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Seanad Éireann debate -
Wednesday, 18 Dec 1974

Vol. 79 No. 4

Health Contributions (Amendment) Bill, 1974: Second Stage.

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

The Health Contributions Act, 1971, provided that health contributions are to be paid by persons with limited eligibility for health services. The explanatory memorandum which has been circulated gives information regarding the categories of persons who have limited eligibility for health services, the services to which they are entitled, the rates of contributions fixed by the Act of 1971 and the revised rates of contributions which it is proposed should operate from the beginning of January, 1975.

Since the contribution rates were fixed in 1971 there has been a substantial increase in the cost of providing health services—from £86 millions in the financial year 1971-72 to an annual rate of approximately £166 millions at present. About £120 millions of this latter sum will be spent this year on the particular services to which persons with limited eligibility are entitled, namely, hospital in-patient and out-patient services, maternity and infant care services and the drugs subsidy scheme, compared with a figure of about £63 millions in 1971-72. At the level of charges fixed in 1971, health contributions were estimated to raise about £5 millions or about 8 per cent of the total cost of the limited eligibility services. At the proposed new rates, the income is expected to be about £8½ millions or about 7 per cent of the present total cost of those services. Health contributions therefore, even with the proposed new rates, will contribute less towards the cost of the services next year than they did in 1971.

The Exchequer contribution towards the cost of the health services has been increasing significantly in recent years. In 1975 it will amount to about 90 per cent of the total cost, not taking into account the allocations made for capital expenditure and payments made from the agricultural grant. This trend has been accentuated by the phasing out of health charges on rates, a policy to which this Government is fully committed. The rates contribution in 1972-73 was £36 millions, the last budget year of the previous Administration. In the period April-December, 1974, it stood at £13½ millions. In 1975 it will have been reduced to about £9 millions.

Only about 10 per cent of the estimated cost of providing services next year for persons with limited eligibility, and their dependants, will be met by way of health contributions at the increased rates proposed in the Bill. As I mentioned earlier, by far the major part of health expenditure must be met from the Exchequer. This creates problems that are only too well known to you all, but, as other and richer countries than ours have discovered, there seems to be no easy solution to the difficulties created by the ever-increasing cost of health care. All countries have difficulty financing their health services and we in Ireland are no exception. I said in the Dáil that I am not enamoured by the system of health contributions. In this regard I propose to have a review carried out of the present system of financing our health and social welfare systems generally to see if there is a better system. The scheme of health contributions will of course be examined as part of that review.

It was made clear when the 1971 Act was being debated that the level of health contributions then proposed would hardly remain static. This Bill is designed to revise the rates fixed in 1971 to an extent appropriate to present-day conditions, without prejudice to the outcome of the review which I have mentioned.

In the course of the Dáil debate on the Bill it was mentioned that some farmers are not meeting their obligations in so far as payment of health contributions is concerned. Health boards have in fact been experiencing difficulty in collecting contributions from some farmers who are liable to pay. As I explained in the course of the Dáil debate, the position in this regard is that persons who are liable to pay are under a statutory obligation to do so. Those who fail to contribute may have proceedings initiated against them for the recovery of any amounts due.

It must be borne in mind of course that there may be circumstances which in individual cases might make it difficult for people to make payments at the appropriate time. It would be reasonable in such cases for health boards to accept payment in instalments. I expect them to do so.

I should like to point out at this point that the Act or the amending Bill do not cover persons with full eligibility for health services. Any person who can establish entitlement to full eligibility will not be required to pay health contributions.

I should like to remind Senators also that apart from persons with full eligibility health contributions will not be payable by agricultural labourers, female domestics or female employees in receipt of widows' pensions, deserted wives benefit or unmarried mothers' allowances.

I mentioned in the Dáil that there are two particular anomalies in the present entitlement provisions for limited eligibility for health services which need to be rectified. Firstly, there are at present differing upper income limits for eligibility for different groups of people. The upper income limit for insured non-manual workers at present is £2,250 per annum, whereas for non-insured persons other than farmers it is £1,600 per annum. This is an anomaly which must be removed as soon as possible so that the upper income limit is the same for the two groups.

The second anomaly is the existence of any upper income limit to entitlement to limited eligibility services. As I said in the Dáil, it is the policy of this Government to abolish income limits entirely, and I initiated talks with the medical organisations in that connection. As soon as the review body which I established has issued its recommendations, discussions with the medical organisations will recommence.

I trust that I have explained the need to have revised rates of contributions provided for, and I commend the Bill to the House.

My first function this morning is to welcome the Tánaiste to this House on the occasion of his first visit here as Minister for Health. Perhaps after 20 months of Coalition Government it is significant, to say the least, that this is the first occasion on which a Minister for Health of that Government should bring legislation to this House.

For the last 12 months the Minister for Foreign Affairs has been running around Europe trying to extract from the EEC Regional Fund a sufficient amount of money for this nation. The climax was reached last week when the Taoiseach went to Paris and managed to get the sum of £8 million for this country for the year 1975. One would get the impression from Government Ministers, and indeed from some sections of the media, that they had achieved something worthwhile. But when one compares this sum of £8 million with the amount of money being raised by colleagues of the Minister for Foreign Affairs for the Exchequer one realises it is a mere pittance.

The Minister for Posts and Telegraphs managed during the year to get for the Exchequer a considerable amount of money by increasing the cost of telephone calls, postage and televisions licences. With a stroke of his pen the Minister for Finance, by placing a 15p tax on every gallon of petrol, managed to secure for the Exchequer a sum varying from £27½ million to £35 million. By another stroke of the pen the Government managed to get for the Exchequer the sum of £2.4 million by withdrawing the subsidy from butter and by increasing the price of butter to the Irish people by 4p per lb.

This morning we reach the final straw by the visit to this House of the Minister for Health and the Leader of the Labour Party who is asking us to give to the Exchequer the sum of £3½ million by taxing the workers, small farmers and small businessmen.

I cannot understand the attitude of this Government, composed of socialists on the one hand and advocates of the just society on the other. Throughout their years in opposition, members of this Government scoffed at the 5 per cent in this country who between them enjoyed the maximum share of the nation's wealth. That 5 per cent do not suffer unduly because of increases in the cost of petrol, stamps, TV licences, phones or buses. That 5 per cent do not suffer this morning by this Bill. Robin Hood robbed the rich to help the poor. The policy of the National Coalition Government, the socialist just society, appears to be the reverse of the philosophy of Robin Hood. They robbed the poor to help the rich.

In this measure before the House the Minister is asking the workers to provide £3½ million in order that the Government can give free hospitalisation to the 5 per cent who control the nation's wealth. I cannot understand how any member of the Labour Party could subscribe to this philosophy. We have in the Government today a Robin Hood in reverse. We have a Government who believe that the worker should be taxed in order to provide free hospitalisation to a section of this community who can well afford to provide it for themselves. We have been told that a considerable amount of money is being provided for the health services at present. We have been told that it has increased from £86 million in the financial year 1971-72 to £166 million. We have also been told that the figure for next year is £40 million more than was provided last year.

That could convey the impression that the health services will be vastly improved in the coming year. If we study the breakdown of this £40.5 million we shall discover that there is absolutely no new thinking on an extension to the medical services. A breakdown of the £40.5 million shows us that £20 million will be spent on pay increases and price increases and £9 million will be spent on the relief of rates. Thus the amount of money spent on new services will be relatively small; £1.3 million will be spent on the extra cost of increases in rates of allowances and in expenditure on new allowances for domiciliary care of handicapped children provided in the last budget; £1.2 million will be spent on increases in the rates of allowance; £4.5 million will be spent on general and psychiatric hospitals, including new units and improving staffing and services standards; £1.5 million will be spent on extra places in homes for mentally handicapped persons and new welfare homes for old people; £1.3 million will be spent on development under the general medical services scheme, and £1.7 million on improvements in community care services.

If we deduct what will be spent on paying increases, on price increases and the money provided for the relief of rates, we shall discover that only £11 million extra is being devoted to actual health matters in the coming year. Of that sum there is only one item that is the brainchild of the present Government, that is, the very welcome new allowances for domiciliary care for handicapped children. That covers a sum of £1.3 million.

The rest of the money is being devoted to the continuation of the schemes provided by Fianna Fáil. If we examine them closely we will see that the amount provided for these services is a miserable pittance at a time when practically every county is crying out for an improvement to general and psychiatric hospitals. Surely we must agree that the extra sum of £4.5 million for this purpose is very small indeed. According to the capital budget for 1975, £10 million is being allotted for capital purposes for health for the coming year as against £7.35 million in the nine-month period of 1974. When one turns that into a 12-month period we see that the Government are providing a miserable sum of £200,000 extra for capital purposes for the health service in the year that lies ahead.

No consideration has been given to galloping inflation, to the weekly price rises which are occurring. I would have thought that if the Government were really serious in this matter they would have provided at least double the sum of money for the development of our hospital services in the coming year. Of the £40.5 million increase for 1975 we see that £9 million is for the relief of rates. This was one of the carrots dangled by the National Coalition Government before the Irish electorate in February of 1973. This was one of the ways in which they bought themselves into office. I would submit this morning that, in making the promise to the electorate that they would take health services off the rates, this Government were not honest with the people. They should have told the people that, while the big ratepayers would no longer have to pay rates on health, the workers, the small farmers and the small business people would be asked to subsidise the big ratepayers. On the one hand, the relief of rates on health charges in 1975 will save the ratepayers £9 million. The workers and others are now being asked to pay £3½ million of this amount. The workers must realise that they were codded and fooled by this Government in their 14-point plan. They were codded in other ways as well. They were codded in a much more serious way, in that the balance of this £9 million is being obtained by slowing up the health services. In the 1970 Health Act Fianna Fáil gave the people a blueprint to the finest health services that could be provided. Fianna Fáil gave the green light to the Irish people and to the health boards to provide the people with an excellent health service.

