter what way we improve them, just would not work in other countries. I want, also, to say that we have learned an awful lot from what has happened in Great Britain as to the pitfalls into which we could fall were it not for the experience gained there.
The White Paper proposes a general practitioner service without charge on the patient for a section of the population. In principle, this is quite different from any scheme in the northern European countries mentioned by Senator Alton.
Senator Alton went into the position in Britain in great detail and he inferred I had given incomplete information to the Dáil on this. I cannot see, having listened to him, with all his inside knowledge of the working of the British Medical Association, that he produced evidence to show I was misleading in what I said in the Dáil. I cannot see that I was, and had I been, I should immediately have admitted my mistake and taken an opportunity of correcting it. I read what he said very carefully and I read what I said in the Dáil very carefully and I find I do not have to change a comma.
Senator Alton quoted some references from the British Medical Journal to show the doctors in Britain are not satisfied with how much they are being paid and have been paid in recent years. Anyone who reads the report of his statement will find that the Senator has not produced evidence that a majority of the doctors working under the British National Health Service want a fee for service basis. I think the records show that agitation among doctors in Britain has been mainly against the particular form of the capitation system which they have had there. Under that system a pool of remuneration was established and what went into it was calculated by multiplying the number of participating doctors by a fixed average income per doctor. The distribution of money from this fixed pool did not meet with the satisfaction of the medical profession and one reason was that no doctor could increase his income from it without reducing the amount available for other doctors.
I note that the British Government have agreed to abolish this pool system but they have not agreed that fee for service should be substituted for it as the principal way for paying general practitioners. The review body on doctors' and dentists' remuneration in Britain this month issued a report recommending a certain system. The report has yet to be voted on by the medical profession but the fact that this new system of payment was, by agreement, referred for pricing to the review body is a good pointer that the majority of the British doctors are willing to continue with capitation as the basic system of payment.
Senator Alton mentioned that under the new arrangements in Britain there will be supplemental payments on a fee for service system for certain items. I do not rule out something similar here. I am quite ready to discuss this with the medical organisations, as indeed I am ready to discuss all their ideas on remuneration. At present, this detailed discussion on methods of payment can more appropriately take place, and continue to take place, between the medical profession and myself rather than in a debate here in the Seanad.
I should like to make it clear, in case anyone might think otherwise, that I have never suggested that what we want in Ireland is a capitation system on the old British model with a limited pool related to the number of participating doctors. Finally, on this issue I should like to appeal to Senator Alton and to other doctors not to close their minds on this issue before our negotiations have got under way, so to speak. I am afraid that in this respect I must say that openmindedness has not been encouraged by a recently conducted poll on methods of payment. The Seanad have probably seen the results of this poll as published in a periodical called Pulse International, dated 12th May last, under the banner headline: “Sorry, Mr. O'Malley, but 98 per cent say ‘no’ to capitation”.
They were polite about it.
I suppose they got their inspiration from the Holy Ghost. I suppose nobody pushed them.
It was not the first time He has been drawn into the medical scene.
Or the political scene.
The poll which got this great publicity is called the Pulse Survey of Medical Practitioners. In fact, the poll was based on a questionnaire filled in by only 457 of the 2,952 doctors in the country. One hundred of the 457 were specialists so that only 357 general practitioners completed the questionnaire. Do these 357 make up a representative statistical sample of the Irish general practitioners? Does this justify the banner headline: "Sorry, Mr. O'Malley, but 98 per cent say ‘no' to capitation"? If, as is very likely, those surveyed are all devoted readers of Pulse International—since readers of that journal are continuously subjected to pressure by articles from anonymous contributors favouring fee for service—the validity of the survey's findings is open to question. It is a pity this kind of pressurising should be going on in advance of negotiations. I hope the majority of Irish doctors will not be influenced by the publicity given to it—that they will study the matter in a dispassionate, unbiassed, unprejudiced manner without prejudging the issues involved.
I should like to refer briefly to some of the other points made by Senator Alton. He suggested that instead of giving relief in the purchase of drugs to the middle income group when private expenditure has exceeded a certain sum —as set out in paragraph 55 of the White Paper—relief should be given when private expenditure on drugs had exceeded a fixed proportion of the person's income. I see merit in that; but I see, too, that it would be a very difficult system to administer. If the fixed sum mentioned in the White Paper is not too high—I do not intend it to be—there should be no hardship on any member of the middle income group in the application of the idea, which has the merit of simplicity. I am not binding myself to this but it is only fair that I should say in a detailed way what I have in mind as far as assistance for the middle income group towards drug supplies is concerned.
As a result of the recent Health and Mental Treatment (Amendment) Act, those with an income of £1,200 a year and under qualify for hospital services. It is interesting, and Senator McQuillan will notice this, that the old system for calculating income has gone. No longer is the family income pooled. Now it is only the individual's income or the income of the man and his spouse that is taken into consideration. Those with an income of £1,200 a year and under, whom we would regard as the lower and middle income group, represent about 92 per cent of the population. They are entitled therefore at the present time to the benefits of the Health Act briefly as follows. The lower income group are entitled to free public bed hospital services. The middle income group can be charged up to, and not more than 10/- per day for such services. They have to pay their own general practitioner.
In the White Paper, of course, we propose to continue the hospital charge of up to 10/- per day. In actual fact 60 per cent of the population are paying nothing for these hospital charges which is absolutely ridiculous. We have to draw the line somewhere. The maximum charge of 10/- per day cannot be said to be a hardship and it has been in operation for quite a while. One would not live at home on that.
What happens if a person is earning nothing; would he have to pay 10/- a day?
If a person is not earning anything, he automatically will be entitled to absolutely free treatment in all respects.
That is not my experience.
The Senator could be correct because different local authorities had different scales. You could, for instance, get some genius of a county manager who in his wisdom refused medical cards to old age pensioners. Fortunately, the vast majority of these people act in a Christian way. But, when you have exceptions like I speak of, you have to study the position closely. And as I said in the Dáil, we propose to get into every house in the country a document in simple ordinary parlance telling each individual what he or she is entitled to. The big expense in the middle income group, therefore, as far as my experience goes and as people on both sides of the House have agreed, is the cost of drugs and medicines. This is the crippler. It can be a continuing cost; it can go on for a long period and it is here we propose to give assistance.
Let me say, without binding the Government, the Minister for Finance or myself, what I have in mind, what I hope to achieve. Some medical preparations cost a lot of money. Supposing, for the sake of argument, a person has to pay out of his own pocket say, £3 a week for drugs and this looked like being the demand on his resources for some time ahead, and such a demand was not within those resources to bear, this is where I propose that the health authority would come in and meet say half the cost in excess of an agreed sum.
It could happen that the cost of medicine would be as high as 10-12 guineas a week. Half the excess over the agreed sum could in that case still be a hardship. To cover such a case, it would be only reasonable to invoke a hardship clause which will still be preserved and so give greater assistance. What I want to do is to prescribe a standard of assistance which will be available to everybody and to leave as an option to the different health authorities only the extent of the additional assistance which they will give in hardship cases. We will set out the basic standard in black and white and it will be the exact same for a person in the city as in the remote parts of rural Ireland.
I am referring to the points made by Senator Alton in, I trust, not a destructively critical manner. I have already complimented Senator Alton on the tremendous research he put into the speech which he made here on the 12th May. It has been of great assistance to me. I have read it assiduously and I have learned a lot from it. There is a lot with which I do not agree, but I am grateful to him and if, at the outset, I spoke in a harsh manner about the method of payment to doctors, it was only because I wanted to make it clear that if he comes back on the same line again, I shall not hestitate to tell him that he is riding the wrong horse.
An incurable disease apparently.
Senator Alton mentioned a proposal for a national formulary. He said, as far as I recollect, that he hoped that the body entrusted with the drawing up of the formulary should include practising doctors in general practice and in hospitals. Yes, that is the intention. That will be done. It is quite logical.
Senator Alton said that 200,000 extra people have recently been made eligible for hospital services and that no compensation has been offered to the consultants. This is not absolutely correct. I do not suggest that Senator Alton is deliberately misleading the House. There have been a number of full discussions with the medical organisations on this. I told them that if it is shown that the consultants' income is materially affected by the change, I fully accept that they should be compensated.
A lot of people here do not know what I am talking about. That is not strange as when I came into the Department of Health I was not too sure myself and indeed I am learning every day. The health services of this country are a complex problem. The point made by Senator Alton was that before I came along with the Health and Mental Treatment (Amendment) Act, 85 per cent of the population of this country were eligible for hospital and specialist services. That is so. Senator Alton's point is that I have deprived the specialists, by increasing the eligibility limit from £800 to £1,200 a year etc. and that I have taken a percentage of the population, approximately seven per cent, away from them. I cannot at the moment appreciate his point fully but he will be replying shortly. If the Houses of the Oireachtas pass an Act it does not mean people are going to get sick more frequently or less frequently. They will still continue to be ill and therefore they will be treated by doctors. Someone, whether it is the specialists, who maintains that seven per cent has been taken from them, who are going to continue to treat the patients. That is right, and they are going to be paid.
I can see one thing, however, and I may as well be straight about it. A farmer comes up from the country and he is paying a doctor—it might not happen in Dublin, but in Limerick— and he will say to the specialist "What do I owe you, doctor?" I suppose if it was a major operation it might be £50, and the farmer will take out a roll and peel off five £10 notes. Let us be straight about this—is not the big nark of the specialists that I have stopped this source of ready cash on which they will not pay income tax while we are all caught? Is not this the truth of the matter? Is not this the big crib?
What if he is insured in the Voluntary Health Insurance, as most of the people are?
I can see that Senator O'Quigley is entitled to his little plug and his commercial for the former Minister for Health.
I am not making a plug. All I asked is a statistical question.
