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Seanad Éireann debate -
Tuesday, 13 Jul 1971

Vol. 70 No. 13

Health Contributions Bill 1971: Second Stage.

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

The purpose of the Bill is to ease the serious burden of health costs on the Exchequer and rates through the introduction of a scheme of regular contributions towards the cost of hospital and other services by those who are eligible for the services and who may be regarded as able to bear the contribution proposed without hardship. These are persons in the category described in the Health Act, 1970, as having limited eligibility for health services, that is, persons and their dependants without medical cards who are insured under the Social Welfare Acts, or who are farmers of £60 valuation or less, or who are other persons with means of less than £1,200 per annum. I might mention that I shall be seeking the approval of the House in the present session to regulations which would raise this limit to £1,600.

The description "limited eligibility" may possibly suggest to some people that the range of services open to this category is not very wide. In fact the services in which they share directly account for no less than 85 per cent of the total running costs of the health services, which are estimated at some £76 million in the current year. The principal item in this bill is hospitals, which account for £57 million.

I do not want to confuse the House with too many statistics but I think a few salient statistical facts are necessary to put the size of the contribution yield into proper perspective. The yield from the scheme at the initial rate of contribution will be £5 million in a full year, but since, at the same time, it is intended to do away with the present hospital charges of up to 50p per day on persons with limited eligibility, the net annual income will be something over £4 million. I hope to have the scheme in operation for the second half of this financial year—hence the reference in the last Budget Speech of the Minister for Finance to a return of £2 million this year when he announced the proposal to introduce the scheme. £2 million will meet less than 3 per cent of the total estimated expenditure this year.

Central taxes and the rates will continue therefore to bear what may, perhaps dubiously, be described as the lion's share of health costs. I do not foresee any radical change in this pattern of financing. The total expenditure is so high, and is growing at such a rate, that it would be unacceptable to attempt a large-scale redistribution of responsibility as between the various sources from which money is found for health at present. Most public debate on this subject tends to emphasise the heavy demands on the ratepayers. I agree that the rates' share is substantial and I fully appreciate the dissatisfaction so often voiced on behalf of ratepayers. At the same time, the demand for removal of health charges from rates begs a very big question. Where would we find the large sum at present contributed from this quarter if we were to relieve the rates of the liability? The Exchequer's share of the cost is £46 million in the current year, about 9 per cent of the total Budget. It is quite unrealistic to expect that central funds can be diverted from the many other pressing and competing public needs to the extent necessary to make any appreciable difference in the burden on the ratepayers. It is important also to remember that the Exchequer relieves farmers substantially from rates by the operation of the agricultural grant, to such an extent that, over the country as a whole, the rates pay for only about 25 per cent of the cost of health services.

We have a problem to find money for our health services, but let me emphasise that we are not exceptional in that regard. Finding resources for their health services has become, for many countries, one of the major dilemmas facing governments. In Britain and other Western European countries there have been considerable difficulties in recent years and growing attention has had to be given to this question. As far as I am aware, no country has discovered a financial panacea for its health problems. The picture which emerges from the information available to me suggests that the health services in Western European countries in general tend to be financed by an amalgam of sources incorporating taxation, insurance contributions and charges on the patient.

Senators who attended a lecture given here recently by Mr. Walter Mc-Nerney, President of the Blue Cross Organisation, which is the biggest voluntary health insurance organisation in the United States, will have heard him say that the question of financing the American health services was now a major problem and that next year would be the major national problem. Indeed, the President of the United States has described his country's health services as "a system in crisis." Professor Abel Smith, a prominent British commentator on social matters, in a report published by the World Health Organisation in 1967 revealed that some countries were, in the early sixties, spending over 6 per cent of their national product on health. If that trend continues health services by 1980 would take over 8 per cent of national resources in developed countries and by the end of the century as much as 10 per cent.

There is no reason to believe that there will be any change in that trend. The bill for health is going to go on increasing and we must accept the situation as unavoidable. The remarkable advances of medical science and the growing specialisation which arises from these developments add increasingly to the costs with which we are now faced. In America there are now up to 200 different categories of specialist involved in the provision of hospital care. On top of this we have more and more people living into old age, into that stage of life where illness or infirmity is more frequent or of longer duration. These are some of the underlying causes of the almost insatiable demand for resources to support health services. It explains to some extent one of the great paradoxes of our times, namely, that despite improved social conditions, better food and improved housing standards, the cost of maintaining our national health goes on growing.

What I have said so far provides the background to the introduction of this Bill. The Government is satisfied that the traditional sources for health finance must be supplemented in some other way, and preferably in a way which can be shown to be directly related to the services concerned. This is the means which is proposed by the Health Contributions Bill.

The Bill I am now asking the House to approve provides for an introductory scheme based for employees on a modest rate of contribution of 15p per week—less than the cost of one pint of beer or half a gallon of petrol. Where insured workers are concerned it would be collected in conjunction with their social welfare contribution. Farmers and other self-employed persons would contribute at an annual rate of £7. This is rather less than the total amount which an insured person stamping a card for 52 weeks would pay—£7.80— and is justified by the fact that insured persons are automatically exempted from the contribution during periods off work through illness and unemployment because of social welfare procedure for credited contributions. Farmers will pay their contributions to the local health board and the contributions of other self-employed persons will be collected through the machinery of the Revenue Commissioners. All the money collected will be paid over to me and disposed of in accordance with regulations which I shall make with the consent of the Minister for Finance.

I would hope that since the contribution is a small one the farmer would pay it in one annual sum, but to avoid any hardship for him I have under consideration the possibility of enabling him to pay in easy stages by stamping a card or by some other method.

All medical card holders would, of course, be exempted from making these contributions and there is provision for exempting other specific categories where this is thought desirable. In particular, it is intended that agricultural labourers and female domestics will be exempted. Because the employees' contributions will be collected as part of the Social Welfare stamp, it is not, however, practicable to exempt classes for which there is not a separate denomination of stamp. Hence, employers of most lower income group workers will, in stamping the cards for social welfare purposes, have to include the element for health services. There is no practicable way of avoiding this, so that in these cases there will be a liability on employers to meet the cost of contributions. There is no question of asking medical card holders themselves to pay.

I would suggest to you that 15p per week is not an unreasonable price to ask people to pay who are getting so wide a measure of protection for themseves and dependants. When the scheme starts hospital services will be completely free to contributors: the present charge of up to 50p per day will be abolished. Charges for out-patient services have already been lifted since April last. In addition, on the introduction of the scheme, the present arrangements under which drugs are available to all diabetic patients irrespective of their means will be extended to other specified long-term ailments, in accordance with regulations under the Health Act, 1970. Other benefits are also foreshadowed in that Act and will be brought into operation at a later date, for example, assistance with heavy chemists' bills and a home help service to keep people from having to get institutional care. I should also refer particularly to the important reorganisation of the child health services, which is now operating successfully.

As I said earlier, this introductory scheme is expected to yield a gross £5 million in a full year—not a very large sum in relation to the total current costs of health services, but a valuable contribution in our present very difficult economic circumstances.

Ideally, a scheme of contributions of this sort should be graded to take account of the varying capacity of different people to pay and it would have been my preference that, from the beginning, the scheme of contributions should be so designed. However, at this stage it is not possible to implement a graduated scheme, since it has many complicated aspects and calls for a good deal of organisation which the Revenue Commissioners, on whose administrative machinery we must depend, will not be in a position to complete for some time. The Bill makes provision for a changeover to this more sophisticated kind of scheme when we are ready for it and a high-level working party has been set up by the Revenue Commissioners to plan the changeover. The rates of contribution which would apply in such a scheme will be fixed by regulations which the House will be asked to approve in draft form.

The House will, naturally, be concerned about whether an obligatory health contributions of the sort proposed will give rise to any disequilibrium in our taxation system. The impact of taxation on the various income categories has not been the subject of close analysis here or in neighbouring countries. We are, nevertheless, reasonably certain that the tax measures in force are progressive in character and related to income levels. We are quite sure of once fact, namely, that there is no large wealthy class of persons earning from £3,000 to £5,000 net of tax and that the distribution of taxation is such that every section contributes proportionately to their total incomes.

The introduction of this scheme of contributions cannot be said to impose a charge that is out of proportion to the income of the contributor.

In the 1966 urban household budget inquiry the amount spent by the average household in the limited eligibility group each week on medical expenses was shown as about 30p; the amount spent on drink and tobacco was 162½p. The people of this country devoted 11.14 per cent of their personal expenditure for goods and services to the purchase of alcoholic drinks and soft drinks. I am sure you will agree that, in the light of these figures, the 15p weekly contribution is a very reasonable insurance premium. It can be easily borne by the limited eligibility group and can be increased as incomes increase.

I would ask the House to support the adoption of this new principle in our health services and I recommend the Bill for a Second Reading.

It is very interesting to see the introduction of a Bill such as this. It is quite obvious to all having listened to the Minister's introductory remarks that the Minister for Finance knew when he was introducing his Budget that this amount of money was required to supplement what he had allocated within the Finance Bill to bring it up to £76 million for the current financial year.

What is introduced here is more appropriate to a Budget than to a special Bill such as this. There have been comments in the Dáil from the Opposition —which the Minister may have thought were sarcastic—that on account of the Budget that was introduced in May of this year we would have another Budget in the autumn. In point of fact, the Members of the Opposition who made that statement were optimistic. We have here a type of Budget two months after the annual Budget because what this amounts to is a Budget on a small scale —a mini-Budget. The Minister said in his introductory statement that the Minister of Finance was aware of this. Why was this not introduced in the proper way in the Budget and provision made for it in the Budget instead of wasting the time of both Houses of the Oireachtas in introducing what is termed here the Health Contributions Bill?

In the Dáil the Minister referred to the statement of the Minister for Finance in his Budget Speech reported in Volume 255, col. 316 of the Official Report from which he quoted in his opening remarks. No very great reference was made to that on Budget Day or the days spent discussing the Budget thereafter. It was, in a way, an aside in the Budget. The Minister for Finance should have made provision in the Budget for this amount of money to supplement what was already provided for health to bring it up to the £76 million the Minister has said the health services will cost in this financial year.

It was mentioned by the Minister in his introductory remarks in the Dáil on the Second Reading that this Bill applies to the middle income group, that is those just outside the group categorised by eligibility: the limited eligibility group of the 1970 Health Act. It is proposed by the levy of 15 new pence a week or an annual sum of £7 on each person in this group to obtain at least £5 million. All the benefit they get from that is the relief in respect of the daily payment for hospitalisation of 50 new pence or 10s. per day. It appears that the net result of this Bill will be that the middle income group will get a benefit of £700,000 for a payment to the Exchequer of over £5 million.

This is not all of it. The middle income group, that is the limited eligibility group, will be relieved of the payment of the £700,000. That £700,000 which is now payable is intended not to be payable if and when this Bill becomes law. At the present moment that £700,000 goes to the Exchequer and the rating authorities, at least in the Eastern Health Board it goes in the proportion of approximately 54 per cent to the Central Fund and 46 per cent to the rating authorities. It varies, I think, in other health boards.

It follows, therefore, that this £700,000 which it is proposed to give to the Exchequer will deprive the rating authorities who contribute to the Eastern Health Board, the one I take as an example, of over £300,000 in income which must then be got by way of rates. Therefore, as well as saddling this middle income group with contributions to bring in £5 million it is also an imposition on the ratepayers.

I do not begrudge the benefits given to the middle income group by way of free hospitalisation because they contribute as much as £5 million. But I wonder if this is the right method of dealing with this problem. It would be much better if the relief could in some way be given to these people for domiciliary services. I interpret this Bill as an incentive towards greater hospitalisation instead of an incentive towards domiciliary care and the prevention of people going into institutions and hospitals. In my opinion, it is not a desirable trend.