A few months after the arrival of the National Coalition Government, that green light turned to amber and was very quickly followed by red— red for stop. For almost 18 months those lights have been red: stop to the expansion of the health services in the way that they should have expanded; stop to the development of our hospitals both general and psychiatric in the way that they should have developed; stop to the provision of long staying units and welfare homes as envisaged by Fianna Fáil.

The Government applied the red light to compensate for the money they had to provide for the relief of rates. The Government brought their way into office by making this promise to the people. In the health board of which I am a member, the estimate was cut by almost £1 million. If one is to assume that a similar cut took place in other regions, it is very easy to explain how this Government could provide relief of rates.

On the other hand, Fianna Fáil believe that only the occupants of private dwellings should have such relief. Fianna Fáil would not play Robin Hood—we would not ask the workers of Ireland, as the Minister is doing, to subsidise the 5 per cent of the Irish nation who control the vast majority of this nation's wealth.

In the Dáil last week I listened to the amusing contribution made on this Bill by the Labour Deputy from Limerick. I was particularly amused when at column 1516, volume 276, on 11th December, 1974, the Labour Deputy stated as follows:

We have given the people a health service Fianna Fáil could never have provided for them.

I naturally asked myself which party were in office when the Health Bill, 1970, was introduced. I wondered if that Deputy was making a mistake or was he doing something that most Government supporters like to do, that is, to give the people the impression that the National Coalition Government are responsible for many of the tremendous schemes initiated by Fianna Fáil?

I am glad the Minister, spelled out in his speech that the free hospitalisation for insured workers was initiated as a result of the Health Contributions Bill, 1971. That was a Bill pioneered and introduced by Fianna Fáil. Some Deputies who support the National Coalition Government go around the country trying to give the impression that this measure was introduced by that Government since their election in 1973. I should like to read a short extract from the Donegal Democrat of 26th January, 1974. It reads as follows:

Deputy Jim White, speaking in Fintown, told the meeting that as from January 1st the following increases in means for medical cards had come into operation: persons whose incomes do not exceed the following limits are eligible:——

and he proceeded to give the limits.

——Mr. White said that he was glad that this long overdue increase in means was taking place as there were very many people in Donegal who should have got medical cards, but were turned down due to the very small means test. He said that he had kept in constant touch with the Department to have the means increased——

and he advised people to apply for it.

Mr. White also stated that this change was part of the Government policy to see that the weaker sections of the community get the maximum amount of assistance.

Then we go on to the main point.

Deputy White went on to speak about the £7 contribution under the Health Acts, whereby everyone in the country in the scheme would be entitled to "free" hospitalisation from——

When?

——April, 1974. This contribution covered a married man, his wife and family for full maintenance in a public ward, "free" doctors and surgeon's attention in hospital; "free" drugs and X-rays and, indeed, all hospital services. These two schemes——

the Deputy said

——showed a big step forward in health services and proved that this Government was doing something constructive with the problems that face the weaker sections of the community.

Here we have a Deputy supporting the Government going into a small village and no doubt hoping that none of his listeners had to have hospitalisation for three years before and hoping that they would accept from him the message that he was trying to convey— that this Government were responsible for providing free hospitalisation for insured workers. They even tried to tell them in January, 1974, that free hospitalisation would not be introduced until the following April, whereas we all know that this came about as a result of Fianna Fáil's Health Contribution Act, 1971, and that it commenced on 1st October of that year.

Here we have a situation where a Labour Deputy from Limerick and a Fine Gael Deputy from Donegal are attempting to give to this Government credit for the health services that they do not deserve. When this Government assumed office, Fianna Fáil had left them excellent health legislation that would have improved the lot of the people if this Government had continued to have the same interest in health matters as the last Government.

Fianna Fáil's record was so good that in 1970 there were 12 doctors in this country per 10,000 of the population as against 12.3 in England and Wales. We had 2.2 dentists per 10,000 of the population as against 2.7 in England and Wales and we had 64.7 nurses per 10,000 of the population as against 42.7 in England and Wales.

Fianna Fáil pioneered the health services and set up a service which has provided tremendous improvements in the lot of the people who could not afford to do it for themselves. They provided free medicines, free nursing services, a dental service for medical card holders, an eye service, an ear service, a chiropody service, free medical appliances, walking aids, wheelchairs and so on. They provided a hospital service, free milk for mothers with children under five and gave special consideration to travelling allowances for people who could not afford to visit relatives in hospital. They provided social workers, home helps, blind welfare, set up local social service councils and gave them considerable grants to provide coal and other vital necessities for the needy. We have a record in the field of medicine of which we have every reason to feel proud.

After 20 months of Coalition Government—a Government of socialists-cum-advocates of the just society—we are entitled to ask what has been their contribution to the health services. The only contribution they appear to have made is the legislation before this House today. It is legislation to extract from the workers, from the small farmers and small businessmen, the sum of £3½ million. If we were told that this money would be used to provide better hospitalisation or the extra staff that have been demanded and denied in every hospital in this land, or if we were told that this £3½ million would be spent on increasing allowances under the Disabled Persons' Maintenance Scheme; or, better still, if the money was to be spent to provide for dependants of applicants for disabled person's maintenance allowances; or if we were told that this was being spent to provide more social workers or more home helps or to increase the hours home helps give to the needy—because two hours a day, while useful, is not enough—or if we were told that this £3½ million would go to committees looking after the aged, then possibly we would welcome this legislation this morning and we would have to admit that it was being spent in a very important and useful manner. But this money is not going to any of these schemes.

These excellent schemes, introduced and pioneered by Fianna Fáil, have not been making the progress in the last two years that they should, because the Government are not providing the money that they should. Because the Government bought their way into office by reducing the rates contribution to the health services, they had to reduce the amount of money being spent on the needy by the amount of money they have to pay out in rates relief.

Fianna Fáil adopted the report on the care of the aged presented by the inter-departmental committee set up in 1968 and agreed that institutional care should be provided by general hospitals, geriatric assessment units, long-stay units and welfare homes.

Terms were drawn up to ensure that these recommendations would be given effect. I submit that the present Government are deliberately holding up the provision of this accommodation for as many years as they can in order to save them making the investment in health that they should be making.

It is two-and-a-half years since the North-Western Health Board took a decision to provide welfare homes in the towns of Ramelton and Falcarragh in County Donegal. After two-and-a-half years of planning, postponement and so on, the Department of Health are still examining the cost—two-and-a-half years spent on postponement because the Government have to pay out £9 million or £10 million extra per year on relief of rates to keep their election promise, and they had to find this money by slowing up the health services.

This Government have no reason whatsoever to feel proud of their record. It is easy for the Minister for Health to stand up and say that so many extra millions are being spent now than was spent two years ago. The Government have to spend this extra money on the schemes that were introduced by Fianna Fáil. The standards for full eligibility under the general medical services was provided for in section 45 of the Health Act. Each year the chief executive officers review the guidelines, and only on Monday last the board of which I am a member were told that the income limit had been increased from £20 to £24.50 for a husband and wife, with an allowance of £2.25 per child under the age of 16, as against £1.75; £14.75 for a single person living with his family and £17 per week for single persons living alone.

This would cost the health services more money and that was envisaged by Fianna Fáil when the Health Bill of 1970 was introduced. That was provided for by Fianna Fáil in that section of the Bill which stated that adult persons unable without undue hardship to arrange general practitioner, medical and surgical services for themselves and their dependants would be entitled to free general medical services.

If the amount of money allocated to health is growing, there is only one reason for it and that is that the schemes initiated by Fianna Fáil will have to continue or be stopped by this Government. The only contribution that this Government have made to the health services has been the provision of a domiciliary care allowance. After 20 or 21 months of Government, it is a very poor record indeed. It demonstrates clearly to me, having studied the record of Fianna Fáil in this field and compared it with the record of this Government, that Fianna Fáil had and have a social conscience.

Nowhere in the workings of this Government during the last two years can we find evidence of a social conscience. Over the last three years, many people whose incomes far exceeded the limit received demands for the health contributions. This may apply only in the north-western region, or, indeed, only to Donegal, but it has happened many times. A businessman whose taxable income exceeds the limits laid down has a small farm. He receives a demand for his contribution and, believing that this would give free hospitalisation for himself and his children, pays the £7 each year. He does not read the small print in the demand. As far as I remember this clearly states that, if the income exceeds the maximum, even though a person may have his £7 receipt that person is not entitled to the health service.

These demand notices are sent out by using the rate book. A few weeks ago I had a woman in with me whose brother has been living in England for 30 years and who has not been home since. He owns a small mountain bog farm. This lady received a final demand note from the health board for this brother. If I owned a small farm the health board officials would simply see my name in a rate book and issue me with this demand. If a number of people who year by year pay this contribution were to challenge their claim to medical services they would find they were not entitled to the service for which they are paying. I know of one consultant who, even though handed a receipt by a lady, claimed that the family were not entitled to the service. He presented his bill and was paid.