The Voluntary Health Insurance organisation was initiated during the period of office as Minister for Health of the Senator's Presidential candidate.
Keep politics out of this. You are talking about ready cash. The Voluntary Health Insurance pays by cheque. That is the difference.
I would commend to Senator O'Quigley the White Paper on the health services and would advise him to read very avidly the debate in the Dáil and the excellent constructive contributions by all Parties, and having looked through the various points made I do not think he will be so naïve as to suggest that there is no merit in what I have said.
I am talking about the question of income tax on cash payments.
Does the Senator agree that the point I made is a valid one?
We shall deal with that later.
That is a typical lawyer's reply. If we are going to have a discussion on things I hope that this is the place to discuss them and to have an open discussion.
The Chair would rule me out of order, I have no doubt. The debate cannot be conducted in the House by question and answer. I speak as of the Chair.
Surely that is a matter for the Chair, unless the Senator has ambitions in that direction. It could happen, too. To get back to Senator Alton, there were some matters mentioned by the Senator in relation to the efficiency of hospitals so I must comment on them. He seems to have gone out of his way to attempt to show that local authority general hospitals are inferior to the voluntary general hospitals. I do not know why he is making this point. As far as I am concerned all hospitals are contributing to the health service. I think the voluntary hospitals of this country have done, and are doing, tremendous work, but I cannot see what is going to be achieved by comparisons which are unfair for obvious reasons. Very many of the specialist staff of the local authority general hospitals are no less competent and no less conscientious than their professional colleagues in the voluntary hospitals, and I am sure they will not agree with the point put forward by Senator Alton.
To prove his case that the voluntary hospitals are more efficient than their local authority counterparts he quoted certain statistics about the length of stay of surgical patients in what he describes as his own hospital and what he describes as a regional hospital in Dublin. If the comparison were valid there would be some point in it, but is it valid? Do the surgical beds he mentioned—I presume it was the Mater——
Yes.
——include ENT beds dealing with large numbers of children having their tonsils taken out? These operations involve only a very short stay and this would reduce the average.
Not a large number— the smallest number of ENT work in Dublin.
That may well be but, nevertheless, they are there.
It is very small, and not a big part of the work.
Yes, but in instances such as this where the Senator has chosen to compare one voluntary hospital with a local authority hospital, and when he says that the numbers are small in ENT in the Mater, nevertheless he will agree they affect the average when arriving at certain statistics. In the regional hospital he refers to—I suspect it is Saint Kevin's——
It is.
——is the type of patient dealt with there similar? You could hardly say that the type of patient dealt with in Saint Kevin's is similar to the Mater patient—let us face the facts——
In the main, yes.
——in the Mater considerable numbers of them are otherwise healthy patients but only need to have their tonsils whipped out. I might say, and I think that Senator Alton might well agree with me, that it was I who gave him those statistics and he has used them back on me in a different way.
I gave you credit for them.
I am not giving him credit for the manner in which he used them.
Perhaps the Senators would address the Chair?
Yes, sir. Anyway in Saint Kevin's is it not likely that it is necessary for social reasons to keep the patients longer in hospital than in the Mater? That is not criticised, I trust. Further, if patients already in Saint Kevin's for other than surgical reasons are admitted to the surgical unit for operation and there is not pressure on the surgical beds at the time, does it matter whether the patient is kept in the surgical unit instead of transferring him back to another part of the hospital? Surely that is reasonable.
As I said on the 12th May, I regard myself more as a willing listener to this debate and I do not think it appropriate that I should deal at length with the points made by all the Senators who have spoken on the Motion. What they have said has been carefully noted and when I return to the Dáil with the Bill to implement the White Paper—I hope in November next—I am sure all those points will be debated in the detail appropriate to discussion on a Bill. I think I should also say that both in the Dáil and in the Seanad I have heard some excellent constructive suggestions which I hope to incorporate in the new Health Bill when it comes before the Houses of the Oireachtas in due course.
The White Paper itself—as I have said time and again—is not a bible, it is not anything hard and fast; it is just an indication of what the intentions of the Government are. Having received very wide discussion by all interested parties, organisations, professional bodies, members of the Houses of the Oireachtas and members of health authorities, I shall obviously make certain amendments and have certain improvements included in the Bill. I think, too, that there is a lot of uninformed criticism by members of health authorities. Some of them discussed the White Paper and they did not have it before them; this criticism must have been from what they read in the papers. I propose, in September next, to visit every health authority in the country with my officials and answer any questions they may wish to put to us. They may have problems unique to their own areas and there may be some proposals in the White Paper which would not be workable in their opinion.
I would repeat one thing—that on the question of the abolition of the dispensary doctors I agree that there are areas in rural Ireland where something on the lines of the dispensary system must be preserved. There could not be such a thing in those areas as choice of doctor. It would not be feasible. It is hard enough to get a dispensary doctor, God knows, in some of those places without talking about a choice of doctor. We are also aware of the fact that to get a doctor in some of the isolated rural areas we will have to give them a very substantially increased subvention or bonus to live in those areas because after all a doctor, apart from his basic salary, is supposed to enjoy a private practice. Naturally, if the population is sparse it is only fair that he would be given this consideration.
Anyway I think the White Paper has been received very well generally by everyone. People have to get in their little political digs and who said what on such and such an occasion. I forgive and overlook that.
That is magnanimous of the Minister.
I know everyone does not agree fully with everything in it but I am confident that after the discussions on it in this House and in the Dáil and the consultations which I intend to have with health authorities and the other interested bodies I mentioned, I shall be able to introduce legislation which will recast our services so that they will fully meet the standard required for our country in this age. I might say I do not believe the Health Bill I will bring in in November next will be the be-all and end-all for health services in this country. I do not know what is the matter with Senator O'Quigley; whether he does not want me to bring it in or whether—as has been said by some of his colleagues—he thinks this will never see the light of day; live horse and you will get grass; where will I get the money and so on.
I am merely agreeing with the Minister that his Bill will not be the be-all and end-all; that is for sure.
I am glad Senator O'Quigley interrupted me because it is my turn to introduce a little tone of politics for a second.
——that would be a pity.
I cannot resist Senator O'Quigley's little interruption. I got slagged by the Senator's Presidential candidate and he said I stole his ideas and that he invented this White Paper, although he merely cogged it from the Labour Party in 1961. What he said in 1961 he cogged from the Labour Party in 1958 but the point I am trying to make is this —he then said—"I propose a choice of doctor"——
He proposed it in 1957—eight years ago.
The Senator is getting confused now. May I inquire from the Senator what month in 1957?
While he was still Minister for Health and before he left the Department of Health he promised a choice of doctor to dispensary patients.
I am afraid the Senator is very badly informed on this matter. I shall explain what happened here. The Senator's Presidential candidate was Minister for Health——
From 1954 to 1957——
From 1954——
——and implemented the Health Act of 1953.
He was Minister for Health from 1954 until the early days of February, 1957. That time stands in my mind because of the 97,000 unemployed and the emigration—I have to get this little part in to balance Senator O'Quigley's contribution. Emigration was running at the highest rate since the Famine. That is why the early days of February, 1957, stand out in my mind.
There were more houses being built in 1957 than there ever were.
The Chair could not possibly allow me to go into a debate on housing or the building industry but I should like to have the opportunity on any occasion or on any forum which the Senator would suggest and he would come very badly out of that.
Preferably on Telefís Éireann.
I was on that too. The Senator's Presidential candidate was Minister for Health, as I said, from 1954 to 1957. During that period did he do anything about giving the people of this country a choice of doctor, wiping from the face of this country what he described as this iniquitous system which we inherited from the British—this dispensary system?
He was implementing a Fianna Fáil Health Act.
He was so busy that he could not deal with the upper stratum. He brought in the voluntary health insurance——
Which cost nothing.
He started at the top. What about the less well off members of the community?
He established a committee to investigate fluoridation.
Deputy Ryan must not have known about that from his subsequent reaction.
To inquire into fluoridation. If the Minister wants to talk about that I can say that his own officials with their technical experts did not know what fluoridation consisted of.
When I became Minister for Health I had to be very careful, and I read through all the speeches of my opponents and predecessors in office. Fine Gael will claim things which suit their own purposes. Senator O'Quigley mentioned fluoridation. That was a tremendous measure. I was not aware that the Senator's Presidential candidate proposed it, because if he did he deserves great credit for it.
He established a committee to inquire into it.
The Act was a very good measure indeed.
He did that among other things.
We brought in the Constitution in 1937 which was vehemently opposed by Fine Gael throughout the length and breadth of the land. They are now quoting it and throwing it back at us.
We accept the verdict of the people and Fianna Fáil do not. The Constitution is the Constitution of the people and we accept it whatever criticisms we have of it. That is the difference between us and Fianna Fáil.
I am very grateful to Senator Alton and to the other Senators who spoke. We are all very anxious to see improved health services. I was interrupted in my intention to conclude my remarks on the White Paper by saying that the health legislation we shall be bringing in, in November of this year, will not be the be-all and the end-all. Medicine, hospitals, hospital design, health services generally will improve as well as the standard of living of our people. Design of hospitals will change. There will be new methods, new inventions, and new drugs on the horizon, such as those which have almost wiped out TB. Although it is still quite a serious problem it is not anything like as intimidating as it was in the past, although I do not want to be complacent about it.
The point I am trying to make is that there will be further improvements in the years that lie ahead, and I am sure that whatever Minister for Health and whatever Government bring them in, they will all be advancements. I am grateful to the House.