I have great admiration for the Voluntary Health Insurance Scheme, but it has the same drawback: it is an incentive to hospitalisation. The aim of any Health Bill should be the prevention of people going into institutions and hospitals. The Minister has explained on a number of occasions that the biggest part of the country's health costs is the hospital bills. Although the Minister himself referred to the high hospital charges this Bill is directing people rather towards the hospital than preventing them from going in.

In this regard the Minister, in discussions on the 1970 Health Bill which is now an Act—I will call it a Bill in my reference because it goes back to the time of our discussion on it— pointed out, and we all agree that he is correct, that the emphasis should be on domiciliary care: home nursing, home visiting, social welfare officers visiting people, reporting on what is going on in the home, the provision of day centres and other things like that. Domiciliary care is of great benefit, but I am afraid this Bill is sidestepping the Minister's own views in regard to where the emphasis should be in the health services in general.

The Minister is this year looking for £76,000,000. I would like to refer the Minister to the Seanad Debates of 29th January, 1970. This is when the Health Bill, 1970, was going through the Seanad. I am quoting from volume 67, of the Seanad Official Report. The Minister had made some reference to his considering an insurance scheme. He then said at Column 1241:

We have reached a phase of thought in this which is very interesting. There is this psychological impact, and to my mind nothing would be worse than to introduce a contributory insurable scheme which would be intensely resented by a great number of people although the Government of the day thought it extremely equitable. Now that is what I really feel about it—

This is the Minister speaking.

—The matter is still under consideration and it may have to remain under consideration for some time.

There is also the question of its introduction and all I can say is, and I do not think there is any reason why I should not say this, that the collection of taxes from the self-employed community would involve changes in the method of collection by the commissioners for revenue and would involve also the climax of certain administrative changes in the use of the computer that are now taking place and it could not possibly be introduced economically for quite a considerable time while these gradual changes in the use of technical methods are being introduced.

I am being absolutely fair to both sides about this. I do not think I should say anything more about that. I have told the House, first of all, that there will be an extra sum in the Budget and through which the increase in the health rates will only be modest, and secondly, that the contribution scheme has been thought of in a sympathetic way, by myself, my party and the Government. We have already a great deal of data on it and we are continuing to examine it but I cannot announce approval of it yet.

I then said—

The Minister has been very explicit, very kind and gracious in his reply to me. I welcome the supplementary grant the Minister for Finance has promised. The Minister mentioned keeping the rate levy for health down to a few pennies.

Mr. Childers: I did not say a few pennies, I said a modest amount.

I then said:

Well, a modest amount. There are a few aspects of which I should like the Minister to consider. He did say that some type of contribution scheme is being examined, that certain complexities were involved and that it would not be workable for about four or five years and therefore if we let this remain the way it is we will still have the demand on the rates. The supplementary grant will reduce this year—I think the Minister was referring to this year—

The Minister then corrected me.

Mr. Childers: The coming year, 1970-71.

I replied:

Yes, the coming year. The grant will be in relation to the estimates for the coming year.

Now I come to the crunch. I refer to the £76,000,000. I then said:

There is one point which has not yet been mentioned here, although it may have been mentioned in the Dáil, and that is that the implementation of this Bill when it has been enacted will, within its first year of enactment, increase the cost to the ratepayers by approximately 50 or 60 per cent. That is my view: it may not be everybody's point of view. When you come to consider the various concessions being made and which have to be paid for by the health boards—possibly the fee for service for doctors, possibly taking out the income of dependants, all of which I agree with—then in regard to the actual cost of running the finances of the country, which are now running at the rate of about £51 million—I am open to correction on that——

Afterwards, by the way, I did verify it was £51 million.

——then within two years it will be running at the rate of about £85 million to £90 million. At that stage the impact on the rates will be so great that there is sure to be an outcry. While the Minister has said that he is examining a type of insurance contribution, that is so far away that it is not material to the examination of this Bill. Although the Minister has been very frank, I am afraid I must still press the amendment.

The word "amendment" of course was wrong. Whether I used it myself or whether it was a word misreported I do not know; I will take the blame for the use of the word "amendment" because I was speaking to the section. The Minister put me right on that when he replied as follows:

The Senator can press for the rejection of the section but he has got the question of the services recommended in the White Paper— I think he said £60 million to £80 million—completely wrong. The cost in improvements or extensions of services as estimated back in January, 1966, was £4,265,000. Some of these estimates have proved to be incorrect because of changes that have taken place. Some of the services have already been established and I would say that on a rising basis over the next three years, not including any inflationary element, the extra costs will be between £1 million and £3 million. We are carrying out the policy stated in the White Paper, that the cost of further extensions of the service should not be met in any proportion by the rates, which means that the taxpayer would have to pay the cost of the fee for service arrangements and not the ratepayer. If we provide long-term disability benefits for children in hospital regardless of the income of the parents that extra cost will be met by the taxpayer and not the ratepayer.

As I said, this promise is going to be kept and the extension of services, such as the new system of child health examination which I announced the other day, will be paid for by the taxpayer. The Senator is being extremely pessimistic and perhaps he is being pessimistic because of the fearful effect of inflation. However, we cannot have a debate on that; it takes place in other countries but it has been particularly pronounced here in the last two or three years. Inflation affects costs and to some extent it also increases the buoyancy of taxation.

Acting Chairman

I do not like to interrupt the Senator, but the quotation is becoming somewhat lengthy.

It refers to the figure of £76 million here and our anticipation that some such figure would come. That is why I am quoting this here.

Acting Chairman

It is customary for quotations to be reasonably short, not a whole debate.

I shall cut it short, I shall only read extracts from it, if I may. Later on the Minister said:

At present the cost of providing the middle income group with the hardship allowance is costing the State £100,000 to £120,000.

Then he winds up a paragraph by saying:

I have been very careful to say I am not including any possible inflationary effect on the general economic situation, but I think the Senator has exaggerated.

In view of the fact that the Minister is looking for £76 million in the financial year 1971-72, to what extent have I been pessimistic? To what extent have I exaggerated?

The Minister has advisers who advise him. I do not know who complied the White Paper that was referred to, but surely the people who projected this increase in respect of expenditure from that time were completely in error?

Another objection I have to this Bill is the fact that it is attempting to introduce for the first time a contributory insurance scheme. I suppose somebody may point a finger and say "Surely that is Fine Gael policy". A general overall contributory scheme is Fine Gael policy, but a contributory insurance scheme which is taken completely out of the context of the entire health system of the country is not part of our policy.

This deals with only one group of the community. It has been estimated—I do not know if this is declared here but I have read it in the debates of the other House—at approximately 60 per cent of the population. In my view this is going to be received by that section of the population with bad feeling and bad faith when they realise that they are contributing £5 million and receiving in return £700,000. It will in effect destroy in the minds of most of these people the idea of a contributory health insurance scheme.

The time has come when we must examine the whole method of financing health services. There are three methods that have been suggested. I am not going to come down on any one side here. The current method is the one of partial payment from the rates and partial payment by the central Government. There is another mooted; that the central Government should pay all; and a third; that this money should be got by a contributory insurance scheme.

If sometime—and it must happen sometime—responsible people sit around the table and try to work out first the system for financing, these three methods will have to be discussed and because this group, upon which this impost falls, will have had a taste of what I consider a bad contributory scheme, they will therefore be biased. A proper discussion—I am not going to say at this stage what side I will come down—on contributory insurance schemes would from the start be prejudged. I feel that the Minister, by introducing a partial contributory scheme in which the total payment is so far higher than the benefit to be received, will discourage any consideration of a general contributory health scheme.

The Minister in the Dáil—I think it was when Deputy Tully was speaking of the proper definition of eligibility, or of people who are entitled to a medical card—said that regulations would be introduced in the new session of both Houses of the Oireachtas. He should have brought these regulations in before he brought this Bill before us today.

Coming back to domiciliary treatment, when the Minister for Finance was before us with a measure giving relief in taxation to married women— he increased the limit of income tax relief from £45 to £74—both Senator Alton and myself wanted him to increase it to £120 or higher because we had in mind the Minister's statement on the Bill I have just referred to that there should be an increase in the domiciliary nursing service and treatment, social welfare and all the domiciliary services. It brings me back to the preventive type of medicine that should be emphasised—prophylactic medicine will prevent people getting serious diseases in many cases—and it should be one of our priorities. It has been stated that the number of beds in hospitals here per thousand population is the highest in Europe. I am not quite clear on this point.

I should like to refer the Minister to his reply on the Second Reading of the Bill in the Dáil. He referred to the doctor's fee-per-service scheme. The fee-per-service will become operational on 1st April, 1972. I feel that the discussions and negotiations with the medical profession in this regard should have commenced earlier and the scheme should have been introduced at an earlier date. Following that, the Minister made the statement that he envisages over the coming years those in the eligibility bracket will be reduced in number due to the increase in wages and salaries. I do not follow the reasoning in this. If you have increases in wages and salaries you will inevitably have increases in costs. It means that the value of money falls and when this occurs it leads to a demand for an increase in the upper limit in the eligibility category. I do not envisage any great change in the number of people in the eligibility category in the future. My view is that the number will remain roughly the same.

Play has been made of the fact that the middle income group will get free medicines in certain cases. Such a concession is already in force to a great extent and the Minister has referred to it. Medicines for diabetics and persons suffering from other long-term illnesses are supplied free under the hardship clauses of the 1970 Act. In this regard there was reference by the Minister to severely-handicapped children. I am still awaiting the establishment of institutions catering for mentally-retarded children under the age of six years.

There is also the question of the number of empty hospital beds available at present. In certain institutions that I know of there are empty beds due to the fact that we cannot get sufficient staff for such hospitals. This has already been mentioned by the Minister so I will not dwell on it. I should like to mention here an aspect that I have been flogging for years. There should be a review of the infectious diseases legislation in this country. Two infectious diseases hospitals in Dublin are not now needed and one of them could be utilised to provide more beds for other more necessary purposes.

We are opposing this Bill. Before I give the reasons for my opposition I should like to preface my remarks by saying that if £76 million is necessary it should be forthcoming. I do not think any Member of the House would oppose such expenditure. Health is a very necessary service and must be paid for. We all agree on that point. The opposition is on the grounds of the method of collecting finance to cover such expenditure. Firstly, it should not have been brought in here in the form of a Bill but should have been introduced in the Budget. Secondly, such financing of the health services is an imposition on one section of the community only. It should be spread throughout the different sections of the community who should contribute according to their means. Thirdly, it is an imposition on the rates. Fourthly, it is to some extent an incentive to hospitalisation and fifthly, it prejudges an impartial consideration of the methods of financing the health services for the country at large. Those are the grounds on which we oppose this Bill. Some other method should be devised of financing the health services.

The Minister, in his opening remarks, said:

Ideally, a scheme of contributions of this sort should be graded to take account of the varying capacity of different people to pay and it would have been my preference that, from the beginning, the scheme of contributions should be so designed.

This is a statement that I wholeheartedly endorse. It is regrettable that the Minister did not delay bringing in a scheme until he could introduce one which concurred more closely with his own stated ideal scheme. Like the previous speaker, I have certain objections to this Bill and some of my objections have already been outlined by Senator Belton. Because it is a pilot scheme we have tended to judge it more sympathetically. We have all been aware of the tremendous rise in expenditure on health and the great need to tackle the problem of the financing of our expanding health services. I believe that the concept that the nation should look after the health of all the citizens is being recognised in all democracies. It also recognised that the cost of it should be borne equally and in proportion to the ability to pay.