Something will have to be done about this. Now that the demand is for £12 per year, the health services, the Department and the health boards will be subject to considerable criticism from people who even though year by year they pay the demand, may be later denied the service. I realise that this is provided for in the small print but I do not think that this is good enough. People should be told that, if their income limit is in excess, they will be stricken off. I do not consider that this is a Health Bill.

This morning I read over some of the speeches made in this House on the Bill in 1971 by Fine Gael Senators, who then claimed that that was not a health measure but another measure to increase taxation. In 1971 the Government were introducing a new service, tremendous facility for Irish workers and small business people. Today, in asking the workers of Ireland to pay 80 per cent more, the Government are not providing an improvement in this service. They are doing nothing new. The time has come for the National Coalition Government to stop playing the role of robbing the poor to subsidise the rich. It is time they began, if they have a social conscience at all, to emulate Robin Hood's work in the past.

I welcome this Bill and congratulate the Tánaiste on the tremendous work he is doing as Minister for Health. I could not agree with Senator McGlinchey and especially with the note on which he finished. The Minister has done a very good job in spite of difficulties placed in his way by vested interests. I hope he will continue the battle to have the medical services extended and improved. He has the backing of the general public, if not of the Opposition.

We should all like to see extensions to the medical service but, unfortunately, because of economic reasons this is not possible. For instance, we should like to see the present income limits for medical card holders increased so that the vast majority, especially all working class people, could have medical cards. We look forward to the day when this can be done.

Regarding the choice of doctor scheme, I should like the people whose doctor has opted out of the scheme to get more generous consideration. There are many cases where an outstanding doctor has opted out of this scheme and as a result his patients do not benefit from the free health scheme. People have individual attitudes towards medicine. If they have a doctor they feel can help them, under no circumstances will they change. It is unfortunate that the health scheme, as it stands, does not cater for these people in a better way.

In my opinion the regional health boards have been a failure. The degree of representation which local representatives have on these boards is far too limited. I would prefer if we reverted to the old system of health authorities.

I would be glad if the Senator would pass from that point as it is not relevant to the Bill.

In conclusion, I look forward to an extension and modernisation of existing hospital facilities. The Tánaiste is most suited to carry out that task. Therefore, I recommend the Bill to the House.

This Bill is more than a Health Bill, it is a taxation bill. It imposes further taxation on a section of the community who can least afford it. For some unknown reason the Minister has not increased the maximum figure of £1,600. This amount has remained the same since 1972 despite the increases in petrol, postage and so on. It amazes me that this aspect of the Bill seems to have been passed over by the Press. It leaves one wondering if this has been another Press gag by the Government.

During the last three weeks we have had the imposition of tax on petrol to the tune of £28 million, on butter to the tune of £2.4 million, and in this Bill a further taxation of £3.5 million —taxation totalling in all £33 million. That is an average of £11 million per week by this socialist Government and represents twice the amount of taxation levied on this country by Cromwell. We all know how bad Cromwell was.

This is the true position, but it has been glossed over. I wanted to make this point in case anybody might have missed it. The cruellest blow of all is that it is hitting a section of the community unable to pay. The workers have to pay the tax. The Taoiseach has said we must tighten our belts and that workers must not make undue demands on the Exchequer in the coming months. Yet this is approximately an 80 per cent increase on the working classes, some of whom are on short-time. This is undeniable. It has been publicly stated by Ministers.

At the Labour Party Conference in Galway the workers were asked not complain about having to pay the price of providing health services for those who are not working. Yet three weeks later we have an imposition of an average of £11 million per week on the working classes.

The farmer who is asked to pay this new rate has been and is continuing, to suffer by the mismanagement and the miscalculation of the Government in regard to Agriculture and Fisheries. He has not got the fodder to feed his stock. I learned yesterday that the Government failed to honour a commitment given in the Dáil a fortnight ago. Yet today in this House that farmer is asked to increase his levy from £7 to £12. Have the Government any moral conscience? They had trouble trying to collect the £7, but, in the circumstances prevailing in agriculture today how can the farmers afford to pay an increase to £12?

Only last week the Minister for Agriculture and Fisheries gave a promise to allow £30 under a voucher scheme to help those farmers feed their stock. That amount was cut in half because the Government were unable to pay. Yet the Minister for Health asks those farmers to increase their health contribution from £7 to £12.

I know the Minister comes from an area which includes both sections of the community. If he talks to his constituents, he will learn, that it is the people in these two sections who are asked to pay the extra £3.5 million under this Bill. I do not know why the limit of £1,600 was not raised to £2,000 or even to £2,400 or £2,500. The figure of £1,600 is ridiculous. I am sure the Minister will agree that today £1,600 is no use to a man trying to rear three or four children in a city, country town or rural Ireland.

Has the Minister reviewed the enormous expenses of the health boards in the past two years? Have they given the services they were intended to give? If they have not, why not? I am not a member of the Western Health Board, but I am not blind. I believe that, for a number of reasons, that health board has been a failure. Yesterday the Minister received deputations from two hospitals in the Western Health Board region —Roscommon Hospital and Portiuncula Hospital, Ballinasloe. It is only in the last two years that those two hospitals have been in trouble. There are others the Minister has not heard about yet.

The hospital in Tuam is run privately by nuns. I fail to understand how they have survived so long without help. They must have a wonderful management and organisation. On the other hand, the Western Health Board got a loan of £4 million for the first quarter of next year. If they need £4 million for the first quarter, I assume—and I am sure the public assume—they will need £4 million for the other quarters, bringing the total to £16 million. Has the Minister or the Department vetted the demands of that health board and of every other health board? The last decent act of the Galway County Council, in their capacity as a health authority before the health boards, was the opening of a hospital in Clifden.

The Senator is going into too much detail on hospital services. He is entitled to speak generally about the benefits available but not to discuss the hospital service in detail.

I am trying to find out where the £3.5 million in this Bill will go and how it will be spent in order to give a better service to the people who are paying for it. I am trying to illustrate the point by referring to the Western Health Board, who, I assume, will get a portion of this money. To date the people in the community in which I live have not seen much result from this great investment of public moneys. The Western Health Board have not added one extra bed. No extension has been made to the Galway Regional Hospital, which is a central hospital. In the maternity section of that hospital a woman holding a medical card will be kept in that hospital for three days only. After that she and her baby will be thrown out.

A university student with a medical card wanted to have a foot operation during the Christmas holidays. She was told by the authorities in the Galway Regional Hospital that she would have to wait three months before she could have her operation. It is a scandal that she should have to write asking me to intervene for her. There is a failure to provide under the health services proper hospital care for such cases.

Yesterday the Minister met deputations from Portiuncula Hospital, Ballinasloe, and Roscommon Hospital, two fine hospitals to see what could be done to keep these hospitals open. All this does not seem logical to me or to the ratepayers, the people being asked to supply £3.5 million extra under this Bill. I am asking the Minister to examine the health boards' expenditure. The health boards have done quite a lot of good, but they have cost an enormous amount of money.

I feel that if the Galway County Council were operating the health services and getting one-third the amount of money the Western Health Board are getting, we would have a programme of expanding health services. Every sick person in that area would be well cared for, and the Minister would not have to come here to ask for an extra £3.5 million. There would be no need for this Bill, which is imposing extra taxation on the poorest and the hardest hit section of the community.

I am being fair in my criticism. There are instances in my county that would shock this House and the nation. I know of a poor person who sought admission to St. Brigid's Hospital, Loughrea, but who could only be accommodated in the Mental Hospital, Ballinasloe. That is the type of situation which arises in the Western Health Board area because of a lack of money to provide sufficient beds. The money needed seems to have disappeared somewhere quietly, because we have not seen it. We have not got it on the health charge. There is an increase of £1.2 in respect of the general health charges in our county. Where has this money gone? This is the question being asked by the people in the Western Health Board area. More questions will be asked when they receive demands to pay a further £3.5 million.

Business suspended at 1 p.m. and resumed at 2.15 p.m.

Prior to lunch I was endeavouring to get an answer from the Minister about the manner in which millions of pounds in health contributions are being spent. Are the people who are paying these health contributions getting a fair return? Will the people who are being asked to pay a further £3.5 million get proper health services for the extra taxation and the extra levies being imposed?

Taking into account the millions of pounds that were spent in the Western Health Board area, there has been no extra accommodation made available since the health board was established. I have been trying to find out where the £4 million allocated for the first quarter has been spent. Accommodation in the regional hospitals is not to the satisfaction of the general public.

On the other hand, we have hospitals such as Portiuncula Hospital in Ballinasloe, Roscommon Hospital and also Ballina District Hospital. I have read of the many attempts by Deputy Calleary to upgrade Ballina District Hospital. A stroke of the pen from the Minister would create further bed space, which could be utilised to improve the general health services. In the Western Health Board area also Castlebar Hospital has been seeking training nursing status but that has not been accorded it. There has been no intimation how this £3.5 million will be spent.

There is clamour in the Regional Hospital, Galway, for girls of good education to be trained as nurses. On the other hand, Castlebar Hospital always had the reputation of being a good hospital. We are demanding training facilities for nurses; yet the Minister sits idly by and does nothing about it.

I am afraid I will have to intervene again to point out to the Senator that this is a Health Contributions Bill concerned with the level of contributions. The question of the general nature and level of the services which are available is in order but it is not in order to discuss them in detail. It is not in order to discuss particular problems in detail or particular hospitals into detail. I would ask the Senator, who has already painted in a good deal of background in regard to these matters, to confine himself to the subject matter of the Bill.