It is very difficult to get annoyed with the Minister although he does not seem to have much difficulty in getting annoyed with some people. He put on a great show of getting annoyed with Senator Alton early on in his speech. Indeed, one might almost imagine that Senator Alton had signed the Presidential nomination papers of Deputy T.F. O'Higgins. However, the Minister has given some indication of his interest in improving the health services of the country. I suppose there are few more fertile fields in which any Minister can work than in the field of the health services. I am not going into past history because I am concerned with the present and with improvements in the future. Of course, it is quite true to say that the Fine Gael Party will not oppose the White Paper on the Health Services because everyone knows that half a loaf is better than no bread. If the Minister offers us half a loaf, or even perhaps threequarters of a loaf, we are not the people to say no to that——
It depends on the size of the loaf.
——even though the loaf is a bit stale, because what is contained in this was fresh and palatable eight years ago.
The Senator must be reading "The Best of Myles".
I have not time with the Presidential election upon me.
The Senator will have plenty of time from 2nd June.
If the Minister is correct in saying that the Labour Party adumbrated the bones of this scheme—and I do not concede that— it does not matter who outlined it. It was there, and the Minister for Health who stared death in the eye for Ireland was so mesmerised by his former glories that, although he was Minister from 1957 to 1965, he did not adopt what had been put forward either by the Labour Party, by the Fine Gael Party or by both. It took the new Minister to do that. That is an argument against putting old people in high office. The Minister might agree with that.
By the time I am finished the Senator may be sorry he did not keep old people in high office.
The Minister has shot his bolt. From 1957, the then Minister for Health played around with the Committee. In one year he was not able to convene a meeting of the Committee because, as he said, there was no room in which the Committee could meet, whereupon Deputy T.F. O'Higgins offered him the Fine Gael Party room to meet in. Whether this is a product of the Labour Party or the Fine Gael Party, makes no matter. This health scheme was available to be introduced by the then Minister for Health seven or eight years ago. I emphasise again, without wishing to repeat myself, the danger of putting old men in high office.
The Senator will never learn.
The Minister introduced this White Paper and then went on television, and through courtesy of television, he was discourteous to the medical practitioners of this country.
In what way?
I shall return to that. The Minister said that five per cent. of the medical practitioners were pigs.
No. I said five per cent of the medical practitioners treated some of their patients like pigs, and I may have made a mistake in the percentage.
The percentage may have been even higher? Is the Minister prepared to revise his estimate of five per cent and bring it up to ten per cent?
The Senator may take it whatever way he likes.
I want to know if the Minister wants to revise his figure of five per cent to seven and a half per cent, or ten per cent or 15 per cent.
Statistics have to be constantly brought up to date or they would lose their effectiveness.
I should like to know what is the percentage of medical practitioners who treat their patients like pigs. If the Minister wants to revise his figure upwards I do not mind, because I hold no brief for anyone.
If the Senator wants to know, I am continually getting evidence on the matter.
Does the Minister want to revise the percentage from five per cent upwards?
If the Senator were a non-paying patient he might be able to make an estimate.
If the Senator wants to know the truth I am getting evidence weekly of doctors in this country treating their poorer patients in a most callous, uncivilised, and unchristian manner.
I want to know from the Minister if he wants to raise the figure from five per cent to seven and a half per cent, eight per cent, ten per cent, or 12½ per cent. If he does not wish to avail of the opportunity to revise the figure, I do not mind. The Minister said that five per cent of the doctors—and he was talking in particular I think about dispensary doctors—are treating their patients like pigs. He was right in that or he was wrong. If he was wrong——
I did not say they were pigs.
That does not make any difference. I do not mind whether the Minister called them pigs or said that they treated their patients like pigs. It does not matter a damn to me. The thing I am concerned with is either they were pigs in the way they behaved towards their patients or they treated their patients like pigs. The Minister can take his choice. That remark is regarded as so scandalous that not one Irish paper published it. They felt if the Minister wanted to throw mud like that he could do it on television but they were not prepared to publish it.
I now want to develop my argument. First of all, if the Minister is wrong in saying that five per cent of the dispensary doctors or the general practitioners in this country treat their patients like pigs, then it is a very wrong and a very serious thing that the Minister should say what is wrong, that is, five per cent of the doctors treat their patients like pigs. If the Minister is right what is the Minister doing about it and what has the Minister done since he discovered this on taking up office? I remember when three or four doctors in Galway were accused of charging fees when they were not entitled to charge fees. That, of course, is quite wrong. They should not do that. The then Minister for Health, Deputy MacEntee, held a public investigation that went on for days. To me, charging fees is a matter of no account compared with treating patients like pigs. The Minister has said that five per cent of the doctors were treating their patients like pigs. If that is correct what has the Minister done about it?
The Senator is talking absolute nonsense.
That is what the Minister said. He said that doctors were known to him who treated their patients like pigs. The Minister regards himself as a wonderful Minister for Health yet he allows this to go on.
I do not regard myself as a great Minister for Health.
The Minister knows that is going on but he has done nothing about it since he took office as Minister for Health. He made that statement so that he would exasperate the doctors.
Will the Senator allow me to answer?
No, I shall not. Debate is not conducted in this House by question and answer. The Minister for Health has known this was going on and yet he did nothing about it.
Can I answer the Senator?
No. The Minister had his opportunity.
Perhaps the Senator would get on with his speech.
I do not find anything in this White Paper referring to the five per cent of doctors who treat their patients like pigs. If that is correct surely something should have been done about it.
It is not Scéim na Muc.
If that be a correct statement of the situation, then the Minister is in grave dereliction of his duties. There is nothing in this White Paper to indicate what the Minister is doing about it.
We are making great headway.
I believe that is a calculated statement made by the Minister for Health for the purpose of irritating the Irish Medical Association and the Irish Medical Union.
That is very wrong.
This is a good excuse for not introducing a Health Scheme. The Government are short of money. Because of that the Minister for Health cannot introduce his Health Scheme. Therefore, his statement that five per cent of the doctors were treating their patients like pigs would create a row with the Medical Association and the Medical Union. He could say: "What can I do? Look at those fellows. How can I implement a Health Scheme with those fellows?" The Minister's remarks here today were directed towards the same end. The Minister knows, even if he wanted to introduce a good Health Scheme, that there is not any money available at the present time to implement any of the proposals in the White Paper. Having said all that, I want to commend the Minister for Health and the Government on the introduction of this White Paper. The Minister has referred to the county managers continuously as geniuses. The Minister should get as wide a volume of opinion as possible as to what is the best way of producing good health services for this country so that when anybody comes from abroad we can say: "This is the way we treat our old people; this is the way we treat our mentally handicapped people".
It is for the people here we should be proud to have good health services. We are not on exhibition to those from abroad.
I thought, in another context, the Minister was talking about the people from abroad, particularly with regard to the Presidential election.
I had three brothers solicitors who used to go on the same way as the Senator. The Senator is getting confused.
The Minister should not talk in that way about solicitors. There was a time when the Minister was glad to have the services of a solicitor.
That is not Christian charity on the part of the Senator. Any mistakes I made I paid my debt to society for them, not like some of the Senator's friends in the Fine Gael Party.
I am merely trying to say that solicitors have their uses.
The Senator is full of Christian kindness. Everybody knows exactly what the Senator meant when he made that remark.
The Senator must be allowed to make his speech without interruption but the Senator must come to the point.
The Senator has been personally hurtful and insulting.
The Senator has no interest in the White Paper.
He has no interest in it at all.
I want to commend the Government and the Minister for laying the proposals in the White Paper before Oireachtas Éireann. I particularly want to commend the Minister for introducing the White Paper.
I do not want any commendations from the Senator.
It is right and proper, before the proposals in the White Paper become crystallised in a Bill, that the Minister, his advisers and the Government should have the widest variety of opinions and experiences that can be obtained. Some of those can be obtained in this House and in the Dáil. If the Minister proposes to see all the health authorities and some of the local authorities who are not health authorities that is all to the good. It is right and proper, as I say, to commend him for introducing this White Paper. I doubt whether what has been said in various places is having an impact on the Minister as he has already conveyed in his speech this afternoon. As I say, at the present time, there is a great shortage of money and that shortage is likely to exist for an undefined period to come. I detect also that the Minister is beginning to have new views about the method of financing the health proposals. I again commend to him——
Another of your geniuses has come in to join you.
Apparently the Minister came in here in a rumbustious mood. I said something he did not like and he is not able to take it.
Will the Senator please confine himself to the motion?
I shall deal with the Senator in my own way, and let him remember that.
As long as it does not come to blows. I will not be browbeaten by the Minister.
Will the Senator please comply with the rules of order?
I trust I will not be interrupted any more by the Minister for Health.
Perhaps the Senator would cease baiting the Minister for Health.
I am not exactly baiting the Minister for Health. I am merely debating the White Paper.
That is what the Chair would wish.
When I proceeded to commend, as I wish to do again, the Minister and the Government for laying a White Paper before the Houses of the Oireachtas while speaking to a motion that welcomes the proposals in the White Paper, exception was taken to that course of action. I think it is a good thing that proposals of this kind should be incorporated in a White Paper before being crystallised in the form of a Bill. When a White Paper is laid before the Oireachtas it is open to debate and there is no loss of face on the part of the Minister if he says: "I have listened to the debate. I do not think well of this proposal or that proposal. Such and such a proposal would be better. I think such and such a proposal is a good idea and shall incorporate it in section so and so of the Bill". That is the kind of thing we regret was not done in relation to the Succession Bill. The first Bill had been crystallised before we got it and we found it impossible not to change some of the malevolent provisions of that Bill.
I join with Senators Alton and Sheldon in welcoming the proposals contained in the White Paper in so far as they go but I must confess that it would be a very good thing if the Minister for Health were to familiarise himself again with the proposals for insurance as a basis for financing the health scheme. These proposals were outlined, according to the Minister, by the Labour Party before the Fine Gael Party, before the paper of Deputy T.F. O'Higgins on health. I detect in the Minister a feeling that these proposals are not the last, that he may well move in the direction of financing this scheme, perhaps because of the exigencies of our financial circumstances, on the basis of insurance. If he does that, I assure him that as far as I am concerned I shall not say a word to the effect that it was our proposals or the Labour Party proposals that started it. All I shall do is commend the Minister for adopting these proposals.