That is why I find it extremely difficult to appreciate the Minister's point in bringing in this Bill, which puts the burden on one section of the community, a section which will find it particularly difficult to bear this extra burden. It would have been a much better start to this idea of a health contributions scheme if it had started at the higher income group, which could easily bear it. The people in the affected category, described in the Health Act as those of limited means, are the very people who are suffering heavily from taxation. They have no means of easing their income taxation, because having no expense accounts, there is no loophole. Very likely they are people who have struggled hard to collect deposits and may be are paying very heavy repayments on their houses. They are also likely to be people with young children and so incur additional expenditure in providing for those children.

The other aspect of it which I find puzzling—it was also referred to in the Dáil—is that the idea of hospitalisation encourages people to go into hospital, where perhaps beds are scarce. I know that the Minister, in replying in the Dáil, said that there was no evidence of this. I do not know what research has been done in connection with this factor. However, I firmly believe—and I have witnessed it among my own colleagues and friends—that people who have insured for voluntary health schemes opt, in very many instances for hospitalisation, for minor ailments which could be treated at home. They do this because they feel that they have been paying voluntary health insurance contributions and it is a way of recovering some of that expenditure. The medical profession very often encourage this attitude in people. They will ask a patient if he is covered by the voluntary health scheme and, if so, will suggest his going to hospital for a few nights so that he will be looked after there. I have personal experience of this. It cost me £25 to have a minor operation done in an out-patients' department. I could have had it paid for completely by the voluntary health scheme if I had opted to take up a bed in a hospital for one night.

I should like to ask some questions about the scheme. One is about the £1,600 income limit. Recently, the Minister for Social Welfare and Labour indicated in the Seanad that the £1,600 limit would be discontinued. However, he did not state if he intends to increase the limit by another £400 or if he will abolish it altogether. If one or the other is adopted, how will it be possible to define a person's limit for benefit?

The other question I should like to ask is will there be a period of eligibility when you exceed the £1,600 limit? In some cases, there is eligibility for four years after exceeding the £1,600 limit. What will it be in this scheme? It is important that we should know what it will be, because a number of people will not know if they are entitled to the benefits of hospitalisation. It would be very important for the head of a household to know that.

When arriving at the income which is to be reckoned, will overtime be reckonable? We have had cases in other spheres where overtime has had the effect of putting people outside the scope of social welfare benefits. I should like to know if the same methods are to be used of computating income so that the people whom I represent could be forewarned. Incidentally, this could be a disincentive to working overtime.

I should also like to know if the Minister intends to give people the option of remaining in the scheme by paying the contributions themselves. This is already in existence in the social welfare code: if you wish to continue your right to a widows' and orphans' pension, you may pay the full contribution yourself by opting into the scheme within a specified period, I think 18 months.

A number of people who will be affected by the 15p per week may already have themselves covered to a limited degree by voluntary health insurance. In this particular year they will probably have paid their premiums already, or the premiums are being deducted at source under a group scheme. That means that for this year they are at an extra financial loss. This is grossly unjust. For the sake of £2 million extra, which is what the Minister says he will get this year, he is going to rush through this Bill, and it will be hard on many people. I agree with the last speaker that it means extra taxation on one group of people.

I should like to ask the Minister a further question, to which he may be able to reply. On calculation of income, the Bill states:

Income shall include, in relation to any person, income of a spouse of that person where the spouse is resident with that person.

This brings us to the problem of the married woman who is working. How will we arrive at the £1,600 for that? Will the income be gross, or will both workers be paying the contributions? For income tax, there is a method of making one assessment, although separate ones may be asked for. However, I should be interested to know if both earners in a house will be required to pay the 15p or if the combined income will put both outside the scope of benefit.

It is a pity the Minister did not take more time to draw up a contribution scheme, which would have been welcomed generally by the public if it were a comprehensive one. We all respect the Minister for the efforts he has already made and for what he has done for the health services already and for his dedication. We were all impressed when he introduced the Health Bill and, in a way, I consider that this Bill is spoiling what was otherwise a rather remarkable performance by the Minister feeling obliged to rush through this rather hasty measure.

First of all I should like to say that to me the Minister's speech is a comprehensive explanation of the situation as it is today. It gives some information that is very useful. There is one question I should like to ask. In the case of the farmer's contribution, does this cover the farmer and his family or only the farmer himself? It refers to 15p as being £7.80 per annum.

The farmer and his dependants.

We must admit that the Minister is trying to achieve something which is not by any means easy to achieve. Our economy is at a stage where further contributions directly from the Exchequer are hardly permissible.

In this Bill, there are some very welcome improvements, of which I have personal knowledge. That is where the Minister refers to the present arrangements under which drugs are available to all diabetics irrespective of means. Will this be extended to other specified long-term ailments? I hope so. I have come across quite a few cases in this area.

I should like to welcome, as a hope for the future, one of the Minister's comments on the Bill, referred to by Senator Owens. It is the reference to what the Minister regards as the ideal scheme of contributions, which should be ready to take account of the varying capacity to pay of different people. He stated that such a scheme is not practicable at the present time because it would call for a good deal of reorganisation which the Revenue people are not in a position to complete at the moment.

The aspect of it which I welcome is, as the Minister says, that the Bill makes provision for a changeover to this more sophisticated kind of scheme when we are ready for it. I think this is the sort of scheme we would all welcome, although the Minister is not in a position to deal with it yet. That section in the Bill is the one which Senator Belton was referring to indirectly. It gives the hope that we will be able, at a future stage, to reach a more desirable situation where perhaps something approaching the Voluntary Health Insurance Scheme may be applied to everybody. This, of course, is the idea and it has been thought about and talked about here for many years.

It is quite obvious that the Minister, whom I regard as one of the ablest Ministers for Health that we have had, has not been able to bring this about yet. I should hope that he may be able to do so sometime in the future. Meanwhile, I welcome the improvements that the Bill will bring about despite the fact that there is an additional contribution, but it is not a contribution which is so very high when one takes into consideration what is being spent on other things. I, therefore welcome the improvements that we are getting here and I express the hope that we may, in the not too distant future, see a broader type of total health contribution situation.

I am afraid I cannot honestly say that I welcome this Bill. I recognise the necessity for some measure such as this to try to make both ends meet in the health service. I say, "try to make both ends meet" because I am quite certain they will not anyway, even with this Bill and, presumably, the extensions of this which we can anticipate in the years to follow.

I have not any alternative suggestions to offer as to how this exercise might be done. I think it is a pity that the clearcut divisions which we have had in the people obtaining services under the various sections of the health service to date will be somewhat blurred when this Bill comes into effect.

I have spoken in many places about the way in which our health services are organised and I have always found that it was easy to talk about them: they were easily explained, they were easily understood by other people and the great majority of people, having heard about them, felt that they were a very useful compromise between the total comprehensive service such as in the United Kingdom and the type which used to obtain in the US where there was very little done by the Government at all, in any State, for any section of the population unless he was medically indigent.

It is a pity that we are departing from that rather clearcut situation but I cannot propose any alternative at present. I am, like Senator Owens, worried about the effect that even this small contribution may have on certain sections of this particular group in the population. I should like to suggest something to the Minister in regard to the people who determine those who are to be in the middle income group and those who shall be in the lower income group; in other words, the group with limited eligibility and the group with full eligibility. When somebody has decided in which category a head of a family or his family shall be placed, would they please take into account, when they are deciding that a particular family is not to be rated for full eligibility but only for partial eligibility, that does not only mean in future that that person pays for his hospital services as heretofore; it means that he also pays this additional charge. Therefore, there may be some cases of hardship among the people at the lower end of the partial eligibility group. I should like the principle applied, which is defined in the Health Act, that they be specially considered in this new situation.

Ba mhaith liom fáilte a chur roimh an mBille seo, mar is eol do gach duine atá ina bhall de comhairle condae ar bith nach mbeidh sé ina chumas go deo coimead suas le costasaí sláinte muna ndéantear rud mar seo.

Anybody who is a member of a county council knows that unless something is done such as is being done in this Bill we cannot possibly cope with rising costs of the health services. The lower income group are already being catered for and it is only fair that those in the middle income group who can make some contribution should do so. Indeed, 15p per week or £7 a year is not a great hardship on anybody especially when £7 would hardly keep a person in hospital for one day. I am glad the Minister has said that the contribution, at a future date, will be on a graded scale. Senator Jessop made a reference to some hardship that might be caused even within the middle income group but this is covered by the hardship clause which will be there for those in this income group as well as for those in the lower income group.

I am glad the Minister has said in his speech that soon we will have the home help service. Aged people and those with limited disability would thrive much better in their own environment than they would in hospitals. This would also leave more beds available for those who are more seriously ill.

The Minister has done a good job and this amount of money—15p, the price of a pint of beer, or £7 per self employed worker or farmer—is very little especially in the farming community when this £7 will cover the whole family for the whole year. It is time that those who can pay some little contribution should do so.

It is only right that people should be encouraged by insurance when they are well to look to the day when they may be met by ill health. However, I do not think insurance should be aimed in such a way that we would recoup what we are spending. The £4 million surplus aimed at in this scheme is not something that I should like to support. Many aspects of this might not work so well. We have in my own county, particularly in the regional hospital, a shortage of beds. As a member of the Limerick Health Authority, time and again I raised the point of how difficult it was for the medical people to look after their patients without sufficient accommodation. I was a member of a visiting committee and a doctor told us they had to treat patients in the corridors. I think that was a deplorable situation.

If we introduce this scheme we will add to that hardship and make it more difficult. As Senator Owens has pointed out, it will create an incentive to bring people to hospital, because people who are making a contribution feel that they are entitled to get something for it. When the numbers of people increase and accomodation becomes more difficult to obtain, as in the case of the regional hospital in my county, it could be suggested by the house doctor that those who do not need surgical treatment be sent to other hospitals, such as the county home. This will not please the people who are making a contribution towards the regional hospital and who feel they are entitled to treatment there.

What is the position of the Voluntary Health Insurance contributors? Many people are paying as much as £25 and £30 per year. Will they obtain any recoupment if they have already paid most of this year's contribution to that scheme and become eligible for that proposed in this Bill?

It is mentioned that agricultural labourers and domestic workers will be exempt from the scheme. I wonder why. Single agricultural workers and single domestic workers do not qualify for a health card and I should like to know under which category they will come or will they be covered in any way?

Senator Owens referred to the ceiling of £1,600 for eligibility. The Minister should specify that this £1,600 should be the base, excluding overtime, such as applies for loans or grants. As regards the hospitals, I should like to know how the £4 million will be used. Will it be ploughed back to the eight health boards? Would it be possible to make some contribution to the Voluntary Health Board who have played a great part in taking from the ratepayers' a heavy burden? Quite a number of people with limited incomes who would qualify for limited services within the health services are paying contributions. There should be some arrangement, in which the family doctor would be involved, through the services to which those people are making such a big contribution.

This is a Bill that will be welcomed by everybody in the middle income group. They have become accustomed, particularly for income tax purposes, to making weekly contributions through PAYE. In Dublin there are budget accounts where all weekly bills are paid by companies, through a weekly contribution. I know people who fear that if they must be hospitalised the bills will be very big. This applies particularly to young married couples. Although the Health Act is in operation for a long time, some people still do not know they can have a surgical operation free of charge, except for ten shillings per day hospital fee. This fear sometimes keeps people from having an operation but this weekly contribution of 15p will make people feel more secure. It is a great help to a person who is ill to have no financial worries because of treatment costs. This Bill can be recommended for this reason and the weekly contribution of 15p will be readily accepted by the wage earners.

Farmers, even those in the higher income group, have been very slow to make any contributions towards health insurance, yet it is a worry for them also when illness occurs. The Minister is prepared to accept this £7 per year in instalments and it will take a good deal of worry away from people. I think doctors are to blame in quite a number of cases for putting people into private wards when they are not in a position to pay for them. You have the case of people in the middle income group getting bills because they attended a doctor privately and on account of that they had to pay the full amount. We have all heard of glaring cases like this.