I would not dare challenge the Chair's decision. As I intimated earlier, I am endeavouring to find out where millions of pounds are to be spent. I am endeavouring to point out that it is not being spent——

It is not being spent under this Bill or under the Bill which it proposes to amend. The Senator is entitled to place health contributions within their context but it is not permissible for him on this Bill to discuss health generally, the administration of any particular regional health board or any particular hospital.

Again, I would not dare take the Cathaoirleach to task, but I fail to understand the ruling on this. Here we are spending £16 million, gathering another £3.5 million——

The Senator made a remark that he failed to understand the ruling. It is for the Senator to accept the ruling. If he fails completely to understand the basis of the ruling, this is a matter that can be explained to him outside the House.

I accept the ruling of the Chair and always have done. I would like to point out to this House and to the Minister that the vast amount of money being gathered from the people who can least afford it is not being spent properly. I ask the Minister to look into how it is being spent.

In the Dáil last week Deputy Coughlan, who is a member of the same party as the Tánaiste and Minister for Health, painted a very bright and prosperous picture regarding bed space and expenditure of public funds in his health board area. On the other hand, we had another loyal and faithful friend of the Labour Party, Deputy John O'Connell, condemning the situation regarding the expenditure of public funds in general. I quote from column 1520 of the Dáil Official Report for 11th December, 1974:

I would be dishonest to the House, and to the public, if I spoke out and condemned the Health Contributions Bill in 1971 and now fully endorsed it. If I did so I would be a hypocrite and that I will not be. When I decide to be a hypocrite I will quit this House.

What that man was saying to his party Leader was that either he was a hypocrite or that the Leader of the party was a hypocrite. That is how I read it. Deputy O'Connell definitely said that he was not a hypocrite, so there is an inference there from one of the leading lights in the Labour Party, a man who got one of the highest votes in this country.

Deputy O'Connell also stated at column 1521 of the same date:

I am astonished that consideration has not been given to this aspect because Labour Party policy is that taxation, or the Exchequer, take over more of the burden of the health services. We should not be asking this section of the community to bear this burden; we should be asking the entire community to bear it, particularly those best able to do so. It would have been more desirable to ask the Exchequer to bear this.

Here is a member of the Labour Party saying precisely what I am saying. He said that he was not a hypocrite and that Labour Party policy was being thrown to the wind.

Perhaps there was evidence of that in the recent North-East Cork bye-election when the labour section of the electorate ran away in hoards from the Labour Party. They did not all come to Fianna Fáil I know, but we lost only 82 votes whereas the Labour Party lost approximately 7 per cent. Deputy O'Connell, a respected member of the Labour Party, a respected Member of the other House, is saying that the Leader of the Labour Party is not carrying out Labour Party policy. What Deputy O'Connell said is factual. We are spending millions of pounds in all the health boards areas and the people who are paying are not getting from the health services what they are entitled to.

We can read in The Irish Independent of Thursday, 12th December, 1974, a leading article by Mr. Arnold headed “Sharp Jabs and Treacle for Big Brendan”. I would not refer to the Minister in those terms but I am quoting the heading of the article. Deputy O'Connell could have headed his contribution in the other House: “Sharp Jabs and Treacle for Big Bad Brendan”.

This morning, we heard Senator McGlinchey saying that they had not increased the income limit. When I was sitting on that side of the House I understood when the then Minister —the late Mr. Erskine Childers— brought in his Bill, that it was meant for the lower income group and I assumed it would include county council workers. Now we find that county council workers are not eligible for medical cards. With their miserable pay they are being asked in this Bill to be the first section of the community—I think everyone in this House will agree that they are the weakest section—to increase their health contributions by 80 per cent.

The Minister should be fairminded. It appears in this situation he is not, when he maintains £1,600 as the income limit. Some people have suggested £4,000 as a time limit. Here, at the other end of the stick, is the county council worker who is not well paid, and indeed the farm labourer, too, who cannot be included in the free medical card service. The two weakest sections of the community are being crucified by being asked to increase their health subscriptions by 80 per cent, and without a murmur. It is being glossed over by the Press. Is is one of the most cruel pieces of legislation that I have seen introduced in the Seanad. I know of an instance in my own area where a medical card was taken from a man and his wife, who were receiving a small farmer's pension of £9 a week. I appealed against it and was successful, but it was because I thumped on the table, and for no other reason. In the first instance, he should not have been considered for review because anyone should know that when the State has to pay a pension to a man because he has a poor living it has a responsibility to that man, and to others like him.

During the course of the "Late Late Show" on television last Saturday some people made a big song and dance about this. If they had to live in circumstances similar to this man, they would not speak in such manner. Yet officials of the health board take the medical card from that man, while the Minister for Social Welfare was granting him £9 a week in order to try to enable him to survive.

We are talking about public funds. That man should not have to come to me. He should be included in this Bill. I know of an old age pensioner with no other income, who was sent a review form in connection with his medical card. I should like to ask the Minister if that was correct. Is it a fair application of the health services? If that man had not come to me, in all probability he might have been refused a medical card. I am not saying I got it for him, but I am sure every Deputy and councillor in my area could give similar instances. I am giving this instance as an example of how our health boards are working. I should like the Minister, in honesty, to bear out those facts.

I could give instances of children suffering from certain rare diseases, where the mothers of these children got nothing for caring for them. The Minister straightened out those cases. I know of a child who is suffering from a rare disease but because his father is accumulating about £2,300 a year, that child is not entitled to a medical card. I do not understand why a child with a rare disease will not qualify for a medical card. It is hard to believe some of the cases that are brought to my knowledge. In my county we are collecting £3.5 million, and already spending £4 million for the first quarter of next year but we have not one extra bed in the county. We are downgrading two good hospitals. We will not upgrade another good hospital and we will not give status to still another one. I am sure that Senator O'Toole will understand what I am talking about in the Ballina instance. A stroke from the Minister's pen——

The remark to Senator O'Toole is irrelevant.

Senator O'Toole is from Ballina and I know a little about it, since I read the western newspapers. For the past two years I have seen what Deputy Calleary and Senator O'Toole have been trying to do in connection with this. The Minister for Health, with one stroke of the pen, could rectify this but he says that he cannot do it.

We cannot do it.

It is sad. There are patients who should be in St. Brendan's Home in Loughrea but are in the mental hospital in Ballinasloe. I ask the Minister, in conscience, is it right that we are spending £4 million in one quarter in 1974 and collecting a further £3.5 million, in the Western Health Board area? It is not all the fault of the Western Health Board. They cannot do the job if they do not get the money. I do not think that any health board was set up to freeze health in this manner.

I stand over every statement I made in this House, although I may be abused at home when my words are heard. The millions of pounds being poured into the health services are not being properly spent. The people who are paying for them and who are in possession of medical cards are the hardest hit, because they are the people who are on the waiting lists for operations and for other services from the national grid.

I ask the Minister at this late stage to have a look around his Department to see if they are doing anything at all. It is in that little nest that the rotten eggs are laid. It is in the Department of Health that the fault lies. I ask the Minister to use his fist on the table to awaken them up from their slumbers. It is a public scandal to see how some people in the national health services are being treated.

This afternoon we are dealing with this important business of contributions to the health fund. Listening to Senator Killilea one is amazed, and to look back on the debates in 1971——

I was not here then.

It does not matter. I can read.

Senator Killilea said nothing about it in 1971, if the Senator checks.

I am saying, in relation to policy and the introduction of the 15p specific charge in respect of the national health fund, that that represented a very considerable charge at that time on the insured worker. It was an innovation for them and also was an innovation in respect of the agricultural community. At that time this country was spending £86 million on health services. Today the Government and Minister for Health are expending £116 million. This is a very substantial increase in the volume of expenditure for which the Minister and his Department are responsible. Having regard to the tremendous escalation of hospital costs, the vast majority of people that come within the limited eligibility section of the community can be assured of free hospitalisation, free specialist services, free maternity services and limited relief from drug expenses for themselves and their dependants. They are, I would consider, extremely lucky.

Taking the average family to be five, which is the statistical evaluation of Irish family size, it works out at a State fee in excess of 5p per week for coverage for that section of the community. I would remind Senator Killilea that at the time it was 15p on the insured worker and £7 for the agricultural community, the rates bore a very substantial portion of the cost of the health services which the Minister and his Government have removed. In the last year of service of the previous Administration the contribution through these same taxpayers —because a very substantial volume of insured workers and the agricultural community are ratepayers also— was £36 million. Through the decision of the National Coalition Government this has been reduced to £13½ million, which is a very substantial saving for those people.

I would now like to deal with medical cards. Medical cards since their introduction have been a problem. But credit is due to the Minister for, despite the fact he is not yet two years in office, making an effort to introduce uniformity by bringing the health boards and their chief executive officers together and seeking a proper standard of eligibility for medical cards. What was the position before the Minister took over? I never saw a guideline on medical cards. In fact, political influence played a great part in eligibility before the Minister got the chief executive officers and the health boards to endeavour to establish national standards and to have those eligibility standards well publicised for single people, married people and have specific allowances for children.

These are important aspects and I believe the Minister deserves credit for his efforts. We will have an opportunity, perhaps at a later stage, of dealing with the wider aspects of the health services. The aspects on which criticism has been levelled at the Minister here this afternoon are mainly the responsibility of the health boards, who have direct responsibility for the operation of the health services.