It was a source of some disappoinment to me to find that the Minister in his White Paper had not adverted sufficiently to the condition of old people. I think a very good test of any man or woman, son or daughter, son-in-law or daughter-in-law, is the respect they pay and the tolerance they show and the patience they accord to old people. That is the great test of the family. It is also the test of a nation. The respect it shows for its old people and the provisions it makes for their well being is in my view a great touchstone of the moral standards of a nation.
I regret to say that in this White Paper we do not find any elaborate provisions of a detailed character for old people. One can read from page 44 to page 47 of the White Paper merely an expression of a vague feeling that something should be done, that some little money should be provided, that the Government will encourage voluntary organisations to provide the most effective system of home aid for the aged. I do not think we can dismiss a growing population of old people in a few pages of a White Paper. Their problems are too serious to dismiss, too varied to be covered in the few paragraphs devoted to them in the White Paper. I have a recollecteion of reading in the newspapers that the Minister for Health discovered some old lady in Limerick. He was like St. Paul after Damascus. He had seen the light. He had never known before that old ladies living in small, unheated rooms spent their evenings in churches telling the beads because they did not have sufficient fuel or comforts in their homes to stay there. The Minister announced this with the frankness of a Saul turned Paul.
He did not suggest taking a shilling from the old age pensions as Fine Gael did.
I confess he did not do that and I confess what I am talking about is not what happened in 1925 or 1927. I am talking about something that is here and now causing pain and distress to old people. What happened in 1925 or 1922 is of no avail to people who are hungry, cold, suffering physical and mental privation, people who are senile before they should be. If the Senator wishes to go back to 1925 he will find there is not an old person in the country who will be one whit the better for one single bit of what happened in 1925. What I am concerned about is what the Minister for Health proposes to do for the old people. I find in the White Paper that what he proposes to do is distressingly inadequate. He merely gives expression to a feeling of dissatisfaction with the way old people are being cared for.
As a lawyer I come across a great variety of people. I have to deal with workmen for half an hour and the next time I am in court I have to act on behalf of an old person who signed away her farm or house and the son-in-law finds her an intolerable burden —an old person who is trying to get back her farm or house. I should like to refer to the case of an old lady who slept with a dog to provide her with sufficient warmth. That is the kind of problem we should be concerned with, not what happened in 1925. That old lady slept with the dog in bed to keep her warm. She was too senile and too far gone in mind to get her neighbours to do anything. She did not have a fire to heat her.
They are the people we should be dealing with and not with the happenings of 1925. I do not find anything in the White Paper to deal with the condition of the large numbers of old people whose sons and daughters have left the farms because they could not get a living, old people whose spouses have died and whose children in England have not come home. They are removed from the kindly ministrations of their neighbours, living perhaps on a mountainside. I urge on the Minister to conduct an early intensive survey of the conditions of these old people and to do something to alleviate their conditions.
There is reference in the White Paper to the mentally handicapped. We are told we can await a White Paper. I cannot understand why White Papers and reports published by the various commissions and committees, all of whom do admirable work, require such detailed and prolonged consideration by Government Departments. If I were in the Minister's position I would insist on early proposals from my official advisers. It is disgraceful that we provide no proper system of health or education for our mentally handicapped. In this respect, health and education are inseparable. Under our Constitution, which the Minister does not like us to accept for some reason or another, mentally handicapped children are as much entitled to a primary education, paid for by the State, suited to their particular condition, as are the healthy minded children of the country.
We have failed and failed disgracefully in relation to this country's mentally handicapped children. Equally, it can be said we are failing in relation to the physically handicapped among us and there is nothing in this White Paper that I can find to deal with physically handicapped children or physically handicapped people.
There is also one paragraph devoted to the school medical examination and treatment services. The Minister has been giving statistics. It seems to me, and I speak merely about the services provided in Dublin, that the examination of children in the national school is merely another exercise for the purpose of providing statistics for the Department of Health.
I have children going to a national school and I can tell the Minister that one of them was suffering from an ailment that must have been diagnosed by the school medical attendant. I never heard anything about it from him. It was quite by accident that the child around the same time was referred to our local general medical practitioner. She diagnosed it and then we had weeks in and weeks out in the children's hospital in Harcourt Street.
I do not know what they were doing at the school medical examination. We signed forms to have the children examined; they were presented for examination but we never heard a word since as to whether they were in good or bad health. It is not confined to that one child. There is another child who had another ailment of a passing character. The ailment of the first mentioned child was of a more substantial character. The latter child was quite ill on the day he was examinted but at any rate we sent him out to be examined like one of his fellows in his class. But, there has been a great silence since then.
If my recollection is correct, I think I wrote to the county council to get a report on those children but I never got a reply. I know, of course, that in other cases children's ailments have been diagnosed and rheumatic heart disease or incipient rheumatic fever has been detected. But what is the purpose of these examinations if we hear nothing, if the parents having filled in the forms are not told that if they hear nothing they can assume the child is all right? If there is something wrong the authorities should write to tell the parents what they ought to do.
I would commend to the Minister that he make it obligatory on the health authorities, if they are spending money in conducting examinations, to make some report to the parents. After all, it is the parents who have to look after the children day in day out. As I have said, had it not been for our own private medical practitioner we would never have known what particular ailment that child was suffering from, which we took steps after to deal with. There is a grave defect in the medical services provided in the schools if that attitude is in any way general. I have no reason to believe that my children were singled out for any kind of unfavourable treatment. I think this is the system. In relation to that kind of thing, I would suggest there should be some liaison between the Department of Health and the Department of Education.
I have seen many national schools and I will ask the Minister for Health to find out from his colleague, the Minister for Education, how many times in the year are the windows cleaned in national schools in the country. I do not mind whose responsibility it is but in how many schools on the 19th November, to take a random date, at 11 o'clock is there light for the purposes of reading? In how many offices all over the country is there light on the 19th November at 11 o'clock for reading? It is necessary, but still we expect our children to go into schools—some of them are perhaps short-sighted, some long-sighted and some of them suffering from astigmatism—where their health is being impaired through lack of lighting.
Under the Offices Act which was introduced by the late Deputy Norton and pushed through by the present Government there was a standard laid down for lighting in offices but there is no standard for lighting laid down for national schools. There is no point in sending doctors around to examine children and prescribing glasses when we will not provide proper lighting in the national schools. These are the kind of things an alert Minister should deal with.
The light can be switched on; it has nothing to do with the Minister.
Is preventive medicine not a part of the health services?
The teacher could switch on the light.
There is no lighting in the schools.
No electricity? There are not many schools without electricity.
The Senator I am afraid is not au fait with conditions in rural Ireland.
They must be as bad as the courthouses in rural Ireland.
Rural electrification has nothing to do with the Minister for Health.
Is prevention not better than cure? The Minister has been forced into a sulky silence and I appreciate Senator Yeats coming to his rescue. However, the Minister may revive.
On the question of the fee for service, I have not read what Senator Alton said on the last occasion and I do not know what is the best system. I do not know what system would suit doctors and I do not know what would be the best system for the patients. That is a matter on which I have not sufficient knowledge to offer an opinion. But, when I hear the Minister for Health ranting about people and expressing in a trenchant form his views characterising them as pressure groups, I do not think it is the most tactful way in which to lay the ground for fruitful negotiations with these people. Let them say what they want. Let them clamour hither and thither but eventually what happens is the Minister must get around the table with the medical association, the local authorities and his advisers and all the talk and all the noise and all the pressurising would be of no avail to sensible men. Eventually they will have to sit around and work out a sensible solution to the problem of the needs of this country. I do not think for a moment that the Minister does the medical people any service and he certainly does not add service to the patients of this country by exacerbating the feelings of the people with whom he will associate.
Senator Alton is a medical doctor elected by the medical representatives of the National University of Ireland and what else would he do in this Chamber but express what he supposes to be the views of the people who elected him? What else would he do in this chamber but express what he believes to be the views of the people who elected him? What do the Labour people do? What do those people on the industrial and commercial panel do? What do the farmers do when they come up here but express in the most intelligent form the views of those people whom they are supposed to represent in this professional and vocational chamber? Then the Minister rounds upon Senator Alton as if he was most antagonistic to his political point of view. For a moment I was beginning to wonder. I do not think that that kind of approach is likely to produce fruitful negotiations.
I say it here and now, and this I shall repeat, that if the Minister fails to introduce and put through a Bill because he says that the Medical Association and the Medical Union are trying to make money out of the sickness of the people of the country and to trade upon the ill-health of the poor population— if he comes in and says that kind of thing and that for that reason he is unable to bring in a Health Bill—I shall point out to him that he has paved the way for unfruitful negotiations by the reference to five per cent who treated their patients like pigs and by his diatribe here against the democratic expression of view by Senator Alton on behalf of the medical people of this country.
I observe that we are making slow progress in relation to grants for multiple births. The Minister said that he is not under the domination of his Department and his Departmental officials, and one would welcome that being the position. Is it not remarkable that in paragraph 88 of the White Paper they say: "It is also intended to introduce an amendment to section 23 so that where there is a multiple birth a grant will be paid for each live-born child"? The typical civil servant comes to life in the words "each live-born child". Does not the mother who has the misfortune and disappointment of bearing a still-born child suffer the same amount, indeed more, than the mother of the live-born child? But the Departmental mind and the Civil Service mind says "This would upset a whole lot of new principles in giving grants for children who are born dead", and they put in "for each live-born child". This is not a very generous measure and it is certainly not the product of an affluent society. I would commend the Minister at least for going the distance of giving a grant for each live-born child. I go a further distance in saying that when a child is born alive, especially where you have twins and more especially triplets and in the exceptional cases, as in the Minister's own constituency, where you have quads, the burden thrown upon the parents rearing those children is quite exceptional, and I cannot understand the attitude of mind of the Minister and of the officials whether in Health or Social Welfare who have not at ths stage woken up to the fact that the mother of twins and triplets is quite unusually burdened in rearing those children.