If there was this service contemplated in the Bill I feel it would improve the position. You would get away from the position where people are being sent in through a private service. We hear stories sometimes of where hospital beds are full and you are sent to another hospital which happens to be a private one. I have heard doctors say: "You will have to pay here but it will not be very much". I know some of the bills would stagger any of us. I have mentioned a few of them to the Minister, but his hands were tied and so were the local authority. They could only make the normal contribution, I think it is £1.60 or £1.75 a day, towards it.

I see mention here of budgeting for a surplus. I think the Minister is very wise in taking this step. We are only following in the footsteps of others, but indeed, we could take a lead from other countries. I think the price per day in a Dublin hospital is something around £4 4s. In England at the present time I believe it has gone to something more than £80 a week in public wards. I think that is true. I believe it was only £58 2s in a public ward three years ago.

Business suspended at 6.5 p.m. and resumed at 7.30 p.m.

I had been mentioning how the cost of the health services has risen in England and in America, particularly in regard to hospitalisation. I suppose we will follow to a certain extent. I see that Western European countries are more or less in the same dilemma trying to meet the costs of the health services. England brought in a health service for everybody and it has been the dilemma of successive Governments to try and cushion the overall cost. We know the Labour Party today in England had to make a very hard decision to bring in different charges and to depart from the original intention of the free service.

We hear a good deal about the cost to the ratepayers of the health services. Very few realise that the actual cost to the ratepayers in any place is around 25 per cent, as the Minister has said. This varies from county to county. In County Meath and in parts of my own county it is higher but only by one or two per cent. If we went away from the ratepayers, as has been demanded on numerous occasions, we would lose local control. We might even say that under the new health boards we are losing a bit more local control, but at least 50 per cent of the members are from the county council and the others are from the county concerned so that there is a certain amount of local control and these people would have an idea of the different areas. In that way it is reasonably justifiable to have a certain amount from the rates to meet the health services. You cannot have local control without having to pay for a certain amount for it. It covers a fairly wide field, there is the Central Fund and rates and then this new amount now that we will be meeting under this Bill which is not a very high figure.

I was very pleased to see in the Bill that agricultural labourers and female domestics are excluded. I presume this means that in future they will all have medical cards when they are exempted from the contribution. This is one thing which we have often tried. It is very hard to explain to people who are in this lower income category that they cannot have free medical services which one would imagine they should have.

One aspect which I do not like to see is that it is the Revenue authorities who will be collecting the money from the middle income group who are self employed. I suppose the Minister will argue that it is the fairest and easiest way to know a person's income but I would prefer to see some other body of people, possibly some more humane people rather than the Revenue Commissioners, dealing with this income group. Possibly some of the home assistance officers or some group like that would be better to deal with it.

I would like to throw out the idea on this Bill that possibly at some future stage the Minister might include, under this scheme, the fees of the ordinary general practitioner because this amounts to quite a sizeable figure for the wage-earner, particularly if he has a family and the children get sick. Most children are inclined to get sick quite frequently and if the doctor is called it costs from 30s to £2 in most areas at the present time. This can amount to quite a figure in a week if the doctor pays two or three visits and it takes a good deal of money from the wage packet. Doctors, particularly in the case of wage earners, are inclined to look for their money at each visit as this is the only way they have of collecting it. If they send a bill it will be very hard to collect it. There is a growing tendency in the medical profession to look for their fees. I have heard many parents, especially mothers, say it is a very real worry to them to know how they can meet the local doctor's bills. They may be covered for hospital expenses, but the local doctor's bill is a worry. This is something which might be considered in the future, because it might not take so much extra to cover this aspect of the health services.

People in the medical card category are exempt. I presume that there is some section or regulation in the Bill which deals with the situation that as soon as they get a medical card they stop paying contributions and that they resume payment when they lose it. For ease of administration I should like to see it coming at the beginning of a year so that when the medical card is withdrawn these people would not have to start paying until the beginning of a new year.

Overall, this measure is welcome and will be accepted readily throughout the country. It is an easy way of meeting the health contributions which the middle income group have to meet. They are always worried about hospital expenses involved in a prolonged illness. People who have had to meet such bills will feel more relieved in paying contributions if they can be sure that they will have free medical services.

The Minister, in the Dáil, said that he proposed to bring in regulations during this session to standardise the eligibility for medical cards. As Senator Belton said, it is a great pity that this regulation was not made before the introduction of this Bill. First of all, it would be a great help to members of local authorities and perhaps to officials of local authorities if there was a standard available for the issue of medical cards. Any member of a local authority knows that there is quite an amount of unrest. We hear it said: "So-and-so has a medical card and I do not think he is entitled to it and I cannot get a card". There is no standard or no regulation laid down. It is sad that so many people who should be entitled to a medical card should have to kowtow either to a member of a local authority, a member of a political party, or to an official to enable him to get one.

When we come to those who have medical cards at the moment, we find that there is a certain anomaly in this piece of legislation with which we are dealing inasmuch as a person who should have a medical card will have to contribute 3s per week out of his pay packet, or 15 new pence, that is a total of £7.80 a year. The man on the other end of the scale, with a valuation of £60 or £1,200 a year, will have his free hospital treatment for £7 a year, or 16s less than one who should have a medical card who is stamping a card every week. There is an anomaly there and for that reason it is a pity that the holders of medical cards were not standardised.

Much play has been made of the advantages of this piece of legislation to people who have to pay hospital bills. There is no advantage in this Bill for people who have to pay hospital bills, but there is an advantage in it for a man who would normally have to pay 50 new pence per day in a hospital. He saves £3.50 per week if he is sent to hospital and this will cost the State on the figures here—perhaps the Minister will correct me if I am wrong on these figures—£700,000. In lieu of that they will collect £5 million. I think it was Senator Belton who pointed out that part of that £700,000 will now be paid by the local authority.

There is very little in this Bill for the middle income group, those who do not hold a medical card and who have to go to their local doctor or the dispensary doctor to be examined and provided with a prescription. It is the prescription he brings to the chemist that is the most worrying thing a patient has to contend with. He knows if he is sent to hospital, it will cost him only 50 new pence per day. When his prescription is compounded by the chemist and he receives the bill he finds that it costs him much more than 50 new pence, and may, perhaps, cost him as much as a week in hospital. There is nothing in this Bill to protect that type of person.

What the Minister has said is true, that there are certain types of chronics, such as diabetics, who may benefit as a result of regulations under this Bill. There is a very interesting paragraph— the second last one—in the Minister's introductory speech and I think it is worth reading. I might ask the Minister one or two questions on it. The paragraph reads:

In the 1966 urban household budget inquiry, the amount spent by the average household in the limited eligibility group each week on medical expenses was shown as about 30 new pence. The amount spent on drink and tobacco was 162½ new pence. The people of this country devoted 11.14 per cent of their personal expenditure for goods and services to the purchase of alcoholic drink and soft drink. I am sure you will agree that in the light of these figures the 15 new pence weekly contribution is a very reasonable insurance premium indeed. It can be easily borne by the limited eligibility group and can be increased as incomes increase.

When the household budget inquiry was being conducted we were told it would embrace all sections of the community. However, it seems to me that that inquiry was conducted amongst the mohair group or the elite because no one can believe that the average person spends 162½ new pence on drink and tobacco. There are very few people in the income group with which we are concerned in this Bill who could afford that kind of luxury.

Senator Crinion referred to the anxiety of people who had to go into hospital because of the amount they would have to pay. That person is now relieved of the 10s per day hospital charge and that is the only relief given to him under this Bill.

I am disappointed with the Bill and I am sure the Minister is disappointed with it too. The Minister for Health is a Minister to whom many have paid tribute and I do not believe he was happy at having to introduce such a Bill as this in this House. It is a Bill that should have been introduced by the Minister for Finance because it attempts to collect an extra £4 million from the taxpayers. On the figures given we find that we can collect £5 million to £5¼ million and by doing so we can relieve the people this Bill is intended to help of hospital payments of £700,000.

I would agree with Senator O'Brien when he says that if there is a profit of £4 million under this Bill the regional health boards should be the first to benefit as a result, because there is very little benefit for the people it was intended to help.

Anything to do with health is naturally an abrasive problem. So many people are implicated in the administration of the health services in each county that it is almost impossible to indicate precisely where costs have escalated. I am not at all impressed with reports of the health costs in England and America and I was surprised to hear somebody refer to them. We are an entirely different economy and there is no point in trying to relate the health costs here to those of England and America.

I have had some experience of the health services because I was chairman of a hospital committee. In that hospital we had some good doctors and more who were not so good. Sometimes doctors do not pay as much attention to their patients as they should. What concerns most people in public life is the qualification point—I should hate to see it written into legislation—for medical cards. The Minister was here, I think, when I made this point on a previous occasion. The main difficulty is to get a point of adjudication. Who can decide when a person is entitled to a medical card and when he is not so entitled?

I know of some people who have a wage of £10 per week and, because they are people who have the natural ability to live on such a sum, they can make that £10 go as far as the person who has £20 per week. On the other hand, there are people who, perhaps through illness or family difficulties, may have £15 per week but find themselves in very serious financial difficulties and in need of help. We have nobody in local authorities with the necessary competency to adjudicate on such a case. I suggested here previously that every county council charged with the responsibility of administering the health services should be provided with the services of a trained almoner who would be the final authority in deciding such cases. Many human factors should be taken into account when a medical card is sought that are not taken into account at present. There is no point in saying: "He has £10 per week so he cannot get a medical card. If he had £9.75 he would be eligible." This is a point on which I feel very strongly. We members of local authorities are pestered because of this medical card business. There are grave injustices in some cases and the administration is too lax in some other cases.

There should be a standard practice whereby every health authority would have a trained almoner who would interview the applicant for a medical card, see his living conditions, the state of his health and that of his family and take all the relevant factors into consideration. It is of paramount importance in the operation of a Health Act which lays down legal limits that all those human considerations should be taken into account. I appeal very strongly to the Minister to have this entire matter looked into.

Mention was made of the Minister's effort to collect an extra £4 million. Who would like to estimate the amount of money that is being spent at the moment on animal medical services?

The ones who are free from turnover tax.

I am quite serious about this. There is no question but that there is a responsibility on people to have a certain amount of preparedness for their own health and for the health of their families. I do not know to what extent they should contribute to this. However, £4 million out of £5 million is not exorbitant. The position should be that every family, rather than 20 cows, be provided for in respect of health. There is no crib about the cow end of it—I never hear it anyway—but there are always cribs about the hospital bills. If the people want services, the effort should be made, although there are many who can afford to contribute only small amounts. I wanted to emphasise mostly the point about the almoners. I know of people who are completely incompetent to decide for themselves. Therefore, I recommend to the Minister that an almoner be appointed to each local authority in order to ensure that the needy people receive medical cards.

First of all, I wish to return to square one, the purpose of the Bill, which significantly is called a Health Contributions Bill, and not a Health Insurance Bill. In the penultimate paragraph of his speech, the Minister makes the only reference to insurance, where he says:

I am sure you will agree that, in the light of these figures—

He refers to the amount of what is spent by the average household on drink and tobacco

—the 15 new pence weekly contribution is a very reasonable insurance premium. It can be easily borne by the limited eligibility group and can be increased as incomes increase.

I suggest to the Minister that this is not an insurance scheme in any shape or form, and that it is a misnomer to describe the 15 new pence weekly contribution as an insurance premium. What the Minister stated in the first paragraph of his speech is very germane to the discussion that followed in the Seanad, and to the content of the Bill. The Minister stated:

The purpose of the Bill is to ease the serious burden of health costs on the Exchequer....

I think we would all accept that.

...and rates through the introduction of a scheme of regular contributions towards the cost of hospital and other services by those who are eligible for the services and who may be regarded as able to bear the contribution proposed without hardship....