I congratulate the Minister for ensuring that the health services will continue to expand. In this wide, comprehensive contribution scheme, no unreasonable hardship is being imposed on those on whom he is calling. Senator Killilea mentioned farm labourers. If he had read the preamble to this Bill he would have seen that the Minister and the Government have excluded farm labourers, among others, from this extra contribution.

My contribution on this Bill will be very brief as I have a bad cold and my voice is not too good this afternoon. I feel it important for me to comment on this Bill because it deals with the raising of increased revenue to finance the activities of the various health boards which have been established throughout the country.

I am one who was never overenthusiastic about health boards. I felt that the work could have been more effectively carried out by each local authority, as was the case previously. However, the health boards are now established. They are functioning and I do not know if anyone has any intention, either now or in the near future, of changing the system. I would ask the Minister, in view of the enormous cost of maintaining the health boards, to examine the administration of the health boards and examine their methods of administering the various headings under which staff officers, personnel officers and so on are appointed, because we have groups who are all lieutenants with very, very few privates under their control. The Minister should seriously consider——

I must intervene because the Senator is going wide of the Bill. He started to discuss regional boards and is now discussing the question of appointments of certain categories of staff. It is very wide of the subject matter of the Bill.

I am trying to indicate to the Minister, because he is the responsible Minister, some areas that he could explore and examine with a view to getting better services for the money being provided.

I am not saying that the points being made are not valid; I am indicating that they are not relevant, though they may have something to contribute to the general background of the Bill. If they have they should only be mentioned in passing.

In order to make a point a person often has to give the background.

As long as the Senator's voice does not give out before he eventually comes to the Bill.

I hope not. This Bill has become necessary to provide the Department of Health with further finances to service the activities of the various health boards. Like every other Bill that calls for new taxation, this Bill is unwelcome now because many people feel they are already being overtaxed and that the proposed increases will add further to their difficulties. Therefore, it is important that the Minister ensures that the best possible value will be obtained from the money he hopes to raise by the further increases mentioned in the Bill.

I am disappointed that there is no provision in the Bill for the extension of hospital services. Throughout the country the hue and cry is for the extension of hospital services. I live in the Midland Health Board area and I live in the biggest county in that area. Mullingar town is crying out for hospital extensions. They are crying out for a major regional hospital, and I am anxious to know if any of the money being raised for those further increases will be channeled towards the provision of hospital services in Mullingar or even towards the provision of a children's ward. The Minister is fully aware, from receiving deputations and so on, of the need for a regional hospital and for a children's ward. We are dealing with the hospital which was first erected in 1938 and which has had very very few extensions since then, despite the fact that there has been expansions in the health services and that many new aids have been introduced into our hospitalisation programme. Therefore, I would like the Minister, to spell out the new items to which he proposes to allocate some of this increased expenditure.

Greater flexibility should be exercised by the CEOs of the various health boards in the implementation of the health services. I refer now, of course, to the borderline cases. There are the cases where the old £7 contribution covered farmers with up to £60 valuation. On a £61 valuation you may have a man who is in more difficulty than a man with a £40 valuation or a medical card holder who has had long periods of illness within the family, invalidity, disease and so on. Those people should be considered under this scheme. The qualifying valuation limit should be increased mainly because of the falling-off in farm incomes and because of the falling-off in the value of agricultural land in general. If the Minister decided to increase the valuation to £65 for the new £12 eligibility, he would be catering for the section of the community that has suffered a great deal since the implementation of the present £7.

The instances of hardship in that category of people are many and their problems have become difficult. In many cases people have been unable to avail of hospital treatment or expensive drugs because of the prohibitive costs of the services involved. Therefore, I would appeal to the Minister to endeavour to increase the valuation limit to £65.

I would ask the Minister to improve and extend the services dealing with the treatment of alcoholics. It is a tragedy in this day and age that alcoholism has become a real and pressing problem. It is a problem that has attracted the attention of many people and one which has caused ruin in many homes. I would like the Minister to establish within each health board area a special unit or special ward solely for the treatment of alcoholics.

I should be glad if the Senator would depart from this point, which is absolutely too specific for a debate of this kind.

The reason I mentioned that subject is that we were dealing with the raising of new finances——

The Senator need not go into any detail in explaining. I am merely asking him to deal with a point which would be more relevant to the Bill.

I am appealing to the Minister to allow the CEOs of the various health boards to exercise greater flexibility in determining the qualifying incomes for the issue of medical cards. Somebody mentioned old age pensioners being asked to have medical cards reviewed. Under existing regulations all old age pensioners qualify automatically for medical cards, and therefore I do not know how any health board should ask that the income of any old age pensioner should be reinvestigated.

I want to draw the Minister's attention to the problem which has arisen in the past with regard to farmers with land valuation and the demand for £7. I have evidence that people have paid the £7 and the following year they have got a demand for £14, and the third year they have got a demand for £21, despite the fact that they have had in their possession receipts for each contribution for the particular years. These errors were due to there being no proper accounting system. I would ask the Minister to ensure that problem does not occur again, because people feel very annoyed when they receive a final notice and read the small print that they are liable to a fine not exceeding £100 if that £21 is not paid, despite the fact that the individual concerned holds already receipts for the £7 each year. This should not happen. The Minister should impress on the various health boards the importance of keeping a proper record of all contributions from people within the various categories.

I refer now to one item in our hospitalisation services which is lacking, facilities for the training of nurses. It is a tragedy that our girls have to go to England to train and come home then and seek employment as qualified nurses. I know the Cathaoirleach will check me again for wandering away from the terms of the Bill, but we lack adequate training facilities——

The Senator, indeed, knows that he is out of order and I would ask that he pass on to relevant matters.

I would ask the Minister to spell out more clearly for us any improvements he envisages in the hospitalisation services in the near future.

I appreciate the difficult job that any Minister for Health has to perform. I readily admit that he has to be a dedicated person and that he must have a great concern for the health of the nation as a whole. In saying that, I am not implying that the present Minister is any different from any other Minister for Health we have had. I freely admit, too, that to give the best service that can be given it is necessary to get the funds because without the funds the services cannot be provided. Those of us who are on health boards, on county health committees or connected with services like that appreciate the enormous amount of money it takes to carry out even slight improvements in these health services. Consequently, one can understand why a Minister for Health has to come in here and look for an extra £3½ million. I find no fault with that, but I do find fault with the method by which it is being done.

This idea of giving people a budgetary injection every two or three weeks is not the best way of doing it. An annual budget is an annual budget, and people should try to budget for the service of the nation for the year ahead. When we take into consideration that £27 million was raised in taxation recently on petrol, £2.5 million subsidy on butter, that is a total of over £40 million and is a very big mini-budget. The people who are asked to pay this are, in my opinion, people who can least afford to pay it.

I agree that the value of money has depreciated considerably since this was first introduced, and I am quite sure that any one will say that £7 three or four years ago would be equivalent to £12 now. For that reason I would agree with this increase because of inflation, but the people who are being asked to pay this now are the farming community, that section of them who have been hit very badly in 1974. This year will go down in history as a disastrous year for the small farmers. Indeed, it will go down as the year when the great exodus of these people from rural districts was started and augmented. When these people pull up the roots and decide to go, it does not matter what type of health services or what type of schools we have, Ireland will be losing the best part of its people.

I do not want people to stay in places like that and live in poverty. The people who were living on these small farms were hard working industrious people who made a wonderful contribution to this nation. They were the people who brought in the milk to the creameries and ensured that thousands of our workers were kept in jobs in milk powder factories, making butter and cheese, and in various other industries based on agricultural produce. The day we lose that we will lose something of great value.

There is another section who will find that their contribution increased from £16 up to £26. It is easy for other people to say that that increase is only the price of a packet of cigarettes, but all these things add up. The natural question any of these would pose is, if it is necessary to provide all this money, why was the Minister for Health suggesting that we should have a free-for-all health service up to the very top of the scale. Why was that being contemplated when at that time thousands of people were quite satisfied to join the voluntary health and were able to pay for their own services? The people we have to keep an eye on are, of course, those people who are sick and, in particular, those who have not the means to pay for their medical attention. You will find these people are in the lower income bracket and these are the people for whom we should cater. We could not try now to saddle an overburdened rural community, in particular, small farmers and these workers, with this extra taxation.

In the dental service there is ample room for improvement. There must be something wrong with our health services and our whole approach if in 1974 young people have to have teeth removed and find that when they come to 20 years of age they have to get artificial teeth. There is something wrong with our food and our health services and things in general. Prevention would be far better than cure and some body should be set up to study this, because it certainly tied up very closely with the health services. There is another discrimination that is often made, and that is in dental services for children who are over 12 years of age——

Again, I must intervene. The Senator is talking in detail about particular aspects of the health services. This is not a debate on the health services; it is a debate on health contributions.

I was just making the point that children who leave national schools at 12 years and go to a secondary or a vocational school are caught between two stools and they have no dental services.

Another point I would like to mention, although I suppose it has been flogged often enough, is our hospitalisation services. In my county of Cavan over the years various bodies have made representations for the new hospital there. I am a member of the health committee and I am a member of the health board; I am also a member of the Dublin Hospitals Board, and they have all cleared this up along the line to have this hospital built in Cavan where there is need for it, due to fire hazard, inadequate equipment, and a danger that the staff would become depleted. I would appeal to the Minister—he is a reasonable man— to make his decision on this and to press the Minister for Finance to provide the finances. We have to accept our geographical position in the northwest, but when we see that already three hospitals have been sanctioned for Dublin city, we up in the northwest feel we have been left out. We would not be asking to have this done except that it is needed for the patients in that area and that it is long overdue. I am quite confident the Minister will make the best possible provision for us.