Most mothers will tell you that to rear one child at a time is quite sufficient. You sometimes hear mothers talking about the problem of having three in three. I heard recently about four in three, which is a remarkable business. Where you have three in three you hear from time to time from mothers that they do impose great stress on their physical resources, their emotions and everything else. We in this country sit back and are not able to rejoice with nature when there are triplets and quads and provide the parents of those children with exceptional grants to meet the kind of real physical difficulties that they have in rearing those children. I wish that any Minister would amend section 23 in order to provide the most liberal grants for triplets and quads, and I do not think that there is a single person in either House of the Oireachtas or anywhere else in the country who will say that he is being extravagant in providing that kind of grant.
On a point of order, I cannot see what is on the other side of what the Minister is reading but on my side it says "Crisis and picket line in Malawa". Is the Minister in order in reading what he is reading? Is it relevant to the debate and is he showing courtesy to the House?
What I am reading is what was referred to in the debate earlier, Pulse International—“No, Mr. O'Malley, 90 per cent say no capitation”. It was referred to by me on several occasions.
Is the Minister in order in reading it during the debate? The Minister may want to read about it himself but the question is whether this is the best place and occasion for him to read it.
When I want a lesson in manners I shall not ask Senator FitzGerald and I shall obey the direction of the Chair. This is entirely relevant to the point raised by Senator Alton and was among the matters mentioned by me in the course of my reply, or my attempted reply. I might say that my name only occurs once.
I did not address my remarks to the Minister. I put a question to the Chair and would welcome a reply.
An Leas-Chathaoirleach
The position of the Chair is always very difficult in regard to matters of this sort. In particular it is difficult when the Minister is not a Member of the House. The main concern of the Chair must always be with the matter of order in debate. The Chair may have views on what is courteous but is not able always to enforce them.
As I said, I do hope that when the Minister reads what I have to say if he does not hear what I am now saying because of his absorption in Pulse, he will in the generosity of his heart and at the expense of public funds provide more liberal grants for multiple births, especially triplets and quadruplets in this country, even in his own constituency.
It seems to me that the health services and their further development involve doing something about providing appropriate research that is necessary, especially for the particular type of diseases that occur in this country. I do not find anything in this White Paper dealing with research. I believe that the research workers of this country, as they have shown in both Trinity College and in the National University, provided with the appropriate funds can produce results comparable in different fields to those produced in other countries. There seem to me to be a lot of endemic diseases in this country which require a good deal of research, and it is a lack in our health services, especially in the field of preventive medicine, that nothing is being provided in that direction of a worthwhile character. Certainly there is nothing in the White Paper which would indicate a further development in that line.
Finally, one of the main criticisms of this White Paper is the fact that when people are in bad health in the upper income level within the ambit of the health services to be provided under this White Paper they will still have to worry when they are ill as to how much money they will have to pay for their maintenance in hospital. It is all very well for the Minister to say "It is only 10/- a week." It is very easy for the Minister, who has never known hardship and want, and has never found himself trying to make ends meet on a slender income, to say that this is no worry. But it is not all right for the father of a family of seven who may be paid part of his income when he is ill in hospital and who has to worry whether it is going to be 10/-, 7/6, or 5/- a day he will have to pay while he is ill in hospital. Of course the Minister will be aware that if the father of a family is involved in a road accident that he and his legal advisers—if he is taking an action— will receive regularly from the health authority a bill for £13 10s., representing 27 days at 10/- a day for maintenance in hospital. Of course, the man may have got no income at all during his sojourn in hospital. While the Minister says he should not have to pay anything, the health authority insist upon sending out that bill so that it can be claimed from the person who caused the accident and, subsequently, recouped to the health authority. That happens, in our experience, every day.
That is under the Road Traffic Act.
What is in the Road Traffic Act is a different thing and something which has never been implemented by the health authority. What is in the Road Traffic Act is a right on the part of the health authority, where a person is involved in an accident, to look to the insurer of the person causing the accident to reimburse the health authority for the hospital maintenance.
And thereby be recouped 10/- a day.
But I have never seen a single incident, in my experience, where a local authority has done that. They may be more alive to their legal rights in Tipperary than they are in the Corporation of Dublin, in the County Council of Dublin or County Council of Mayo, of which authorities I have experience, but certainly I have never seen the health authorities do that.
Is not that why the bill is sent out?
Under the Road Traffic Act the bill should not be sent to the person who is injured but to the insurers of the person who caused the accident. What is provided in the Road Traffic Act is not 10/- per day but the full cost of the treatment; that is what the health authorities are entitled to get but is something which the health authorities, in my experience, have never sought.
They are not entitled to it.
They are entitled to the full amount under the Road Traffic Act. There is no use in the Minister saying—"Oh, 10/- a day is nothing, you could live at home for that". When somebody gets sick in Belmullet, has to be transferred to Castlebar and sojourns there for 18 to 21 days there is no use in the Minister saying—"Oh, it would cost that to keep him at home". People have to visit him; there are always new pyjamas to be got; husbands do not go into their wives or wives into their husbands with their hands hanging, they buy a whole lot of things and these are the kind of additions which cause an imposition, readily undertaken by people and relatives of sick people. In a civilised community, when it is possible to do so, we ought to relieve people who are sick in hospital from any worry of that kind. God knows anybody who is sick has enough to worry about as to how soon and to what extent he will recover from the illness from which he is suffering. It is uncivilised, in my view, in modern times to have people worrying about the hospital charges they may have to face.
That, to my mind, is one of the great defects of this White Paper. I hope the Minister, notwithstanding all that has been said, will find it possible to revise his attitude in this matter and bring in a kind of health service—in so far as it concerns the ordinary illnesses in the home and the ordinary illnesses which require hospitalisation—which will relieve people from all financial worries in so far as these prevent them from recovering. If he does that kind of thing, he will bring in a much better Health Bill, which will require much less amendment, than the Bill he has at present in mind.
I welcome the opportunity to put briefly some points I think should be aired again at this stage on the question of health. Senator Alton, in his opening remarks, said that two matters caused great heat in Irish politics—one was the question of milk and the other was the question of medicine. I hope Senator Alton will remember that, because it is all very fine to come into this House and make an impassioned speech on behalf of a particular interest, but there are two sides to the story. I do not agree with the Minister in his views on health in general but I do agree with one statement he made—that the prime interest in health should be the welfare of the patient. That should be the decisive factor in the implementation of any health service. In any civilised community where that is put number one or given priority all the other things fall into their proper place. After that it is a matter of the interests involved fighting hard to ensure that they are not left behind and that proper regard is given to their position.
Senator Alton is a well-known medical man, for whom I have the greatest respect in his capacity as such. I cannot say the same when it comes to my views on him as a politician. He was elected by the graduates of the university and I must say that, since he spoke on this White Paper, a number of graduates have spoken to me—who played a prominent part in the election of Senator Alton—and they disagreed completely with his views on medicine. In fact, it would appear from his remarks in this House that, when the tapes went up, he was running, if you like, as a graduates' candidate for the university and when he came to the winning post he had donned IMA colours. I may be unfair to him but the reason I say that is that he himself said that health has generated heat in the past.
My experience of the health services in this country goes back a good deal further than most people in this House. I remember in 1951 when the first attempt was made to bring socialised medicine into Ireland. We had the unholy alliance, in my opinion, of the medical association and the hierarchy condemning socialised medicine on moral grounds. They were helped, of course, in this task of killing a first class health scheme by certain politicians who were, again, used as fronts or puppets, particularly of the IMA. I want to say clearly now that the blame for the disgraceful health service we have today must be traced back to those people who in 1951 sought to suggest that a socialised health scheme was immoral, contrary to the morals of the Irish people and that the period from 1951 to 1966, which is 15 years, was allowed to elapse in which people had to put up with very poor services; many people had to emigrate and secure the socialised services in Britain. I should like to know is there even at this late stage one iota of regret in the minds of those people who irresponsibly sought to finish for all time the idea of treating all the children of the nation equally in the question of health, as we should be doing also in education and other fields.
I want to make it quite clear that many of the people who stood by the idea of socialised medicine in 1951 are still prepared to stand by that view, and so far as it lies in their power, vested interests whose main purpose is to feather their own nests, will be opposed tooth and nail on local platforms, at public forums and in every democratic way, in order that the public will realise what is being attempted, and what they have in mind, to prevent the people from getting the socialised services to which they are entitled.
I have no objection to trade unions, be they the Irish Medical Association or the Irish Medical Union, making their case. To me the Irish Medical Association are a trade union and as such they are entitled to fight, and to fight in a courageous and bold manner, for the rights of their members, but they are not entitled to go further and suggest that they have the sole right to decide what the health services should be. They have no right to attempt to sabotage the health services. They have no right to set themselves up as being above society because in their profession they look after the sick. They have no right to expect the rest of the community to bow down before them as if they were some mysterious group of whom we should live in awe.
A case was made that the dispensary doctors and the district medical officers were a distressed group because of pending changes in the proposed new legislation. Senator Alton said that they have "accepted a rather quiet dull life in the country". I wonder how many medical doctors are prepared to accept that smug paternalistic description of these people who, to my knowledge, live anything but quiet dull lives in poor old rural Ireland.
The majority of the dispensary doctors are first class doctors who do wonderful work but, like other groups of men doing their work, they often allow spokesmen to arise on their behalf who do not represent their true interests. I have found that the majority of the dispensary doctors have spokesmen down in Fitzwilliam Square or elsewhere who on numerous occasions manipulate and utilise the dispensary doctors for their own ends.