Then he goes on to describe the different categories, as described in the Health Act, 1970. With all due respect to the Minister, I suggest that this Bill does not in effect attempt to distribute the burden equably among the classes to be provided for in the Bill. In the first place, it does not take anything off the rates, or if so, I cannot see where it does. In common with other Senators, I am a member of a health authority, the Mid-Western Health Board. We shall be asking our contributing local authorities to increase substantially their contributions to the health board during the coming twelve months. That is common for all health boards.

There is no question whatever of reduction in rates. If the Minister can prove otherwise to the House—I hope that I am sufficiently fair-minded to accept a proof from the Minister—I shall certainly withdraw the statement I have just made. The Bill makes no reference to any reduction in the rates. Certainly, it mentions the serious burden on the ratepayers and about easing that burden. However, in the mechanics of the Bill I cannot see where the burden will be eased. The ratepayers, who are already contributing towards the cost of the health services, are being asked to pay an additional £4 million net towards the cost of their health services, The cost of health is becoming a more and more serious burden, not only in our own country, but in every country in the world.

Another fact of life which has taken the Minister's party about 18 years to realise and for the Irish public to appreciate, is that there is no such thing as a free health service. Somebody must pay the bill in the long run, and many of the slogans about free health services which were touted around the country in the early 1950s are no longer in vogue. It is an indication of the change in the times when the Minister presents a dressed-up Bill which talks about easing the burden on the ratepayers. Indeed, it will ease the burden on the Exchequer to the tune of some £4 million net. In any equitable health scheme the burden should be shared fairly among all sections of the community who are in a position to share the burden. Some are not.

There are three sources from which you can get the necessary funds. The obvious and primary one is the State itself, the rates, and finally the individual, either by paying partly or wholly for his health services, or by contributing to an insurance scheme. The principle of a comprehensive insurance scheme has a lot to recommend it, on social grounds and on many other grounds. It is a sharing of the burden, provided that the premiums are related to the income of the individuals concerned. This Bill makes no reference to the incomes of the individuals covered by the Bill. In fact, the Minister admits that this is a defect in the Bill. He told us:

Ideally, a scheme of contributions of this sort should be graded to take account of the varying capacity of different people to pay and it would have been my preference that, from the beginning, the scheme of contributions should be so designed. However, at this stage it is not possible to implement a graduated scheme, since it has many complicated aspects and calls for a good deal of organisation which the Revenue Commissioners, on whose administrative machinery we must depend, will not be in a position to complete for some time.

We all share the Minister's regrets in that regard.

The Minister is a very dedicated and conscientious public man; he takes a lot of time over his ministerial work; he is very thorough in his examination of a case; he does his homework well; and he is known as a man who does not shirk long hours in preparing a factual presentation to the Dáil, Seanad and eventually to the public. It is a pity he did not take a little more time over this Bill. In this regard the Minister has stepped down a good deal from the high standard he has set himself and maintained over a number of years. This is a shabby little Bill. It is a deceitful little Bill. It does not do what it sets out to do in the first paragraph of the Minister's speech. This House, and the other House would have been glad to wait a little longer for the Minister to bring in a comprehensive Bill that would have been, in a real sense, a comprehensive insurance scheme, equitably sharing the burden amongst those who were in a position to pay to a lesser or greater degree.

We have arrived at the stage where the recipients of health benefits or the people who are entitled to, as the case may be, health benefits are divided into three categories: those entitled to full eligibility, those entitled to limited eligibility and those not eligible at all and who have to pay their way. These are divided by way of income groups. Generally, the lower income group are those who qualify for a medical card. As Senator Honan very rightly said, every public man has come up against the case of the extraordinary means by which medical cards are distributed. There are cases of people who appear not to be entitled to medical cards on the face of it, if one can believe what their neighbours say about their income. There are others who obviously appear to be entitled to medical cards and yet cannot get them. There is a weakness in the system.

Then there are the people in the middle income group, those with limited eligibility, who are the people who are hit the hardest. Many of these are young married people with young families living in SDA loan houses who, with the withdrawal of the rates remission, are paying very substantial rates on their houses, and a large part of the rate goes as a contribution to the health charges imposed by the various health boards throughout the country. They are the people who deserve the greatest sympathy. They have to pay the piper all the time. They have to bring up their children and educate them, they have to meet all the charges that people living in that strata of society have got to meet and they are now being asked to pay a further impost on top of that. It appears, on the face of it, to be a very small impost, but, it is an additional impost on top of the already heavy charges which they are paying. The only thing they will get from that, as I read the Bill—I think I am correct in this because other Senators have referred to it—is that the maximum charge of 50 new pence per day is now being abolished, and for that the people concerned will pay an extra £5 million. I do not think that this can be regarded as equitable in any sense.

It seems to me that this Bill has been very hurriedly drafted and with a purpose in mind other than of assisting the people for whom the Minister expresses concern in his speech. I am one of the public representatives who has been condemning the unfairness of the rates. I have been one of those who has suggested that a greater share of the costs of the health services should be levied on central funds. The rates themselves are an inequitable charge. As we all know, the charge for rates bears no relation to the income of an occupant of a house so that the very system on which a large proportion of the health charges is based is an unfair one. Any variation of that system is only adding to the unfairness of the charge on the individuals concerned. I am not suggesting that a magic wand could be waved to get rid of this problem. It is something that would want to be very carefully considered. As of now the health charges are not fairly apportioned on the public concerned and this Bill will not make it any more equitable. It will have the very opposite affect.

There is the situation where the urban ratepayers are the people who really pay the piper. The farmers have the benefit of an agricultural grant, and good luck to them! The urban ratepayers have no such benefit. Therefore when the Minister talks about the percentage paid by the State on the health charges, within that statement there is a tremendous variation between area and area. The one certain thing is that the urban ratepayers are the people who are paying the most all the time.

The situation is so extraordinary that the landowners inside an urban area, small farmers, market gardeners and small dairying people, do not enjoy an agricultural grant. The Minister quoted some rather significant figures to which Senator Jack Fitzgerald referred a few minutes ago. These figures were taken from the urban household budget inquiry of 1966. It seems quite extraordinary that the average person spends only 30 new pence per week on medical expenses and on drink and tobacco he spends 162½ new pence. On the face of that the Minister would seem to have some grounds for his comment that the people concerned should be able to pay another 15 new pence. The Minister should have mentioned the fact that the people who drink and smoke pay an enormous amount of tax to the Exchequer, which in turn helps the Exchequer to finance the health schemes. This fact should be brought out because when one hears this at first one is a little bit shocked, but as one looks into it a little more closely one begins to realise that the man who takes a drink and smokes cigarettes is paying a huge burden of tax weekly to the Exchequer.

This Bill has all the appearance of rushed legislation and the impression it leaves on me, having knowledge of the Minister's thoroughness in past measures and his dedication to detail and to statistics, is that the prime purpose of this Bill is to relieve the very strained Exchequer of some £4 million. This is the real reason why it has been brought in.

Speaking as a Senator I would have appreciated it if the Minister came around this House and said: "Look we are up to our tonsils in debt and we have got to find some money from somewhere. This is one of the ways which we think we will find it. What do you think of the Bill?" Well, that is what I think of the Bill in this context.

The Minister is also taking powers in the Bill to increase contributions. There is nobody here foolish enough to believe that the small contribution of 15 new pence will remain for long. We might as well get wise to the fact that this 15 new pence will increase in the not too distant future. I am sorry to seem ungracious to the Minister for whom I have personally a high regard but I do think that this measure is a shabby one. It does not do what it purports to do and to a large extent it is an effort to get more money into the Exchequer.

I welcome this Bill. It will get rid of the disparity between the collection of bills in the different areas under section 15 of the 1964 Act and also under the Mental Treatment Act, 1945. In support of that I should like to quote from Volume 255, cols, 559-60 of the Dáil Official Report, where, in answer to a question, the Minister gave the following figures as between different counties of the amount of money collected. I stress collected—it is not the number of bills which were sent out, but the amount of money collected between various counties. County Leitrim, £5,000; county Mayo, which is, I would say, about three times as large, £4,600; county Wicklow, £2,900; and county Carlow, £3,700. Under the Mental Treatment Act, the figures are: County Leitrim, £6,600; county Mayo, £7,500; county Wicklow, £6,200, and county Carlow, £7,000.

It is obvious from those figures that some health authorities have been lenient in the collection of these bills. In my own county, where the people paid up when they were asked to, they have been penalised. There are people in County Leitrim paying more of their share of the bills than people in County Mayo which is three times as large and they pay almost twice as much as those who live in County Wicklow.

Under the Bill the collection of 10s per day will be abolished. The people in my county will welcome the new contribution. They will see it as being much more equitable. I will give the figures between a number of western counties for allocation of medical cards:

County Leitrim, 40.5 per cent of the population,

County Kerry, 44.1 per cent of the population,

County Mayo, 47.1 per cent of the population,

County Galway, 50.7 per cent of the population,

County Roscommon, 51.0 per cent of the population.

There is a difference of 11 per cent between two neighbouring counties, Roscommon and Leitrim. There is no need for me to stress which of these is the richer. Again there is inequity between the distribution of medical cards. This arose because different norms were imposed and used by the officials of the health authorities in the various counties.

I am looking forward to the day when this practice will end and there will be one system throughout the country, such as the means test for the old age pension, etc. It is unfair that honest people living in a particular county who pay their bills should be at a disadvantage because others are let go scot free.

It has been suggested that we have a free health service. Nobody ever claimed that we would have a free health service in which no one would have to pay and that the money would be produced by magic. This was stressed as being Fianna Fáil policy in the early 1950s. My recollection of the 1950s was that other parties had this kind of policy, too. Some of these parties are still with us and some of them have departed. Nobody believes this any more. We all know the health bills must be paid.

It is easy to say the cost should be removed from the rates and made a central charge but that can be inequitable, too. If we remove health expenses from the rates, we are in many instances taking the burden off people with property and putting it in the form of direct or indirect taxation. This will fall on those who are already paying heavily. If we can, in this Bill, make a start in having a more equitable distribution of the methods of collecting money for the health bills, we will have done a good job.

Like other Senators I have to express disappointment at this Bill. I must agree with them that, on reading it and on reading the Minister's introductory speech, it appears to be a very piecemeal and inadequate measure and seems to have been rushed in at the end of a session and not thought out to the extent to which it ought to be. It is based on the wrong principles and, like other Senators, I would prefer to see a comprehensive scheme for the reason stated by the Minister: that health forms an increasing cost to the community and that this will accelerate in the years to come. Unless we have a well thought out, comprehensive plan we cannot possibly cope with this.

In his introductory speech the Minister stated:

As I said earlier, this introductory scheme is expected to yield a gross £5 million in a full year, not a very large sum in relation to the total current cost of health services, but a valuable contribution in our present very difficult economic circumstances.

feel that it is the last phrase "our present very difficult economic circumstances" which has dictated this Bill. It seems to be a rushed measure to provide a badly-needed maximum £5 million at this time and this is being taken solely from the middle income group and not forming part of a comprehensive scheme. I would agree with the Senators who have pointed out that it is clearly a budgetary matter in that no extra services are being provided in return for this contribution by the middle income group.

This is a very inadequate way of facing up to the increased cost of health services in the community. As a lawyer I am astonished at the extent to which it is an enabling Bill. It consists of sections which say "The Minister, may, by order", "The Minister may make regulations". In other words, it is difficult to know on the face of it what this Bill will be like in a few years time. The provisions are entirely enabling and the Minister will fill in the substance of it. I would ask the Minister for some assurance that this Health Contributions Bill, 1971, will not form the basis, as it stands at the moment, of health contributions, and that he will not increase every year the contribution which the middle income people will be liable to pay as a form of increased taxation. I would ask the Minister when it is likely that he will implement the scheme that he spoke about of graduated contributions and for further elaboration about this scheme.