There is another point, which may not be a matter for the Minister, but I have often felt that in setting these various guidelines for giving medical cards or giving other benefits this practice of providing for valuations of up to £20 and then probably from £20 to £35 and £35 to £50 is antiquated, and there should be a sliding scale. It might be difficult to administer but it would be better for the individual.

The Senator is departing from the subject of the debate.

I shall not intrude further in the debate.

I should like to comment very briefly on what has been said here already and on the health services in general. Firstly, on the introduction of the health boards many people had misgivings in varying degrees about the new board's ability and capacity to give a service to the public. The old system, worked on the county basis, had been there for many years and the attempt to rationalise a system through the introduction of health boards covering wider areas was looked on with a certain amount of apprehension at the time. But after some years in operation we are now in a position to look back and assess to what degree the health boards have been successful in giving us this service.

The Senator will have to wait for another occasion on which to make that assessment. The organisation of the health services is not relevant to the Second Stage debate on this Bill.

The reason the Minister has to ask for an increased contribution is that the yield from the local authority rate has been diminishing since the Minister took office. We now find ourselves reaching a situation whereby the total dependence of the health scheme will be on the Exchequer. We all know that we are living in a period of inflation and in order even to mark time we must provide extra finance which must come from somewhere. When the Minister and Government decided to take the health costs from the rates the only other source of income for the Exchequer was from increased taxation.

This increase of £3½ million has been mentioned by Senator Killilea as being a vast one. I would not quibble with figures but I would quibble with his use of the English language. He mentioned "vast" and repeated it a few times. Three and a half million pounds on a total expenditure of £166 million could not be regarded as a vast expenditure. It is a very small percentage of the total outlay.

The position with regard to taxation increases, we know, is that it will hit many people who are ill-prepared to pay the extra cost. However, there is real hope for the future in what the Minister has said, in that he is prepared and has under active consideration the whole review of the financing of the health scheme. This is something for which we should be very grateful. Before I conclude I should like to point out that the Western Health Board have been mentioned here.

If the Senator is to be out of order, would he be quick about it?

I am told that in upgrading and downgrading of hospitals it is a function of the health boards to make representations to Comhairle na Ospidéal who decide what kind of grading a hospital should get. I would suggest to the Minister that Comhairle na nOspidéal are made up of faceless people, that they have not been elected. They have great influence and authority. Because of their make-up they have too much authority and the Minister should look carefully at this situation to see if the administration of the type of hospitals we want is not placed in the hands of people who must not face the public and must not stand over their actions. The Minister is being used by Comhairle na Ospidéal as a man who must face the public to carry the can for them. This is unfair. The present format under which we all work was introduced by the last Government. The Minister is now trying to see in which way this can be improved and he is to be complimented for this effort.

I will be very brief because, as you have pointed out, much of the debate on health matters is not relevant to the Bill. This Bill is basically a taxation Bill. It is concerned with how to raise moneys so as to continue the existing level of health services. The whole principle involved in raising money in this way is regressive rather than progressive. The Minister admitted in the Dáil that that was a view that many people held. There is not much merit in relieving the rates on one hand—rates relief is a regressive form of taxation—and on the other seeking to increase payments of this kind which are basically taxation payments on a fixed headage basis. The fixed payment basis in regard to mature persons now rises to 26p per week and in regard to farmers of under £60 valuation to £12 per annum, an increase of 80 per cent in each case. These measures are just as regressive in the form of payments to revenue as rates, and they have the weakness in contrast to rates that—we made this point consistently in the argument against the manner in which the rates were relieved by the Government after the last general election—by applying that relief right across the board, many people, not just those in the middle income or the limited eligibility groups but those at very high rateable valuation levels, in the private, industrial and administrative areas, were relieved of rates in respect of health contributions.

This has been our consistent criticism. We are now going back to a regressive form of taxation but it is limited to people who cannot afford it. Under the redrafted regressive taxation system of rates relief in regard to health charges, people above the social welfare insurance category and the £60 valuation—firms, insurance companies, banks and so on—were relieved of their liability to pay rates in respect of health charges. I concede that the Minister and the Government were in the straitjacket of an election promise, which was very inadvisable. They will now have to reconsider it.

The Minister has rightly set up a comprehensive review in the whole financing of rates and social welfare. What will emerge in that review is some form of differential within the rate relief system so as to ensure that ratepayers in the very high income category are not relieved of liability in respect of health charges while at the same time introducing an 80 per cent increase in the form of regressive payments per head by people who are social welfare contributors and farmers under £60 valuation.

This is a retrograde step. I appreciate the Minister's situation. He is faced, as he said in his statement, with a bill in respect of health services which cannot but create alarm, a jump from £86 million in 1971-72 to an annual amount of £166 million. I thought that in the Dáil, by implication, the Minister was quite frank in implying, without saying it specifically, that this presented very serious problems to the Exchequer. The Minister said specifically, when he referred to the problem, that during the next two years there would be serious Exchequer implications particularly in regard to the growth of revenue. This holds problems in finding sources for the financing of the health services.

This is why—I am being very critical here—I feel that the Government have got themselves into a straitjacket over their pre-election promises in regard to rates. By reason of that they are depriving themselves of a source of finance in the very top income and ratepaying bracket. That source of finance would be available to them only for the blanket nature of the pre-election promise which meant that they were cut away from a very fruitful source of revenue that would lie in the area of very high income ratepayers.

They now find themselves in the situation that in order to get a mere £3.5 million they are bringing in an 80 per cent increase for the very category whom the health services should now be designed to assist to a greater degree, the limited eligibility category who, by reason of the galloping inflation in which we live, are now in the category that should be within the segment of the general medical services. The people who are now being hit with an 80 per cent increase are people many of whom, by reason of the present cost of living and the inflation situation, are being included in the category of general medical services.

The Minister expressed very frankly the difficulties that health boards are finding in raising the present annual sum from the farming community. I feel that in the straitened financial situation which we have one aspect that should be supported is that of reconsidering the rates relief which is given to the very wealthy ratepayers. The second aspect which will have to be explored—the Minister can get away with it at a Labour Party conference or through the Labour Party—is the question of pursuing the free for all health and medical scheme in our present circumstances. The Minister is well aware that it is just not on in the present financial situation. We do not have the hospitals and there is no sign of the capital being available to provide the hospitals; we do not have the facilities or the capital to provide the facilities; we do not have the personnel on the medical and nursing side to provide for such a free-for-all scheme. All we are doing by following a doctrinaire approach rather than a pragmatic approach is bringing in again the wealthy category that could be well serviced through the voluntary health scheme. I feel the logical way to do this is to expand the voluntary health scheme for that category, and within the middle and the lower income category to improve the services considerably in these two areas.

The two areas that I think should be improved enormously are the dental services and the people who are suffering from permanent illness. We should gradually blend the general medical service category—the lower income group—into the middle income group by taking a greater share of the middle income group into the free medical services net. From the viewpoint of pragmatic improvement and in the period of scarce resources that will be with us for the next two years—the Minister mentioned this— we should be concerned about allocating revenue for health purposes in the most effective manner possible. We should not waste money in an area where it is not required. I am talking about the upper income category. If we do not have the hospitals, facilities and the personnel to do it, why do it? In an era of scarce resources we should devote the resources to where they are required, the areas of people in the middle and lower categories. We should devise taxation methods that will burden those two categories as little as possible.

This measure burdens one of those categories totally. The only people affected here are the people in the middle income category who are being asked to pay an 80 per cent increase for health services while at the same time the Minister is planning to have a radical change in the health services. He is going to bring in a wealthy category that will burden everybody to a greater degree, while at the same time people in the higher rate paying category are being relieved of the obligation to pay health charges.

I make those few remarks because I think they are relevant to the Minister's problem. I know his problems are part of the overall Government problems in the present situation. I think that in any review of the financing of the health services the two attitudes I mentioned will have to be borne in mind. Regarding the Health Bill we are now being presented with, the doctrinaire scheme that was announced by the Minister at the Labour Party Conference is just not on. The Minister would get far more credit from the community if he was straight with them.

My implication arising from his speeches in the Dáil and in the Seanad on the very frank picture of the revenue situation, is that it is not on. A comprehensive scheme to include all the people including the wealthy category is not possible in our present situation. We should concentrate on the areas of real need. In that situation the financing should bear as lightly as possible on the people who are in real need.

I will also be brief. I think it is necessary to stress again— it has been stressed by Senator Lenihan—that this is essentially not a Health Bill but a taxing Bill. It is part of the general pre-budget activity on the part of the Government designed apparently to load as much pre-budget taxation as possible on the community in order to lighten, or seem to lighten, the ultimate effect of the budget itself.

The Minister pointed out that one of his problems is that there is a considerable shortfall this year in receipts from these contributions. The figure he is short is £500,000 due mainly to the fact that farmers, in particular, have done very badly this year. Owing to the extreme economic problems that they have been suffering they have been unable or unwilling to pay this £7 per week. Therefore, the Minister is short a half million pounds. It seems an extraordinary time for any Minister, particularly a Minister who always claimed to be progressive, to come in here and load a still further demand on those who have already shown that they are unable to pay.