Back in 1951 the majority of the dispensary doctors were prepared to operate the Health Bill although it was sought to suggest afterwards that they were against it. In fact, it was well known that at that time the people in Fitzwilliam Square, the Crescent in Galway, and similar places in Cork and elsewhere, were behind the opposition and led the fight against the implementation of that Bill.
I believe that when the case is put to them clearly the majority of doctors favour the idea of security. Many doctors in private practice show by their actions in later life that they are anxious for security. They like to come into the public services after a strenuous period in private practice. We all know from our acquaintance with medical people that there is no more strenuous type of work, or more dedicated work, than the work of a doctor in private practice in the city or in the rural areas. He is on tap at all hours of the day and night. He lives under constant stress. He has to worry about his family in case anything happens to him. He has to insure himself and to look after his own interests. If he is ill for a period someone else may come in and take his practice. We talk of the instincts of humanity and this applies to doctors as well as anyone else. Doctors like to have a sense of security and proper remuneration with some form of superannuation afterwards. In those circumstances great work is done, there is a more relaxed frame of mind, and the best possible attention is given to the public.
These medical men must be well remunerated. I will not put a figure on their services but I will say this: they are not entitled to put a figure on their own services by setting up what I describe as their own personal means test to be carried out on each individual patient who comes before them. The difficulty is that sometimes in private practice, or in areas where there are doctors giving part time service to the public authority, or in the upper echelon, there are consultants who are, in fact, far more skilful than the local pensions officers in getting a detailed picture of how many hens a person has and how many eggs a year they lay.
Senator Alton made the case that a capitation approach to payments was not successful in Britain and that there was great dissatisfaction about it among medical men in England. He said that the medical profession would not like to see a capitation system brought in here to a great extent. He went back to the 1948 period when Nye Bevan was in Britain and he said that Nye Bevan implemented the 1948 Health Act against the wishes of the Labour Party. I always had a great regard for Nye Bevan but I never realised that he was such a single-handed wizard or wonder that he was able to implement the Health Act against the wishes of the Labour Party, and I presume of the Conservatives as well. I do not accept that view, and I do not think Senator Alton was serious about it either.
Let us be quite clear about this. Senator Alton made one good point in his speech so far as capitation was concerned. He said:
It was not so bad in England where everybody, 100 per cent of the population, were put on the capitation system. Here, however, we propose to put only 45 per cent under the system and we shall thereby immediately create this second group again.
I am with him so far as the segregation and the differential involved are concerned. He left the door open when he said: "It was not so bad in England where everybody, 100 per cent of the population, were put on the capitation system." I do not want to see two or three different groups, or what I call two or three tier medicine available to the people. I mentioned the rights of the citizens under the Constitution. I do not believe that we should tolerate the idea that there should be a different type of medicine available for people according to their status in society.
Let me clear the air somewhat as far as that is concerned. The best example I can give of my idea about that is the voluntary health service. Here we have a health scheme run on what is known as the unit system. You pay for so many units for maintenance and the cost of upkeep in hospital. You can take so many units regarding an operation, for instance. I think most people will agree that if a person wants to travel in a train first class that is his business. It should be the right of everybody to travel in a second or third-class carriage if he wishes. As far as public hospitals and public wards are concerned it should not count whether a person is a £10 million a year man or a 10/- a year man. Public wards are available to all. If somebody wants privacy or wants luxury in his surroundings in the form of attention he can pay for it. There is nothing wrong with that.
When it comes to an operation or specialist treatment everybody should be treated the same. That is the view I have always had and I regard the voluntary health system as very unfair in this regard. For instance, in the voluntary health scheme, if a person takes out, say, four units, where an operation is involved, and another person takes out two units is it not an extraordinary thing that for the same operation, say appendicitis, the surgeon is paid a different fee according to the number of units which the person has taken out? That is outrageous. It is no concern of the man carrying out the operation or the investigation whether the person has two units or six units.
I know perfectly well what happens. It is human nature. It makes a difference to the medical man whether his fee will be £25, £30 or even 10 guineas. That should not enter into it at all. That system, with regard to the voluntary health scheme, is something to be deplored. I believe Senator Alton, perhaps through his long experience with the voluntary health system and through his isolation from the rural community, feels that poor people become annoyed because they are asked to fill in certain details on a questionnaire, which the assistance officer has to fill up. Senator Alton said:
Perhaps it is the way he goes about the questions or perhaps it is the general approach. It may well be that a few words of explanation to those people beforehand as to why the questions are being asked or perhaps a course in public relations for those officials might go a long way towards solving this difficulty.
Why should there be questions asked? What is the point in it? The Senator bases his case on this. He also said:
I can never really understand this because through all our lives whether we are looking for a loan from the bank to buy a house or getting a car on hire purchase there is always the means test, no matter what class one belongs to.
How can you reconcile that argument with the health services? How can you suggest if children are going to a primary school that there should be a means test?
There is.
When it comes to education up to the primary school age we are all in favour of it.
There is no means test with regard to a medical examination in school.
There is no means test when the ailment is discovered in the course of the examination during school attendance but if the child is unfortunate enough to become ill outside that is a different kettle of fish. The means test then applies to the parents.
It is not applied.
Of course it is. I happen to be on a local authority. When we come to medical card holders as far as those people are concerned they are all ratepayers to the local authorities. They pay rates just the same way as the man with £60 valuation. Unfortunately, the man with the £60 valuation will have to pay for his own health services and he will also have to pay for the man who gets them free. The man with the £60 valuation should be facilitated and brought in.
If the Minister or his representative want facts with regard to this matter I can give them. The 10/- a day hospital maintenance charge is the maximum which can be charged. The Minister admits that 60 per cent of the patients do not have to pay it at all. The remainder have to pay 10/-or 7/- a day. I can assure the Minister that so far as the Roscommon local authority is concerned the collection of that 10/- or 7/- is costly. That is one local authority. I am perfectly sure that other local authorities are no different and that that is the position throughout the country.
We have a huge system of administration set up. We have a Frankenstein created in the form of investigation machinery. We must churn everything through that machine. Of course, this gives employment to the people carrying out the investigation. In my opinion, leaving the moral issue out of it, there should not be this means test. I do not want to say too much about the doctors but it is well known that they want to carry out their own means test because it is only natural that the people in the income tax department and elsewhere do not get the full facts of the shakehands between the patient and the medical man. All the pious talk and all the smokescreens in the world will not hide that.
That is not the system which operates with regard to the TB scheme. When a person becomes ill with TB and goes into a sanatorium, he is not questioned whether he earns £40 a week, £20 a week or even £7 a week. Nobody asks questions about that. The same treatment is available to all. There is no question of snobbery attached to this as there is in other forms of medicine. That system should be adopted so far as the other services are concerned.
I opened my remarks by saying to Senator Alton that this is a very touchy subject indeed. I am speaking from the other side of the picture because as far as I am concerned the patient is number one. The doctors may say that is their view, too, but I say that since 1951 the patient has got the wrong end of the stick and the doctor has thought about the advance of his profession. There are many items that need inclusion in a priority list for departmental attention and I hope the Minister shows the same drive and enthusiasm and interest in his Department as he shows in his speeches and in the way he can deal with those who cross swords with him.
He should give immediate attention to the old people. The study of geriatrics is much behind time in this country. It is outrageous to see county homes still operating on the basis of 50 to 90 years ago. I can tell the Minister that in Roscommon there is a county home the sight of which is enough to depress a visitor, do not mind the unfortunate people who have to spend the remainder of their days there. During the past 15 years we have been listening to plans for a new modern home for people who have no other place to go to. All we have got are plans. We have had architects from the Department, we have had technical advisers and medical advisers from the county and from the Department. The public body are all behind some action but nothing has been done to construct a new building. Now we have got to the stage where people who have made a study of the treatment of old people have come to the rightful conclusion that those large buildings are not places in which old people can be treated.
Experts have been telling us that the idea of institutionalisation is something that should be avoided as far as possible where old people are concerned. The new trend, which I hope the Minister will push in all areas, is to plan buildings which will give privacy, especially to old couples, so that they can live in their own private units where they can have some of their furniture, some of their little belongings, that will remind them of home. There will be a community spirit which will get rid of the idea of a prison society.
In many county homes at the moment permission has to be got from those in authority for old people to get out even twice a week to visit the local town. It is hard to understand such an attitude at this time. The local authority officials responsible for the administration of county homes take the side of the nuns who run the institutions. I am afraid we are a long way behind in our thinking as far as medicine is concerned. The people who should be giving a lead, instead require a course on Christian charity.
I could speak for a week on health issues but I do not propose to do so. I have not said anything that could be regarded as controversial, as blaming one Government or another for our health services. I hope we are all united in the aim of getting the best possible medical services. We must start with the fundamental thought that the patient must come first. I do not deny that all groups concerned with patients' welfare should get what they rightfully deserve but they should not try to get it before the patient is considered.
I do not intend to make a long intervention but should like to query briefly why it is that we still retain the notion we do not want health legislation which will govern the whole population. When Deputy T.F. O'Higgins was Minister for Health he told us that with the voluntary health scheme he introduced and which I did not notice being opposed by Fianna Fáil at the time we would cover all but one-sixth of the population, the remaining sixth being rugged individuals who like to pay their own bills. This sixth has been pared down by the present Government but I should like to know why do they feel it necessary to retain all the apparatus of forms and means tests in order to find out whether a tiny percentage of the population should come under the scheme. Is it not time we had a national health scheme which would cover everybody?