Like some other Senators who have spoken I am disappointed that so many people are excluded from the scheme, especially the upper income group. It is time we faced the fact that the health service is an important factor in the community, that it must be paid for by the whole community d that if there is a certain proportion in the community which does not wish to avail of the services nevertheless they ought to bear the cost of it. There ought to be a distribution of the cost of the service in the community. In a way there might be some analogy here with education. There are still not very many people in this country who can benefit from higher education and yet this cost is borne by the community at large because so much of the cost of higher education comes directly from the Government through taxation. Similarly, there could be some reciprocity in requiring a contribution to the health services from the upper income groups who might not wish to avail of those services.

Another problem with this Bill and again something that indicates that it was a rather hasty measure is the method of collection, which I do not think is a very satisfactory method, and I would welcome an assurance from the Minister that it is a matter which will be regularised very quickly and which will not require the employer to add to the employee's social welfare stampings.

I do express great disappointment with this Bill. It will go down in this legislative year as the Health Contributions Bill which is a very important sounding title for what is really and totally taxation of a certain narrow range of the middle income group, a very limited measure and one which does not meet the problem which the Minister states in his address on the Bill.

I welcome this Bill because, despite what Senators have said during the course of this debate that this Bill will not relieve the rates burden on the community at large, I believe that it will relieve the health——

It will increase the rates.

I did not interrupt anyone who spoke here today and I should like to get the same hearing.

This Bill is more or less designed to look after the middle income group. Those of us who are members of local authorities are not troubled by the medical card holder if he goes to hospital and he wants his bill reduced or abolished completely. We are not troubled by those covered by voluntary health insurance either. The only man who troubles the local authority representative is the man in the middle income group who goes to a hospital and is charged 50 new pence per day. I believe that that man and his family are quite willing and happy to pay 15 new pence in order to have their hospitalisation covered.

I should like the Minister to state what type of people are entitled to medical cards. I do not accept Senator McElgunn's statement that Leitrim pays more than Mayo or Galway even though the figures say so. There are probably wealthier people in Leitrim than there are in poor Mayo because Mayo is the only county in Ireland that has "Mayo God help us" attached to it.

Of the regional health group to which we are attached with Galway and Roscommon, we have the lowest percentage of medical cards in the three counties. We are the poorest county in Ireland at the present time. I suppose we have been for many generations past. It is time there was standardisation throughout the country so that the man who is entitled to a medical card in Dublin will be entitled to the same medical card in Mayo.

I do not believe that because you are a labourer with a large family in a town or city and you receive a £10 or £15 pay packet you are entitled to a medical card. There may be a small farmer working on 15 or 20 acres of land who may have a large family, too, but just because his valuation is a certain amount and he has a car to bring him to a part-time job, he is not entitled to a medical card. That is one of the standards laid down in our county. If there is a farmer on five acres of land, no matter what family he has, if he has a car to bring him to his part-time job such as provided by Bord na Móna, the power station, or the county council, or if one of his family has a car, that farmer is not entitled to a medical card. Until we solve this problem of medical cards we are doing an injustice to a large number of people. A standard should be laid down by legislation to ensure equality in the provision of medical cards, not trusting to the public assistance officer who goes out and counts the number of eggs in the henhouse and other things like that.

Senator Robinson spoke about the upper income group. I do not think there is any need for this House to worry about the upper income group because once a member of the upper income group goes into a hospital the first question he is asked is not: "What is wrong with you? What are you suffering from? Where have you the pain?" but "Are you a member of the voluntary health insurance scheme?" If you are, and you say you are, you will know by the bill you get when leaving the hospital what it will cost you.

I cannot understand why, if a person enters hospital as a member of the Voluntary Health Insurance Scheme for an operation for appendicitis he is presented, on leaving after a period of about ten days, with a bill for 100 guineas, whereas a person in the middle income group who enters another hospital for the same operation will probably be presented with a bill for about £10. I raised at local level this matter of the frightening bills that I think are charged to members of the Voluntary Health Insurance Scheme. It is a scandal that this is allowed to go on in our hospitals. Just because you are a member of the Voluntary Health Insurance Scheme you are charged an exorbitant fee completely out of proportion to the amount of care you get. I do not think we have to worry about the upper income group as regards hospitalisation because if they go in they pay dearly for being a member of the Voluntary Health Insurance Scheme. If your salary is over £1,200 you are covered, depending on the number of people who are members, but it would cost about £30 to £40 a year to cover the whole family. It is a very good thing to be in it, but I do object to the fees that are charged to people who are in it and I should like the Minister to take a note of that. As a matter of fact, when I raised this at local level I had journalists from foreign newspapers coming into this House annoying me and trying to get an interview with me until I told them to buzz off, that I would try and fight it among the Irish people themsleves without their interfering.

Although this £5 million was described as a second Budget, I do not think it is a second Budget. I do not think this £5 million that will be collected will even be sufficient to pay the hospital expenses that will be incurred by the middle income group who pay this 15 new pence per week. We know that if these increasing health charges continue to be imposed on the local authorities as they have been for the past number of years the day will come when there will be a revolution. We will not be able to pay. It is mostly the middle income group who pay these high health charges, especially in my county because we have very few millionaires or upper income group people in our area. They consist mostly of medical card holders and the middle income group.

This is the first real step that the Minister or the Department of Health has taken to reduce the effect of health service charges on the rates. Anybody who is a member of a local authority knows that it is the bill that we present to the county manager from the middle income group which is the main reason for an increase in the rates, plus, of course over the last few years, the increases which hospital staffs have got and the cost of improvements in our local hospitals. It is not altogether the amount of money which is spent on health services which increases our rates; it is the increases that were given to the staff which I maintain are still not sufficient. I do not think the nurse is well paid for the service she gives to the community. Nursing is not a profession but a vocation and it should be adequately paid for.

I welcome the Bill because it is one of the first steps taken to keep the rate charges down for the unfortunate ratepayers who have to meet them. I do not think anybody in my constituency will grumble about paying this 15 new pence per week to have himself and his family covered for hospitalisation costs.

I should like to state at the outset that, in my opinion, this Bill will not reduce the impact on rates. It was not designed to do that. It was designed to reduce the impact on the Exchequer. That brings us back to the old argument about collecting money which is necessary by way of taxation on luxury goods as against collecting it by way of rates, a system which is inequitable, as has been pointed out here today by several speakers, insofar as the amount of rates to be paid by a person does not take into account what he is earning or the size of the family which he has to look after, nor does it take into account long periods of illness and so forth. Anything which adds to the burden of rates is unfair to a very large section of the people.

Indeed it was understood from various ministerial statements in the past few years that the burden of the health changes on the rates would be reduced. Members of local authorities believed that. They had hoped for it last year and the year before. We now have a Bill which makes no provision whatever for the reduction of the impact of health charges on the rates. In fact it adds to the burden. Because of that I am opposed to this measure.

I have grave doubts whether it is a good thing to encourage people to make provision for periods of ill health and hospitalisation. I do not think it right to impose a charge of 15 new pence per week on all classes of people in a certain bracket irrespective of what their income is. A person might be just over the level for a health card and he has to pay 15 new pence, or he might be just under the level of the upper income group and still pay 15 new pence. To have the employer pay the contribution as provided for in this Bill can lead to all sorts of abuses.

If this Bill is passed and a scheme is launched for collecting this £7 per annum from people we can expect an annual increase. That is the pattern. While we are debating the wisdom of collecting this £7 we should remember that the Minister said in the conclusion of his speech: "I would ask the House to support the adoption of this new principle in our health services. This is a new principle." He asked that the House would welcome it. If the House does welcome it we can take it for granted that as time passes this charge will be increased. Indeed, that is hinted at in an earlier paragraph.

I agree entirely with the last speaker and with others who drew attention to the means by which it is decided whether a person should have a health card or not. Every member of a local authority in the country knows that that causes widespread dissatisfaction within the county when comparisons are made with neighbouring counties. In some counties the percentage of people who have health cards is much higher than in neighbouring counties. That leads to a great deal of discontent and dissatisfaction. I realise that it is very difficult to say that persons who earn under £16 a week should have a health card because, as Senator Honan pointed out, there are people who can make much more use of £16 than others can make of £26. A person who suffers a long period of illness and who has had various other setbacks might qualify temporarily for a health card, but others think that favouritism obtains and that cards are given out to certain people who are "in the know" and so on. From now on if a person does not qualify for a health card he will be expected to pay this £7 per annum. Therefore we can expect more and more wriggling to qualify for the health card in order to avoid having to pay the £7.

In regard to what was said by the last speaker, it is quite possible that the person who pays the £7 will have a costly operation for appendicitis. When a man is covered by the Voluntary Health Insurance Scheme it may cost £100 to have his appendix removed. If this scheme is established the removal of an appendix may be more costly in respect of a person covered by this £7 payment. It is like the motorist whose car is damaged a little. He goes into the garage and the charges rocket because the car is covered by insurance, just as the man's appendix rockets in value because he is covered by Voluntary Health. In my opinion that development can take place under this provision, too.

In so far as it is likely to encourage people to go into hospital—a point made by Senator Belton—rather than have domiciliary treatment, it can lead to all sorts of trouble. In Cavan and Leitrim, and probably in several other counties, during the months of winter the hospitals are overcrowded. In December and January it happens— and it has happened this year—that people have to be accommodated on the floor in the hospitals. If there is any increase in the number of people who wish to enter hospital, having paid the £7 and expecting free hospitalisation, for the slightest complaint, that will add to the problem of hospitalisation. We have not a sufficient number of beds in the various hospitals, especially in geriatric units. This Bill will add to the number of people entering hospitals for treatment. It will exacerbate what is already a very serious problem in some parts of the country, and will cause a great deal of annoyance to matrons and nursing staff and to local authorities generally.

What will cause most annoyance is that this is a camouflage Bill with a high sounding title, but it is really a ruse to gather in approximately £4 million to the Exchequer. For that reason, although there are some provisions in the Bill which I welcome, I am opposed to it. It is a very mean way to collect money for the Exchequer.

One point which is of interest to me in relation to Bills of this kind, where a social payment by some category of individuals in concerned, is the problem of political psychology which arises. In some cases it is difficult to persuade individuals who feel that they may not benefit greatly from an increased contribution that their part in the scheme is of value to the community and is helping to deal with the problems of the community as a whole.

As we move forward more and more into the field of socialised health and welfare this is a political problem that we shall face increasingly. It is very important that members of our community constantly feel that the contributions they are asked to pay and the system of taxation is one that is entirely fair and spread proportionately throughout the community. In this way I welcome what the Minister had to say when he dealt, towards the end of his speech with the fear that members might have about any disequilibrium in our taxation system and when he compared the new charges with average household expenditure in certain areas.

A sentence which caught my eye when the Minister was talking about this was that to the effect that the impact of taxation on the various income categories has not been the subject of close analysis here or in neighbouring countries. Looking to the future, when more and more we shall be moving towards dealing with the type of welfare expenditure that is initiated in this Bill, it will be particularly important that we should know a great deal about the impact of taxation on various income categories. I hope the point which the Minister has raised here is one that will be used to get the Revenue Commissioners or other bodies to provide the necessary analysis and background information from which we may make the appropriate political judgment.

It is extremely important that people should have confidence that the tax burden is properly spread over the community. For example, I think many people would find it difficult to accept the Minister's assurance that there is no large wealthy class of people earning from £3,000 to £5,000 free of tax and that the distribution of taxation is such that every section contributes proportionately to its total income. This may well be the case, but I think it would be helpful to have a full analysis to show that this is the case. Certainly, in these days in the Dublin area where ostentatious living is getting go fashionable in some quarters, it is very difficult, except for the particular type of people who may be affected by these contributions, to accept that as a fact. That underlines my point that analysis of the kind about which I am talking would be valuable now and will become more important and helpful in the future.