The Minister gave very little hope for these farmers and others who have been unable this year to pay their contributions. He said he accepted that there would be circumstances which in individual cases might make it difficult for people to make payments at the appropriate time and that it would be reasonable in such cases for health boards to accept payment in instalments. He expects the health boards to do so. I would have thought that a better way to do it would be to suggest that health boards, where satisfied that the individuals were unable because of economic circumstances to make these payments, should remit them. There is no question of that: the Minister makes it clear that the money must be paid but that he expects the health boards to accept payment in instalments. The Minister admits that people are unable to pay but he further stresses that people who do not pay may have proceedings initiated against them for the recovery of the amount due. In this very difficult situation he put an increase of 70 to 80 per cent on the contribution. As Senator Lenihan said, of all the systems of taxation that could be devised, this is the most regressive. It is worse than the rating system itself because the rating system is, in a crude kind of way, geared to the rateable valuations of the people involved whereas these contributions are blanket sums that do not depend in any way on the size of a man's farm or the size of his income. It is a most regressive form of taxation.

The Minister in his speech in the Dáil—he was wise to omit it from his speech here today—took the opportunity to stress the need for all concerned to moderate their demands for increases in incomes. How can anyone expect people to moderate their demands for increases in incomes when the Government are simultaneously taking steps which have the direct effect of reducing their incomes? This is part of a general pattern of Government policy in advance of the budget. It is, of course, one of measures of this kind.

A month or two ago we had the extraordinary onslaught on the public by the Minister for Posts and Telegraphs in loading some £13 million extra on postal and telephone charges to meet a situation where the deficit in his Department was a mere £3 million or £4 million, but the extra £10 million or so was added. We had the notorious petrol onslaught, another £27 million; we had the removal of the subsidy on butter so that consumers, particularly those with large families and small incomes, had to pay an extra 4p per lb. This meant another £3 million for the Exchequer. Finally, we have this rather mean little Bill which adds another £3½ million. The total of these so far this autumn, in advance of the budget, before the budget proposals have even been framed let alone introduced, means that all of us are paying an extra £46 million per year. This is merely part of a much larger pattern and it should be treated in that way.

This Bill does nothing to improve the health services—no one will be any better as a result. It is simply ludicrous for the Minister and others to suggest that it is necessary to bring this in because of a remission of rates. We were not told at the time of the last general election that if the burden of health charges on rates was remitted the ratepayers would have to pay additional sums of this kind. These are two completely different things. Rates should not be brought into it at all. This is simply a taxing Bill. It can be included with the petrol taxation, with the removal of the subsidy on butter and the vast increase in postal rates as an advance notice of the budget in an effort to relieve the Minister for Finance of some of the problems that he will face on budget day. For that reason we must oppose it.

I should like to thank Senators who contributed to the debate. I appreciate their concern about local matters and about some of the general matters raised. I was intrigued to discover that at least one of the prominent members of the Fianna Fáil Party was disillusioned about the health boards. He described them as failures. It is only a short time since these boards were established and Senator Killilea suggested that there was waste, that there were too many people employed, particularly by the Western Health Board. Deputies in the other House were full of praise for that health board, and in particular for the CEO.

The health boards have been established and it would be almost impossible to reconstitute them on the basis of counties. If there is waste, if there are too many people employed, I suggest that members of the health boards would pinpoint where these problems occur. So far as the Department are concerned, expenditure is severely monitored and new appointments are not easily made, unless they are absolutely necessary.

It is a bit late in the day for Fianna Fáil to say that we should revert to the old system whereby the county council were the health authority area. The health boards were made to ensure economies. It is difficult to compare present costs with those incurred under the old county system but let nobody be under the impression that moneys expended on the health services are squandered in any way. It was a bit of a contradiction when the Senator who referred to waste of money said that there were not enough moneys being allocated to the health board in his region.

I was intrigued to hear Fianna Fáil Senators talking about the shortage of hospital beds. Fianna Fáil must take a fair share of responsibility for that. I am not referring to their 16 years of office; I am referring to the time when Deputy Seán Flanagan, as Minister for Health, instructed what were afterwards called the Fitzgerald Committee to draw up a plan for the country. This plan was presented to the Government in 1968 and nobody will deny that from 1968 to 1973 nothing was done about the provision of hospitals and although they said they accepted, in general, the Fitzgerald Report, nothing in the world was done to implement it, to have it discussed or to have it moderated or supplemented in any way. I have been given the task now and I am going about my business as a democrat should.

Apart from the report of the working parties in the various areas. I undertook to consult and am now engaged in consulting local interests. The decisions will be made as soon as possible. In some areas they will not be popular decisions; in other areas, where acute general hospitals will be established, they will be popular decisions. Sometimes we regret what we said five or six years ago, either in the Dáil or in the Seanad, but I was amused to hear Senator Yeats, Lenihan and others describe this as a taxation Bill. If it is a taxation Bill now, what was it when it was introduced in 1971?

A taxation Bill, but call it that.

It was given the title "Health Contributions". Senator Yeats said also that it was neither right nor proper to have pre-budget legislation of this kind before the introduction of the budget next month. One could make the same criticism of the regime in 1970 which introduced this particular scheme about a month after the budget was introduced.

If it had been before the budget, there would be the same criticism. This health contribution was meant to be permanent. Fianna Fáil Senators know that better than anybody else. It was made clear in June, 1971 by the then Minister for Health, the late Mr. Erskine Childers, who said in the Official Report at column 334 volume 255 that "contributions would not remain static and were bound to increase". In what circumstances would there be increases in health contributions? Nothing was done from 1971 to 1973. I do not take the former Minister to task about that. This Bill increases the rates fixed in 1971. It is not unreasonable that they should be increased particularly when one has regard to the increases in all other costs, particularly in the field of health. I will not go too deeply into the colossal increases that have occurred in the various fields of health.

The health services in 1971-72 cost £86 million and in 1974 cost £166 million. That is an increase of £80 million or 93 per cent. One would imagine, in accordance with the manner in which the Bill was originally introduced and in view of the increase in these costs and the fact that health contributions were to be a factor in financing the health services, that there might have been increases in the interim period between 1971 and 1973. It is reasonable to expect that health contributions would also increase. These are but one factor in paying for the health services: the others being the Exchequer and rates. This is the system I inherited from my late predecessor and one at which I intend to have a further look.

Between the period 1971-72 and 1974, the cost of limited eligibility services for the middle income group increased by over 90 per cent. If the late Mr. Erskine Childers believed it should be permanent, in those circumstances he also might have increased the health contributions. It has been suggested that this was a contribution to general taxation and to the Exchequer. The increase of £3½ million will go to the health services as will be seen from the Book of Estimates. I am not enamoured of the present system and I will review the method of financing. There will also be a review of the financing of the social welfare benefits and the assistance group. I propose to carry out that review in conjunction with a review of the social welfare services.

I do not think our difficulty is unique as regards financing health services. Governments all over the world are grappling with this problem of how to finance rapidly rising costs in the health services. Nobody could say we were near perfection, even in this country. Every day more demands are made by people in all sectors. We should always strive to ensure that the best services possible are available for our people. There is no easy solution. I hope this review body will be able to propose a better system of financing. There is no guarantee that this will happen as this problem exists practically in every country of Europe, but in any case it is worth exploring.

There was a suggestion among the contributions today that a system of pay-related contributions should be introduced. I would not be committed to the pay-related type of payments. It is separate and distinct from pay-related payments in social welfare. If one pays at a certain rate, the rate of disability benefit or unemployment benefit is related to the payment made. If they were pay-related it would merely mean that people would be paying different amounts of money for the same service. This may be a system whereby one could get more from those who are regarded as being rich but nobody could say those earning £25, £35, £40, £45 per week were wealthy. Therefore, there would be a disparity between the man with £25 or £30 a week as against the man with £35 or £40.

As with income tax; the more one earns, the more one pays.

That has nothing to do with a particular service. If it were suggested that a pay-related system should be used to finance health I would say that it would be wrong because one is paying for the same service. At times, we have been sneered at as being doctrinaire socialists. We have demonstrated in the last 21 months that we are practical socialists. The evidence of this lies in the field of the Department of Social Welfare. Not even the members of the Fianna Fáil Party really believed we could be so relatively generous. It must be conceded that the benefits given in the two budgets far outshone any of the benefits given by Fianna Fáil having regard to the increases in the cost of living and so on.

While I do not want to anticipate what the Minister for Finance might do, I will merely say that we are committed to helping these people who are dependent on assistance or welfare either from the Department of Social Welfare of the Department of Health.

That is the annual budget, not the monthly one?

The Senator's party had their own in their day. There were a few turnover taxes, wholesale taxes, increases in postage and so on. I am in the House too long to be taken in by this. It has been said that these increases are due mainly to inflation and higher wages. This is not so. We have increased expenditure on health in real terms by 8 per cent in the year 1973-74 and in the present year by 7 per cent. That is not such a bad record. At the same time, we have reduced the liability of rate-payers' in respect of contributions towards health services from £36 million in 1972-73 to £13.5 million in 1974. The rates contributions in 1975 will be further reduced to £9 million until they are eliminated altogether.

Senator Lenihan chided us about this and suggested that this is an advantage which is given to property owners and owners of big houses and big estates, and so on. We have done this only in respect of health and housing subsidies. How much more unfair would it be if rates were to be removed entirely? Surely that would be to the benefit of those in the higher income group and of little or no advantage to——

If commercial firms are excluded?

It does not make any difference. I am talking about these other premises mentioned.

I offered this as constructive criticism. The Tánaiste should be constructive.

Rates will be reduced and finally eliminated altogether. In the last 20 months we have started to remove what I regard to be the most regressive element of health service financing. This is appreciated by the public and by public representatives.