We might give people the right to opt out, to buy privileged treatment, but why should we not devote our energy to the formulation of a scheme which would be an all-in health scheme and abolish the highly cumberous mechanism of the means test which leads to an awful lot of questioning as to whether we are entitled to this or that service? When the Minister earlier spoke about this not being the be all and end all he must in his heart be looking forward to the day when he will have a comprehensive health scheme covering the whole country, all of us, and not have the necessity retained, as I fear he will have it, of applying a means test which will produce more questions about the financial status of a patient than about his health.
On the whole, the Minister should be pleased with the reception of the White Paper. It is inevitable, and he should not show so much irritation, that people on the other side should say certain things are not satisfactory. During the past 20 years all Parties have been responsible for the failure to get things done but all Parties have made contributions to this end. This White Paper is a contribution and the Minister is to be congratulated on taking this initiative. I know him as someone of ability and energy and it is a good thing to have somebody of energy and ability in an office which has for some time past languished a bit. We have not had the progress we ought to have had.
I press on the Minister this question of insurance contributions. The Minister's reluctance in regard to this may be partly due to the fact that the idea has come from the other side of the House but he is man enough to overcome that difficulty. He is not the type of person to allow that to deter him. The reference that has been made from the other side—the other Party—to insurance contributions as a poll tax is extraordinary. We are in the middle of debating an occupational injuries scheme in which the Government are insisting that the finances must be by a flat rate of insurance. They say they do not believe any other system would be desirable. They admit there is a strong case against it but they insist on putting on this poll tax in this instance. There are arguments against a poll tax. If you have this flat rate contribution, regardless of means, you are limiting the amount you can get by the most you think you can take from the community. The flat rate contribution is disadvantageous and is something we ought to be starting to move away from. I think an insurance contribution is something which is accepted in the social welfare scheme and which the Government have accepted as so desirable that they are bringing it in in the social insurance in the case of occupational injuries. To argue that this is all right for social welfare or desirable for occupational injuries, but that they must shy away from it with regard to health because this is a poll tax, is totally inconsistent. It is simply an excuse for fobbing off this proposal.
The Minister has not finally made up his mind against it. He may feel some embarrassment in accepting it because it came from the other side of the House. But it is a mistake to turn it down on the spurious argument that it is a poll tax. I appeal to the Minister to reconsider this. This country is unique in Europe because of the small amount of money which it raises in taxation for social welfare purposes by means of insurance contributions. What we raise in this form is a fraction of what other countries raise. It is only a fraction of what is raised in Britain. There the average amount raised in this way is only one-half or one-third of what is raised in other European countries.
This is the one untapped form of taxation here. It is no coincidence that in this country where this form of taxation is untapped and where we raise only between ten and 20 per cent of what is raised in other European countries in this form, as a proportion of national output and national income, the type of expenditure which is financed by this type of tax for transfer benefits, social welfare benefits, health services and things of this kind, is at a minimal level compared with other countries. We are behind because we have been unwilling to tap this source.
It ties us down to the minimum level and we are appallingly behind in the whole business of social welfare and health services. I think the Minister should consider this matter seriously. Otherwise he will never be able to develop a worthwhile health service, because he will never get authority from the Government to finance a first-class health service here so long as one hand is tied behind his back and he has to finance it out of taxation. He has now for good and proper reasons also tied the other hand behind his back because he has agreed, rightly I think, not to call further on the rates in financing the health services.
If the Minister refuses to use insurance contributions and refuses to use the rates all he will be left with is central government taxation, which is already in most forms at a level beyond which he cannot go rapidly if at all. Some forms of taxation have reached their effective limit. If the Minister will tie himself in that way he will limit the development of the health services and tie his own hand. It is vital that he should open his mind to this question of insurance contribution.
If he feels there should not be a flat contribution he will meet with no objection from this side of the House. This is more relevant in areas like retirement pension, workmen's compensation which we are discussing at the moment and perhaps indeed in social welfare benefits also. Nevertheless, I do not think there would be opposition here if he felt that flat rate contributions are a form of poll tax and if he felt it desirable to vary the level. But that he should have recourse to this form of taxation is essential to do the job towards which he has so courageously set himself. If he does this he will be going a long way towards improving the health services of this country.
There is one other matter on which I would appeal to the Minister also and that is the question of the fee for service. I think Senator Alton made a cogent case for consideration of this. There are certain difficulties and the Minister is right in what he said in the White Paper, I think, that if such a system were introduced it would be necessary to police it most carefully to avoid abuse. It is a system that could be open to abuse. On the other hand. Senator Alton on this point encouraged the Minister and said to him that if the Minister felt that tight policing would be necessary he need not fear that the doctors would object to this. They would accept that there must be control. If there is evidence that the system is being abused policing could be employed and they would not get away, as the dentists did in Britain, with an enormous increase in incomes.
As a system it has enormous merits over the capitation system and it is one the Minister should consider. Again, he has not closed his mind, but he has a pre-disposition in the other direction. The Minister has said repeatedly that he has put this White Paper before the Houses of the Oireachtas because he wanted a discussion on these matters and he said he had an open mind. Sometimes he has seemed to have a slightly closed mind but this is understandable for anybody approaching a subject of this kind who starts with a certain point of view. I take the Minister at his word, that he is open to suggestion and I hope he will listen to this discussion and that in this matter of fee for service he will have regard to the arguments put forward in the discussion in this House.
I believe in the matter of health services there have been signs that we are moving towards a consensus of opinion. In the past there has been serious dissension and political up-heavel in this country. All Parties have made mistakes and all have also made contributions. Looking at it in retrospect, it is sometimes hard to understand how we can have got embroiled in some of the arguments we got embroiled in. Looking back, I shudder to think of the views I myself once held in that regard. Since then we all have learned and our views have broadened and have come together, I think, and this debate, despite occasional asperities which were unfortunate, has shown that this consensus is developing.
Senator Sheehy Skeffington has suggested that we should move a step further and indeed my sympathies are with him on this, and I will be interested to see what the Minister has to say on the Senator's brief intervention. We are moving towards a consensus in a certain direction and it is a great thing that health no longer arouses the passions which it did fifteen years ago, passions which held up development, as Senator McQuillan rightly said, in this field for fifteen years. This is something we must all regret and look back on with sorrow—that when it did become a political issue and, God help us, a religious issue of all things, it held up development for so long.
The Minister is to be commended on this White Paper. He would be even more commendable if he had listened to the discussion which part of the time he was not doing, as I had to point out, and if he applies his mind to what was said in the discussion. Whether he does so or not, the debate has been worthwhile. By initiating it Senator Alton has given this House an opportunity to air views which, even if the Minister does not accept them, needed airing and discussion. Senator Alton should be pleased with the general trend of the debate and pleased that his initiation of this matter has led to a good and useful debate on it. I would hope that account will be taken of the suggestions made here today and on a previous occasion.
There were so many points raised that I propose to deal with the more important of them and I think I would like to refer to what Senator O'Sullivan said about the nurses in Ireland, that we should be much more careful of them and we should look after them better. I could not agree more with this, and I hope that the Minister will in the very near future introduce legislation which will treat all nurses of this country on an equal footing, that the public health nurses, the voluntary hospital nurses and private nurses will all get the same consideration as regards pay and conditions of service and right of pension. We are very lucky in our nurses. One has only to go overseas and see the number of hospitals closed and units that cannot work properly because of the shortage of nurses. They are really a particularly good and hard-working group of girls. We read this morning of a strike in New York where public health nurses are looking for a wage of £2,500 a year and they have gone on strike against immunisation and inoculations and all that until they achieve parity with nurses in other services over there. We would be sorry to have this kind of upset here, and we would suffer considerably by loss of girls going on for the profession. This is very noticeable in England, where they have lost a large number of girls who used to go on for nursing. They are now giving tremendous inducements to girls to go into the profession, but once the demands for a profession has been lost how very hard it is to build it up again as something popular as a career!
I mentioned when speaking on paragraph 128 of the White Paper that I was not very clear on it. This is the paragraph dealing with regionalisation. I was very anxious that the Minister would try to simplify the officialdom dealing with the regional set up. This paragraph says that local staffs engaged in the health service will be transferred to the new boards, and further on it says that it is realised that many of the services will continue to be operated by the staffs resident in the area of operation and that there will be no question of having all the staff working from one centre in a region. There are going to be central regional setups and, therefore, I would be afraid that we would be building up a double set of officialdom—the original setup and also the county council setups still remaining intact, and instead of it being easier to get things done it might be much harder in future. In my experience if you get on the telephone to make an inquiry nobody could be nicer, but if you write a letter for a patient time seems to go on, sometimes there are serious delays of up to six months, before letters are answered.
There seems to be some kind of misconception going on at the present moment, and both the Minister and Senator McQuillan seem to be under the impression that the main soreness of the doctors is that they will no longer be able to dodge income tax. I must at this stage make a protest on this. It is very unfair. It is not justified, and I doubt if either the Minister or Senator McQuillan or anybody here would make those statements face to face with their own doctors, saying as Senator McQuillan said that they view patients simply from what they can get out of them. I do not credit this, and I find it a very bad approach.
Concerning the hospitals of this country, the Minister was under the impression that I made rather hurtful comparisons between the voluntary hospitals and the local authority hospitals. I stated that the vast majority of the specialists' work and most of the super-specialists' work was carried out in the voluntary hospitals. I did not comment adversely on the local authority hospitals other than that I did say, and I repeated here, that it would be much more possible to get better service out of our local authority hospitals and to make them more economic if they were better staffed with both senior and junior personnel.
The Minister thought that I made poor comparisons between St. Kevin's and the Mater, where I work. I do not think I did, because another figure which he did not give me was the admission rate to St. Kevin's and the admission rate to the Mater. If you take away the maternity and geriatric beds out of St. Kevin's you are left with a hospital which has roughly twice the capacity of the Mater hospital. The admissions to the Mater hospital are more per year than the admissions in St. Kevin's. I have very little doubt that with proper staffing with full personnel highly qualified and properly paid you would rapidly produce the equivalent of a new 200 or 300 bed hospital in the city of Dublin.