I am glad to note that the Minister referred to some of the continuing developments from the Health Act of 1970 and I should like to reiterate that I certainly know of many people who are looking forward to the extension of the system for certain specified long-term ailments. I should like to mention one category of which I am aware, that is families with children suffering from the condition known as PKU, which I understand will be assisted from the autumn onwards. That is a good example of a major advance which will be of great value to some families.

I am not sure if I have understood the point fully in regard to the payment of contributions. I understand that the position regarding most lower income group workers will be that when their cards are stamped for social welfare purposes an element will be included for health services. Then, as I understand it, medical card holders will not have to make a contribution. In this situation in which a medical card holder is also a person having his cards stamped for social welfare purposes, the liability to meet the health element in the stamping will be on the employer. I wonder if the Minister could fill in the background here.

For example, is it possible that there would be a problem in the case of a small employer who has a number of employees who are medical card holders? Is it possible that there may be some category of small employer to whom it might be a larger matter than one might think on the face of it to carry this contribution for his employees who are medical card holders? This may possibly be the sort of practical case which is difficult to forecast and I should be interested to know if the Department have any views on how these contributions will work out for small employers in particular.

We must welcome this Bill because, in common with other countries, we have the great dilemma of the soaring cost of the health services. It is only right that those in a position to make an extra contribution, apart from their general contribution through taxation, to the health services should do so. The contribution proposed in the Bill is fair and equitable. However, I am disappointed that the Bill does not take into account the varying capacity of people to pay such a contribution. One might say that this point is not important because the amount at stake is only 15 new pence per week at present but we all know that figure is only the tip of the iceberg and in four or five years' time it will have increased to four or five times its present amount. At that stage the greatly increased contribution from the middle income group will impose a very serious burden on some people and for that reason I feel it should be apportioned having regard to the varying capacity of people to pay.

There is a great deal of dissatisfaction with our present tax structure but the most obvious generalisation is that the young unmarried members of our community do not contribute their fair share in taxation. I spoke today to a young man who had returned to Ireland after spending seven years in the United States. I asked him for his impressions of present-day Ireland. He said that he had been saddened by the great increase in drinking amongst our young boys and girls. These young people should be encouraged to contribute more in taxation for the benefit of our health and social welfare services. It might help to make such a tax burden more tolerable if we could show that specific tax increases were levied for a particular purpose. It would be very satisfying to realise that our young unmarried wage earners were foregoing a certain amount of their personal allowance to enable more money to be provided for the care of the older members of our community. We are lagging behind most other countries in the provision of geriatric treatment for our old people. We should provide more homes for the aged and extra home helps.

I am very disappointed to find that the Government and the Department of Health are dragging their feet in regard to the implementation of the Health Act, 1970. The valuable provisions contained in that Act which provide for assistance in the case of persons with costly chemist bills and extra home help services for the aged, which would result in a reduction in the number of aged people needing institutional care, should be implemented as soon as possible. The need for such services is obvious but at the same time I realise they will cost a great deal of money. However, I can see in the delay in the implementation of the Act the dead hand of the Department of Finance. I appeal to the Minister to push ahead with the provisions contained in it. Any delay in implementing those provisions in order to save money would be very foolish. We realise the only way to keep the health services within reasonable bounds is through the provision of home helps in order that old people will not become institutionalised. There is more humanity in providing extra home helps than in sending those people into institutions.

I wish to refer also to the excellent work being done in our cities by the meals-on-wheels service and other visiting organisations. The Minister would do well to make some financial help available to those organisations. As far as I know at present they operate on a totally voluntary basis. They have the willing helpers who are properly motivated to pass on the cheery word to those they visit but if a little public finance could be allotted towards the cost of the provision of meals the service could be greatly extended. The same applies to all other voluntary organisations.

We are getting away a little in this Bill from the idea that the State can do everything and that it is not necessary for the individual to look after himself because it is the State's responsibility to do so. It has been accepted in the higher income group that they must look after their own interests. Nowadays we have the Voluntary Health Insurance Scheme and we are beginning to face up to the fact that the middle income group must make a contribution towards the cost of their own medical services. I hope the Minister will press ahead with the implementation of the other parts of the Health Act, 1970.

I would urge on the Minister the need for an examination of the working of the VHI. There is a feeling at present that the fees charged to them in many cases are exorbitant. There should be a periodic review of the scheme because their funds are contributed by our wage earners. If exorbitant fees are being charged then, obviously, the contributions required from the group must reflect those fees. We should investigate that matter. I cannot see any reason why the fees charged to voluntary health patients should be any higher than those charged under the other general health schemes. Patients get the same service and treatment and I cannot understand why one group should be expected to pay substantially more than another.

We all suffer a sense of shock when we realise the amount of money being spent on the purchase of alcoholic and soft drinks. That kind of luxury-spending by some sections of our community is out of proportion with what a small country such as ours, with a relatively limited gross national product, can afford. Far from having reached saturation point in the taxation of such luxuries the Government have not levied nearly enough taxation on such items. I have just spent some days in Denmark where a bottle of beer costs around 5s 6d. That is substantially more than what we pay for beer here and yet a penny on the pint brings in around £1.2 million in extra revenue.

We should realise that while we have many really hard-pressed sections in our community, especially those with families, on the other hand, we have a tremendous amount of squandermania and it is high time that the Government took cognisance of this. It can be done by earmarking the yields from this increased taxation for purposes of which we all approve. Surely in this connection the care of the old and the care of the sick are at the top of the list. If the Minister wishes to make a radical adjustment in the health services, or in their financing, it can be done. The rates system is outmoded and is unsatisfactory. The amount involved—I think it is £6 million—is an impossible one to provide by other means. However, I suggest to the Minister that he keep it pegged at that figure and that he gives a guarantee that the Government intend to keep it at its current figure, and that from now on they should look for other ways and means of financing the health services.

I also suggest that the middle income group should be asked to provide more through insurance or, as in this case, through health contributions. Many people in this group are very short of money but have plenty of time on their hands. They would willingly donate time but have little money to give. That raises the question of whether it would be possible to get, say, an extra hour's work per week in certain industries, in order to provide the wherewithal to meet contributions, such as they will be in four or five years' time, or other similar contributions for a worthy cause. Nobody would hesitate for one moment to devote an additional hour a week of his time to the care of the sick or the aged. Already, many are doing so on a voluntary basis. However, all could devote more time if the opportunities were available. An approach should be made to workers in industry to make it possible to donate an additional hour's work a week, so that the proceeds should go to whatever laudable purpose is mentioned. That would provide a way and it would be good for our workers to feel that they were helping the aged, the sick and the infirm in our community. I appeal to the Minister to seek ways and means of enlisting voluntary help from those who are not working in a regular capacity, but who have time and would be prepared to carry out social work that is being done at present on a limited scale—meals-on-wheels, visiting the poor and the sick. This is part of knitting our community together, where each cares for the other.

I should like to thank the House for their constructive observations on this Bill.

First of all, I should like to say to Senator Belton that the Minister for Finance did not mention this £2 million as a kind of an aside. It was mentioned absolutely specifically. The fact that the Minister did suggest that there would be a new form of contribution towards the payment of the health services was in itself sufficiently remarkable. I disagree with the Senator that the Minister for Finance spoke in such a way that people would think that nothing would happen until it happened by surprise, and at the last moment. The reason why the Bill is being taken by me, as Minister for Health, is that this concerns payments for health services, which relate to the middle income group, and do not relate to the taxpayer in general. Therefore, it is only reasonable that I, as Minister for Health, should conduct the legislation through the Oireachtas.

The first observation made by Senator Belton and others was that this new contribution would encourage middle income group people to go to hospital. If they go to hospital excessively, their contributions will go up again. It would be very foolish of people in the middle income group to crowd the hospitals in the belief that they would be getting value for their money. It would simply result in the contributions going up more and more and would be a new form of inflation in this country. I hope that the effect of inflation up to now has had sufficient impact on the middle income group so that they will not adopt what would be equivalent to another form of inflation. Secondly, I hope that the medical officers will be slow to send patients for whom treatment outside hospital can be provided to hospital and that the doctors will be responsible in their attitude.

Senator Belton and others also referred to the need for measures designed to keep people from going to hospitals and institutions. At this late hour I do not need to repeat, for the benefit of the Seanad, all the policies that I am devising which are in course of preparation to examine the whole question of the hospital services in this country, greater co-ordination and integration, the development of more and more out-patient services, the development of work study, and above all the examination of a most elaborate data-processed survey of the patient workload of virtually every hospital in the country, in order that we can try to keep down the ever-mounting cost of hospital services.

I do not know if we can get away from the general North European rhythm, that one out of every ten or 11 people spend some time of the year, short or long, in an acute care hospital, exclusive of mental hospitals, where the numbers of people taking part in a hospital service of the kind I have referred to is increasing at the rate of 4 per cent per annum. This is the case in the North European countries with very high and advanced standards of living, where the social welfare services—through these countries having been free for many centuries—have perhaps developed beyond what they are here. For example, in Sweden there are tremendous natural capital resources to be exploited which do not exist in this country. So that, although we work as hard as we can to make the hospital services more efficient, while preserving the very best of treatment, what we could do would be impossible for me to foresee.

There are people on both sides of the Seanad who have been helping me, as Minister for Health, in starting off this integration through the creation of two great hospital authorities in Dublin— the hospital authority to look after the new St. James's Hospital, and the hospital authority composed of representatives of the Eastern Health Board, Jervis Street, St. Laurence's and the Mater Hospital, who make up the board of the James Connolly Memorial Hospital in Blanchardstown, which we are trying to build up into a great general hospital. So we have made a beginning with the development of integrated hospital services, and I hope that this will proceed further.

I do not think I need to repeat all that we are doing in connection with encouraging domiciliary care. The community programme managers of the health boards will be given a policy statement by me when the point arrives in connection with the takeover of the administration from the old local authorities so that they can usefully examine this with the object of increasing the co-ordination between health board services and the voluntary agencies everywhere. With the development of social service councils a great deal of co-ordination work has to be effected. We can see already excellent examples in the case of some splendid social service councils operating in Dublin, Cork, Limerick, Kilkenny and elsewhere.

In reply to Senator Quinlan, let me say that we are providing a sum of £200,000 for social service councils of one kind or another in relation to the care of the aged. The amount was doubled in the 1970 Budget. When it was doubled this meant that the extra £100,000 can be granted without a corresponding raising of rates. We are making an effort in all these directions to try to keep people out of hospital as much as possible. It would take me too long to refer to it in detail.

I have given some particulars in relation to the cost of the health services. I think the House would like to be reminded that between 1958 and 1969 there has been a huge increase in health service costs not only as a result of inflation but as a result of the increase in the volume of the services. I can give one figure without fear of contradiction. In a period of about ten years, from 1958 to about 1969, the volume of health services, after allowing for inflation, doubled. There is an increase in the volume every year. This illustrates the immense advances that have been made in the provision of hospital services and of treatments of various kinds. There has been a doubling in the volume of the services.

As well as that, as the House knows, the remuneration content of the health services is roughly 70 per cent—a very high content. Whenever there is inflation, even on the basis of what might be described as normal inflation in Europe over the past five years, with the two remarkable exceptions of Germany and Switzerland, it has a fearful effect on the cost of health services. When there are occasional bouts of excessive inflation, as we have had from 1965 to 1966 and again from the middle of 1970 to the present time, this obviously adds to the cost of health services.

The total taxation in this country is high. Everybody knows that we have now reached the level of the upper limit countries. There are some 20 or 30 countries in the world where the proportion or value of total production taken in taxes and rates is now above 30 per cent. It is something like 40 per cent to 42 per cent in England. It varies from 30 per cent to 35 per cent in Northern Europe, but the fact is that the rate of taxation here is very high.