This increase has been described as an imposition on the middle income group. Approximately 90 per cent of the cost of services for those in the middle income group—those who are entitled to limited eligibility—is borne by the Exchequer. This percentage is rising very rapidly every year. All sections of the population, including the upper income group, are contributing towards the cost of the service through taxation. Some people suggest that the entire cost should be borne by the Exchequer. I am not committed, as I said, one way or another in this matter.

I repeat that I hope the review group will be able to recommend a different type of financing. When they do I certainly will give it my consideration to find out what is the most equitable form of providing finance for the health services. Whatever the final decision, I must continue the present method, which I inherited and one about which I am not too happy.

There were complaints as well that there were no dramatic changes in legislation in the field of health. I believe that health services can be improved without additional legislation. I agree that the Act of 1970 was a comprehensive Act which allowed any Minister for Health to make all these improvements that are down on paper, provided the money was there.

As I said, I think the Act of 1970 is good in itself. It provided for a great deal of services which even the late Minister could not deliver. Therefore, the problem is not legislation; it is the problem of finding the financial resources. Within the existing legislation it was possible for me to make improvements over the last 21 months. The situation described here of people trying to get into hospital, not getting dentures and so on, has been there since 1953. In the Act of 1970 there is provision to make certain services available by regulation to those in the middle income group. The difficulty is to concentrate on the application of these funds and services to the lower income group.

I was asked what specific improvements could be made with the £3½ million. I could not say accurately what specific improvements could be made, but I can point out what I did between 1972-73 and 1974-75. In that year, health expenditure increased by £61 million, or 58 per cent. The amount of money allocated to the Department of Health by the Government was not ungenerous. It has been referred to in this debate. It enabled me, for example, to devote £1 million per annum to the constant care allowance for severely mentally and physically handicapped children. I gave them £25 per month, with no means test. That certainly could be regarded as a vast improvement in the position of these unfortunate young children.

Senator Killilea and Senator McGlinchey talked about expenditure on home help. That was increased between 1972-73 and 1973-74. In 1972-73 it was £150,000, and for this year it is £344,000. Many more home helps have been recruited by the health boards. We now have 3,000 of these people employed by the health boards and voluntary organisations. Even this relatively small amount of money helps to keep old people, or those with ailments, in the community rather than have them sent to geriatric homes or other institutions. Allied with that, there has been a determined and successful effort by me, as Minister for Health, and by the Department to develop the social work services. These services are being developed as quickly as our universities can train the new social workers. I am glad to be able to say that 33 post-graduate students are being sponsored by the health boards after their final year. There is evidence as well—I referred to this in my Estimate speech—of increased financial support for community information services through the National Social Service Council. This was very much desired and sought after by Members of the Oireachtas over a long period.

It has been suggested that nothing has been done for hospitals. In 1974 £73 million was spent on the maintenance and development of the general hospital services. The details of that are in my Estimate speech. This year, a sum of £46 million was devoted to services for the mentally ill and the mentally handicapped and provision of services in the psychiatric hospitals. This area of illness is now being highlighted to the extent that much more money is being spent in order to ensure that those who are mentally ill or mentally handicapped will not alone be looked after but will also be trained, where possible, for outside employment or, if that is not possible, for sheltered employment. More money is being provided for psychiatric services in the community, in out-patient clinics, and for accommodation for mentally handicapped children and adults. There is a new emphasis on training for outside employment and, where necessary, sheltered employment. There is also a new emphasis on the community psychiatric services for these people.

Senator McGlinchey referred to the rate of increase in expenditure and to deficiencies in the service. The expenditure on real improvements in 1974— that is, on a notional basis in a 12-month period as set out in detail in the Dáil debates—was £9 million. This is made up as follows: £4.5 million on improving our general and psychiatric hospitals, including the provision of new units and improving both services and staffing; £1.5 million on the provvision of extra places in homes for mentally handicapped and the aged; £1.3 million increase in real expenditure on our general medical services; £1.7 million on improving community care services, especially the home help, child help and social work services. These are just a few examples of the extra services being provided because I was allocated so much money for 1974.

There have been comments about the obligations of farmers to pay the £7 per week—£12 when the Bill passes. Frankly, some do not pay and have not paid since the scheme was introduced. There is an obligation on the health boards to collect this money. I mentioned in my speech that, if anyone had difficult in paying the £7 or £12, it could be paid by instalments. We all have an appreciation of the difficulties of farmers in 1974. We also remember the good years they had in 1972 and 1973.

Under Fianna Fáil.

I would not attribute it entirely to Fianna Fáil. There were some external influences at work as well.

Would the Minister not agree they have invested in land and have not any money now?

I am not an expert on farming or on farmers. As the Senator had occasion to say, I am probably more a "townie" than anything else. He did not mean that in a disparaging sense. Many of these people do not pay anyway. If they are in the bad state the Senator says, the CEO has the power and authority to deem them to be in the lower income group and give them a medical card.

Would the Minister tell that to the Western Health Board?

They do not have to be told it. They have known it for years and years.

To apply it is another question. Either the Minister is the boss or not.

I believe in autonomy for local bodies. I will not impose my will on county councils or health boards. I will consult with them. Does the Senator suggest that I should be the one to determine who should get a medical card?

No, but the Minister has just admitted what is common knowledge. He should ask his friend, Deputy Clinton. He will tell him. He should have looked outside the gates yesterday. They were carted off—the small farmers from Leitrim.

I remember protests on other occasions when they did not appear to be so badly off. When Deputy Haughey was Minister for Agriculture, he would not even see them.

It is possible that a different scheme might be adopted for the collection of contributions from the farming community, to ensure that they pay. Nobody wants to take contributions from a farmer who is not able to pay. The CEOs and other officers in the health boards are well aware of these farmers' circumstances.

Has the Tánaiste referred to the point I made about people with small farms and businesses who are paying but who should not because they are not entitled to the services?

That is the first example I heard of such a case. If the Senator would give me particulars, I shall look into it. There may have been some error, I do not know.

I think it is the system. Many business people have small farms. They have been asked to pay contributions. Some are paying unwittingly, thinking they are entitled to services.

I have noted what the Senator has said and I shall look into it.

It was suggested that there would be a cut-back this year. I want to assure Senators that there will certainly be no cut-back. Again, as I said in the Dáil, I would be dishonest if I told them there would be the same rate of improvements in 1975. I do not want to highlight the economic situation or go into it in detail, but everybody recognises that there are difficulties and it would not be possible to go ahead at the same speed as we did in 1973 and 1974. The increase provided for health in the current Book of Estimates represents an increase of about 37 per cent.

Senators were concerned, as we all are, about medical cards. Some suggested one of my priorities should be the improvement of the guidelines for entitlement to a medical card. In consultation with the CEOs I had proper guidelines drawn up that would be applied uniformly throughout the country. Every public representative or citizen knows his or her entitlement. In addition, because of the review held last January, there was an increase to 35 per cent of the population now covered by the medical cards, representing approximately an additional 100,000 people covered.

With one exception, there were never any guidelines laid down for the agricultural sector.

Does the Senator mean for the agricultural workers or for farmers?

For the agricultural holders.

Their means are investigated by the local assistance officer. They cannot be specific. The Senator could not say that in respect of any particular holding or person.

There are no guidelines.

I am sorry about that. The CEOs, in consultation with me, also proposed to have another review of the guidelines in January. It would be desirable in the present situation to have these guidelines reviewed again in June, again in consultation with the CEOs, because a year is far too long. A man's circumstances can change very drastically in a year. For that reason, therefore, I believe the CEOs will make a recommendation to the effect that there would have to be a review, say, twice a year.

I indicated in my speech that the limit of £1,600 would be increased by regulation. A figure has not been put on it yet, but I would say it will be £2,250 or possibly £2,500.

I should like to say again how appreciative I am of the contributions that have been made by the various Senators. I hope they will agree with me, even though it is a relatively small amount of money, that because it goes to the health services directly it is a worthwhile contribution from those who are required to pay and, indeed, is in present circumstances a very good insurance for the contributor and his family against ill health.

Question put.
The Seanad divided: Tá, 23; Níl, 12.

  • Barrett, Jack.
  • Blennerhassett, John.
  • Boland, John.
  • Burton, Philip.
  • Deasy, Austin.
  • FitzGerald, Alexis.
  • Halligan, Brendan.
  • Harte, John.
  • Kerrigan, Patrick.
  • Kilbride, Thomas.
  • Lyons, Michael Dalgan.
  • McAuliffe, Timothy.
  • Mannion, John M.
  • Markey, Bernard.
  • Moynihan, Michael.
  • O'Brien, Andy.
  • O'Brien, William.
  • O'Toole, Patrick.
  • Owens, Evelyn.
  • Russell, George Edward.
  • Sanfey, James W.
  • Walsh, Mary.
  • Whyte, Liam.

Níl

  • Browne, Patrick (Fad).
  • Cowen, Bernard.
  • Dolan, Séamus.
  • Eachthéirn, Cáit Uí.
  • Garrett, Jack.
  • Hanafin, Des.
  • Keegan, Seán.
  • Killilea, Mark.
  • Lenihan, Brian.
  • McGlinchey, Bernard.
  • Ryan, William.
  • Yeats, Michael B.
Tellers: Tá, Senators Sanfey and Halligan; Níl, Senators Garrett and W. Ryan.
Question declared carried.
Committee Stage ordered for 7 p.m. today.

Amendments have been submitted and will be circulated.

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