The Minister also took the point of view that when he increased the number of patients eligible for hospitalisation from 85 to 93 per cent or thereabouts and transferred 200,000 patients from being private to being patients eligible for hospitalisation he did no more than transfer a group of patients who would normally be private to being paid for by the State, and that from now on we would be paid by the State for these people. But the Minister did not take into account that the payment is limited by the number of occupied beds in the voluntary hospitals, and these are working to capacity at the present moment. The increase in capacity by 200,000 patients will be negligible. Therefore, while he has transferred 200,000 patients he has not made any provision to pay for them, and while the profession is very willing to accept that we must move towards a more socialised state of medicine we are not prepared to accept that 200,000 patients can be put on us and we can be told that we must do work on those patients which will involve extra work, because it will involve quicker turnover of beds to cope with them, because they are going to get sick. Take the surgeon, whose units of work is easily measured. Where a surgeon has done 30 patients in a year that is the turnover of his beds, and he will now have to do 35 to make up for those extra patients. Therefore, there is extra work involved on those patients. We do not want compensation for losing them, we want remuneration for looking after them. We want to get away from this compensation. We have had compensation since 1958 and that has not helped.
There are not 200,000 patients, 200,000 extra ill people. They are not patients, they are only potentials.
There will be a percentage of those who will be sick.
Yes, a percentage of this group of 200,000 people.
As there is a break could I ask if the House would be willing to sit on to finish?
I suggest that if we are not going to be more than a quarter of an hour or 20 minutes——
I have a few more things to deal with.
Would it be possible for Senator Alton to finish in the morning? Would it be possible, before we proceed with other business?
I do not think so.
It does not matter what appointments the Minister has in the morning.
I am sorry. I did not mean to be discourteous in any way. Is it convenient for the Minister?
Could we finish in half an hour?
I would be in favour of carrying on and finishing if it is not going to be more than half an hour.
Acting Chairman
Then that is agreed.
The Minister will be aware of the statement made last week in England about the hospital services. It was proved that the English hospital services are at breakdown point. They are now talking about restricting the accessibility of the hospital to people at random through England. This is a very big breakdown because it means no longer will anybody in England be eligible to go into hospital, as they are at the present moment. The alternative to this is grave and heavy expenditure to bring the system up to date. I do not want to stir up things but I would point out that this is almost certainly the result of the capitation system over the past 20 years, which has so strained England. England has her hospitals very well staffed compared with ours and by consultants on full-time duty, while in this country we are dependent on hospitals, voluntary hospitals staffed by part-time consultants, and local authority hospitals staffed by an inadequate number of full-time consultants. The part-time consultants in the voluntary hospitals are no longer able to cope. For economic reasons, because the number of private patients has been reduced, we are going to be forced more and more out of hospital work to try to keep going. Therefore, the hospital patients have to be dealt with literally in less time. The consultants in the voluntary hospitals are paid approximately one-quarter to half that of the consultants in England; they give about one-third to half of the time which an English consultant gives. But it is not economic for the voluntary hospitals to deal with an ever-growing number of patients in the hospital and give them adequate time, under the present arrangement. I would spare the Minister most things but I shall have to come back to capitation and fee for service.
Has it not been discussed with the Medical Association, with me and my officials?
It is in the Minister's Paper for discussion; it is mentioned. With all due respects, we are moving towards a measure, which will be so far advanced by the time discussions take place that it will be very hard to do much about it. As the Minister knows—though he does not feel I have done it properly—I have taken, to my mind, a random sampling of the medical population, rather carefully, with the results I gave him the last day. The Minister asked me how I did it. I did it as follows: I asked to be given 60 name plates at random from the GP's list in the IMA and from the DM's list and I wrote letters to these. I explained I was in great doubt as to what the situation was like; that there were all kinds of rumours afloat; that the Minister in his own speech in the Dáil felt that it was a lot of hotheads who were leading this thing; that it would be unfair to put on the medical profession the extra clerical work and the difficulty of policing a fee per service system; we had heard rumours of letters to the Minister's Department from doctors looking for capitation. I put all this into the letter; I asked them to look into this, to consult with their colleagues and to let me know what they thought.
There is one other matter. Did the Senator not give his own views?
May I read the letter?
Acting Chairman
Perhaps we might get back to the debate instead of a conversation between the Minister and the Senator.
To quote from the letter:
I might add that I intend to speak strongly in favour of fee per service but that I am conducting this kind of gallop poll in order to make certain that I am on the right lines, that it is the general wish and in order that I may have some definite data to present when making my case.
Do we understand that the Senator would have changed his speech had the data been different?
I regard myself as representing the NUI and the doctors who are the second largest group thereof. I am not on the council of the IMA and I grind no axe where this is concerned. It is the wish of the people with whom I have consulted that capitation is not the mode of choice and that fee per service is the mode of choice.
Some of the letters I got back—and they are very interesting—would warm the cockles of the Minister's heart. Here is an extract from one of them:
As you say yourself the fee per service system would entail too much book work and would be grossly abused. In the present world, and especially in Ireland, a legacy of the penal days when the poor had to steal from and cheat those who had too much in order to survive, petty deceit is considered to be a form of cleverness—not dishonest mind you.
Fee per service is favoured only by the drunkards, gamblers, and the incompetent ones, who would, for obvious reasons, abuse it wholesale.
I understand this doctor sent a copy of his letter to the Minister. He also adds a postscript:
I have just learned to touch-type at the local technical school...
There are others equally in favour of capitation. There are some very, very fine letters as far as going into detail is concerned. May I read again?
Many DMOs will lose income under any system.... In almost one-third of the present dispensary areas there are only approximately 350 eligible patients. Under capitation or fee for service it would be impossible for a doctor to make his present salary in one of these areas as the population is not there. Unless a doctor is guaranteed his present income at least there is bound to be an exodus of doctors from these areas. As you said, the policing of the fee per service would be troublesome for the administrators and the doctors but it is the only system where the busy doctor would be adequately remunerated and the Minister who has stressed that he expects no distinction to be made between Health Act and private patients could hardly himself introduce a distinction by offering the doctors a smaller fee for these patients than they get from their private patients. It would open the eyes of the administrators... et cetera.
These letters, all of them are quite reasonable and the net result is roughly 80 per cent for fee per service and the remainder anything else. But it is the way they feel about it and I do not think they are wrong, for a different reason. Doctors are not trying to make money out of this. I resent this very deeply because if you are going to spend at least £3 million more than you estimate spending on capitation then the Minister might as well put it into a good scheme as a bad one. The Minister's documentation sets out in paragraph 44:
...an eligible person will have the right to be attended by any doctor participating in the scheme who is living within a reasonable distance...
That is the first set of rules and the next set is:
...all existing permanent district medical officers would have a right to be included in the list of participating doctors for the area, but that there would probably have to be some restriction on entry into the service by any doctors, to avoid too many doctors participating in any area and each not having a worthwhile panel.
Obviously the Department intend that there should be a worthwhile panel. Now, what is a worthwhile panel? In England, a GP gets 3,000 patients. That is considered to be too many, so 2,000 would be a worthwhile panel. At present 30 per cent of our population are on the register, and that is now going up to about 45 per cent. If you take the number of dispensaries which have only 1,400 or fewer patients on the register, under the new scheme there would be 330 dispensary districts with 2,000 patients to be looked after. That is about enough for one doctor. I cannot see how these 330 dispensary areas will have more than one doctor. The Minister used the words "a reasonable number".
Most of these dispensaries are in small towns and the capitation method cannot give a choice of doctor unless the lists are so small that they will not be worthwhile to anyone. To my mind that is one of the great disadvantages of capitation. It will give choice of doctor in the cities and in the urban areas, but it will not give choice of doctor in the rural areas— not only in the distant rural areas but also in the more populous rural areas. I cannot see this capitation system working out properly. I still feel that fee for service does not make second class citizens.
I have no axe to grind. I have gone into this as carefully as I could and I do not think it will cost any more to administer. The Minister, when he was talking about dental technicians in the Dáil said:
...I should have to be satisfied that a practice which has been apparently rejected by the authorities in the majority of European countries could be accepted in Ireland without danger to the health of the people.
He knows in his heart of hearts that this is right. Why should he apply capitation when it has been rejected in the majority of the European countries? There is no country in Northern Europe, outside Russia, that has brought in legislation in the past 20 years in favour of capitation. Why should we go backwards? I think we would be foolish to go back. Finland, which every one talks about as comparable with Ireland——
Tell us what happens in Finland.
They went on to the fee per service two years ago.
Does the patient pay the doctor?
The system is the same in the Scandinavian countries.
What happens when a poor person has not the money to pay the doctor?
The Minister has my sympathy.
The patient is my primary consideration. We have been talking about doctors all evening and capitation or fee for service. Let us talk about the patients who are my primary consideration.
The Minister frightened me earlier on when he talked so loudly. I know now that when he is on weak ground he talks in a loud voice. He has my sympathy about this because I, too, have had great difficulty in finding out what happens to the poor patients who have no money in those countries. I have here a letter from the Royal Swedish Embassy which says:
As regards your question as to what happens if a doctor is called to someone so poor that he could not settle a bill there and then and do without the money until he got it back from the State, I wish to state that if he is not covered by an insurance scheme it is always possible for him to turn to the municipal social welfare boards.
That does not cover it.
It does. That is the point the Minister mentioned, the poor patient who has not got the money.
It is a means test like the medical cards at present. The Senator was talking about Finland.
Finland changed over two years ago to a fee per service system. I believe that this is the only system for the future. As it is, the capitation cost would be £3.
Perhaps Senator Alton is right and fee per service is the best. He could be right.
I will let the Minister go home now. That is all I have to say.