As far as I can find out from all the information that I can get the extra cost of the hospital services in the middle income group is something which, taken by and large, must be paid for in some way by the middle income group, either through rates and taxes or through a special insurance contribution which we are asking of them. It would be impossible for me or for the Revenue Commissioners to say how much one particular section of the upper income group are contributing by means of surtax, income tax and estate duties to the hospital services costs of the lower end of the middle income group. One cannot get figures for these things. I have been perfectly honest in speaking on this subject in saying that there is very little information available in any civilised country on the total impact of taxation on various sections of the community. All I know is that if I take 60 per cent of the population as getting the middle income group services it is quite obvious that I cannot ask the medical card group, comprising roughly 30 per cent, to make a contribution to the mounting costs of hospital services in the middle-income group. It is equally obvious that, since the upper income group are paying for their hospital and health services and since the taxation for those at the upper end of the upper income group can be compared reasonably with what can be found in other European countries, the Minister for Finance could not go on squeezing more and more from the upper income group in regard to taxation. For example, a married man without children who has £7,000 a year pays something like £2,500 in income tax and surtax. If he has £5,000 he pays something like £1,300. That is the approximate figure.

If anybody thinks that, after I win for children, one could increase the taxation very largely and keep the many people in this country who, because we live in an international world could leave if taxation mounted excessively, he is not being realistic. It is obviously something that is quite impracticable.

I have been told by all the advisers I have that the middle income group can reasonably be asked to make a contribution. This contribution, once it becomes large or larger than I have proposed, must be income related so that it will have a fair impact in relation to the lower income section of the middle income group.

I noticed that the Fine Gael speakers did not refer in any great detail to the Fine Gael contributory insurance scheme. I imagine the reason was that it became out-of-date very quickly in all its aspects because of the mounting costs of the health services. If the scheme is examined it will be seen that it can almost be compared with some other prophesies that were made as to what the health services might cost by other Members of the Oireachtas from time to time who had optimistic conceptions on this question.

The question was asked whether the £5 million would be a relief to the rates. Unless the Minister for Finance can get this £5 million he will have no hope of being able to make a contribution towards the relief of rates. It is quite impossible for me to promise that every single penny of this money every single year in the future will relieve a given figure of the increase of rates. I am unable to do this. It is the general intention of the Government that the £5 million would be in the nature of a relief on rates. It is a method of getting this specific insurance contribution from the middle income group to pay for their hospital services.

I want to relieve the minds of those Members of the Seanad who think that, if I did enough homework, I could have devised a fairer and more perfect scheme. I have asked all the experts in the Departments affected to give me and the Government advice on this subject. I can find no perfect insurance scheme anywhere in Europe. I can find no country in Europe that ever decided to make a complete revolutionary change in methods for providing the cost of the health service. I can find nothing, to quote a phrase used by an Opposition speaker in the other House, but a series of patchwork changes that were regarded as generally desirable, humanly possible and above all politically possible.

I am very glad to be able to tell the Seanad that, from my own point of view and from my own conscience, there is not one single country in Europe where there was started what appeared to be a logical insurance scheme to cover health and hospital services, whether it was based on insurance of the contributory kind or contributory insurance plus patient charges or contributory insurance alone, that has not been effectively wrecked by enormous increases in hospital costs, with a resulting huge subvention, either from the Central Government or by increased patient charges, or some other device. I can find no logically devised scheme in Europe. If you like you may call the British scheme a logical one. What happened when the Beveridge Scheme came into operation in the 1940s? Everybody thought that somehow the insurance contributions levied from the beginning on employers, workers and self-employed people were going to pay for the health services. At the present time only 12½ per cent of the huge comprehensive health service in Great Britain—covering everybody from the cradle to the grave and costing, if I remember rightly, something between £1,500 million and £2,000 million—is now paid from general taxation. That scheme went haywire.

I do not think anybody can bring before this House any logical method of doing this and, therefore, what one has to do is something which is practical from the point of view of political and human psychology and that is have an insurance scheme in which a small amount is paid initially, in which one can feel that it is not having the wrong kind of psychological impact on people.

To give an example. If we wanted to ask the middle income group to pay for the whole of the hospital services it would cost £35 million or 105 new pence per week. How could we do that? In what way could we relieve the middle income group of what was supposed to be their contribution in rates and taxes to pay for these services? This is one of many examples I could give that one has to base taxation on psychological hunches, political hunches. Governments can make mistakes and they can also have their successes. This Government, looking at a very long record of administration, does not seem to have made too many mistakes in doing exactly what every other country does, establish increases in taxation based on political and psychological hunches, and what seems to be fair, with the very limited amount of information that we or any other country have as to what a particular person pays in taxes to pay for the services that that particular person receives. I assure the House that I have looked for research into this. Any research that I have found is algebraically incomprehensible to me and, I imagine, to every Member of the Seanad.

Senator Fitzgerald referred to the household budget inquiry. I can assure him that in 1966 this was carried out with great care in respect of a household containing two adults with children in the £10 and under £20 per week category. This would seem to be close to the typical limited eligibility group. The figure for medical costs was 30 new pence per week and the figure for drink and tobacco was 162 new pence. I believe that the officers of the Department concerned with the household budget inquiry do their work efficiently and conscientiously.

The people in those households must have been very boastful.

It is an average figure. If the Senator wishes to know, the average loss in betting per family is 6s per week. I did not include the loss in betting.

I could get that from the bookmakers.

A number of speakers asked me how we will vary this. May I make it clear to Senator Robinson, Senator Russell and others that increases in the amount to be charged to the middle income group as an insurance contribution will require a resolution in both Houses, and the method of collection, if it changes and becomes a pay-related method, will require a resolution from both Houses to be passed. I cannot say when the pay related measure will come into force, nor can I give any predictions as to what the likely changes are in the level of the contribution. It would be wrong for me to do this. All I can say is that the legislators will have an opportunity of examining both any change in the impact of the collection or in the amount to be charged.

Senator Honan spoke about the assessment of incomes of people for medical card purposes. The chief executive officers are advised, as the Senator knows, by officers who are concerned with social services in this matter. I would agree with him that, sooner or later, it will pay the whole community to see that there are more opportunities for people to have budgeting courses in order that they may make better use of the money they receive. A lot can be done in that direction. The chief executive officers do their best and, as the House knows, exercise their discretion fairly well in regard to medical card hardship cases, particularly in the fringe area between the upper end of the medical card group and the lower income end of the middle income group. A person in the middle income group can get back into the medical card group if the chief executive officer decides that the circumstances warrant it.

I want to make it clear that agricultural labourers and domestics will not have to pay contributions. Without a medical card they can get the hospital service.

I was asked a question about the medical card group. The position is that I am going to ask the chief executive officers to meet and I will give them indications about how they should prepare a scheme for a universal national standard for medical card limits and I will see what they come up with. They have a great deal of knowledge and they can obtain more information from the various areas. I wish to make it clear also that regulations increasing the limit for middle income purposes from £1,200 to £1,600 will be before the Dáil within a few days.

Senator Belton raised the question of whether the rating authorities would be deprived of the income of the 10s per day charge. The administrative cost of collecting the 10s is very high in a great many areas and only a relatively small net sum was, in fact, secured by the rating authorities.

Overtime payments will not influence entitlement to middle income service and that has been the case previously. A person who is out of the insured category but who was insured may retain the right to health services for up to two years depending on his period in insurance. Persons, other than insured persons, whose income goes over £1,600, cease at the end of the year to be covered by the contribution. A man and his wife who are both employed will each contribute if their incomes are under £1,600.

I want to make it clear to Senators that a medical card holder will not have to contribute to this income under the Bill. His employer will have to pay the contribution.

A number of Senators said I have delayed in providing the promised monthly expenditure subvention on drugs. I have already provided from October 1st, great assistance to people who are suffering from certain long-term disabilities and we will make progress as rapidly as we can in relation to the provision of home helps and also the general subsidy on drugs for the middle income group. I am unable to say at what stage we will be introducing that. I should make it clear also to Senator Owens that the upper income group are not eligible for most of the health services, including the hospital services, and therefore to apply this pilot scheme to the upper income group I think would be injudicious and inequitable in the circumstances.

The lower income group are not eligible for higher education either but they have to contribute towards it. It is part of the community service.

I think I have answered all the questions.

Could I ask the Minister a question? All medical card holders would, of course, be exempt from making these contributions. As every member of a local authority realises, you have spot checks and cards are taken up and a person can be without a card maybe for a month, six weeks or two months. Who pays what then? When is he a medical card holder and when is he not?

As long as he has a medical card and until the annual revision takes place he cannot be deprived of the full service that is given to medical card holders. As the Senator knows, in a general way there is an annual revision and then people who have become unemployed and who have very heavy medical expenses can appeal to be included in the medical card group. I do not know that any special change is taking place in that system or that anybody would be deprived of a medical card because of these health contributions.

The point I am getting at is that if a man has a medical card he does not pay the contribution, his employer pays the contribution. If his medical card is taken up some weekend and perhaps he does not get that medical card back, or he might get it back when representations are made in two or three months' time, who pays in the interim?

The medical card holder has to pay as soon as his medical card is taken up. That is inevitable.

Would he have the right to inform his employer?

When he ceases to be in the middle income group and gets his medical card back, then the contributions will cease.

Question put.
The Seanad divided: Tá, 26; Níl, 15.

  • Brennan, John J.
  • Brugha, Ruairí.
  • Cranitch, Mícheál C.
  • Eachthéirn, Cáit Uí.
  • Farrell, Joseph.
  • Farrell, Peggy.
  • Fitzsimons, Patrick.
  • Flanagan, Thomas P.
  • Gallanagh, Michael.
  • Garrett, Jack.
  • Hanafin, Desmond.
  • Honan, Dermot P.
  • Keegan, Seán.
  • Keery, Neville.
  • Killilea, Mark.
  • McElgunn, Farrell.
  • McGlinchey, Bernard.
  • Nash, John J.
  • O'Callaghan, Cornelius K.
  • O'Sullivan, Terry.
  • Quinlan, Patrick M.
  • Ryan, Eoin.
  • Ryan, Patrick W.
  • Ryan, William.
  • Sheldon, W.A.W.
  • Walsh, Seán.

Níl

  • Belton, Richard.
  • Boland, John.
  • Butler, Pierce.
  • Farrelly, Denis.
  • FitzGerald, Alexis.
  • Fitzgerald, Jack.
  • McDonald, Charles B.
  • Mannion, John M.
  • O'Brien, Andy.
  • O'Brien, William.
  • O'Higgins, Michael J.
  • Owens, Evelyn P.
  • Reynolds, Patrick J.
  • Robinson, Mary T.W.
  • Russell, G.E.
Tellers: Tá, Senators J. Farrell and Brennan; Níl, Senators W. O'Brien and Butler.
Question declared carried.

If it is not intended to put down amendments, might I suggest we take all Stages tonight?

I would normally like to facilitate the House but it is not definite whether amendments will be put down or not and in my opinion it would take 1½ to 2 hours to discuss each section on Committee Stage. I do not think we would have time to do that tonight. I should like to facilitate Senator Ryan but I feel in the circumstances that we have not had an opportunity to deal with the question of whether we will put amendments down. As I have said, the discussion on the sections may take too long to continue tonight.

I should like to support Senator Belton on this. I am not happy with the wording of some of the sections. I am thinking of putting in amendments so I should be grateful for time to do so.

Because of other circumstances I have not had time to draft amendments but, having looked at the Bill tonight, I should like to put down amendments to it and I would ask the Acting Leader of the House to give us at least a week to enable us to put down amendments.

Committee Stage ordered for Tuesday, 20th July, 1971.
The Seanad adjourned at 9.50 p.m. until 10.30 a.m. on Wednesday, 14th July, 1971.
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