Seanad Éireann debate -
Tuesday, 15 Mar 1977

Vol. 86 No. 4

Health Contributions (Amendment) Bill, 1977: Second and Subsequent Stages.

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

Minister for Health (Mr. Corish)

As indicated in the memorandum which has been circulated with the Bill, the object of the Bill is to amend the Health Contributions Acts so as to provide for an increase in the current rates of health contributions. The increases proposed in the Bill are 6p a week and £3 a year, with effect from 1st April next. This is an increase of roughly 20 per cent on the present rates of 33p a week and £15 a year.

It is estimated that the revised rates of health contributions proposed in the Bill will bring in an additional £2.2 million in a full year and in the current year will raise receipts from that source to a total of £12.46 million. The Estimates for the Health Vote for 1977 have been prepared on the basis that this estimated amount will be received from health contributions as an appropriation in aid of the Vote.

The explanatory memorandum indicates the population groups who are required to pay health contributions and the services to which they are entitled. Senators will note the revised income limit of £3,000 for "limited eligibility" services which was introduced last year in order to preserve or restore entitlement to health services where the effects of inflation were upsetting the situation. The revision in effect maintained the limit at its traditional level in real terms. It is not designed to make any change in the proportion of the population which has been traditionally eligible for these services.

As I indicated in the course of the Dáil debate on this Bill, I have set up a working party to examine certain anomalies which arise in the definitions used for "limited eligibility" categories and in the identification of eligible persons and to consider what action might be possible to remove these anomalies during the period when the income limit will continue to exist. The working party is representative of the medical organisations, the Federated Union of Employers, the Congress of Trade Unions, the health boards and my Department. The first meeting of the working party has recently been held.

The limited eligibility services, including as they do hospital services, account for the greater part of the total cost of the health services. The estimated cost of the limited eligibility services in 1977 is about £220 million, which represents an increase of roughly 20 per cent on the corresponding figure for 1976, £184 million. The proposed increase in the health contribution rate is roughly proportionate to this rise in cost since the rate of contribution was revised last year. The estimated total receipts from health contributions this year is £12.46 million. This represents a significant contribution towards the cost of the health services which would otherwise have to be sought from the Exchequer.

Senators will be aware that the financial provisions made in this year's Health Estimate is designed to ensure the maintenance of 1976 health services levels during 1977 and that in addition a further £10 million has been made available to improve and develop the health services in ways consistent with the Government's job creation programme. These additional moneys will be used to open new units already completed or due for completion in 1977 and to provide other specific services which will be identified following consultation with health boards and other health agencies.

The additional moneys which I have referred to relate to non-capital expenditure only. As Senators are aware, I have already issued a statement regarding the health capital programme, for which a total sum of £16.0 million has been allocated. This allocation will enable me to provide finances for ongoing schemes and for new starts on a significant programme of major developments. As indicated in the statement, this capital programme is expected to provide about 700 additional jobs. Over the next few weeks I expect to be able to announce details of the allocations to be made from the non-capital development moneys and the job creation element associated with that development. All these developments will result in a considerable improvement in the level of services which, in the case of persons in the limited eligibility group, they will obtain for a very modest increase in the amount of health contribution they will be required to pay.

I should like to refer to the increased charges for hospital services which will come into operation with effect from the 1st April next. Charges for hospital services are made in the case of persons without statutory entitlement and also in the case of eligible persons who, instead of availing of services in public accommodation to which they are entitled free of direct charge, choose to be accommodated in private or semi-private rooms. These charges have always been substantially less than the actual cost of services. Increases in hospital costs last year widened the gap between charges and costs and the situation at present is that charges payable by persons without statutory entitlement represent less than half of the actual cost of maintaining a hospital bed. Because of this and the further increases in costs which will arise in the current year it was necessary to arrange for an increase in charges.

The increased charges will still be considerably less than the actual cost of services. For example the charge from April onwards for services in semi-private accommodaton in a voluntary teaching hospital will be £15.20 a day in the case of a person without statutory entitlement and £15.10 a day in the case of a person with statutory entitlement. The average actual costs of services in such hospitals will, however, amount to £30 a day.

Most persons who will be affected by the increased charges are insured with the Voluntary Health Insurance Board. The board are arranging to allow members who may be underinsured to increase their cover with effect from 1st April and in advance of ordinary renewal dates. I understand that the board will be advising members shortly of the revised minimum cover which they consider necessary and of the steps to take to secure increased cover.

The extra cost of health insurance based on the increase in the minimum cover which will be recommended by the Voluntary Health Insurance Board will vary according to individual circumstances. In the case of a married couple with four or more children under 18 years of age who have not got statutory entitlement the present premium for maintenance cover for semi-private accommodation, based on the minimum number of units recommended by the Voluntary Health Insurance Board for persons in group schemes is £86 a year. As from April next the corresponding annual premium to be paid will be £108, representing an increase of £22 a year. In the case of a similar family unit with statutory entitlement to services the corresponding costs of health insurance to cover charges in public hospitals will increase from £26 to £36 a year, that is, by £10 a year. The cover recommended by the Voluntary Health Insurance Board for private hospitals is somewhat higher. Income tax relief is afforded in respect of premium payments to the Voluntary Health Insurance Board so that the net cost of health insurance, and of course the cost of the increases in cover, will be substantially less than the figures which I have quoted.

As Senators are aware, the Dáil has agreed that a Select Committee be appointed to examine, inter alia, alternative ways of financing the health services. In the meantime it is necessary to continue to avail of the existing financing sources which at present supplement the moneys provided from the Exchequer to meet the overall financial requirements of the health services. Health contributions represent the most significant of these supplementing sources.

I commend the Bill to the House for a Second Reading.

Mr. Keegan

We are not opposing this Bill because the fact that the Bill is before us this evening is a reflection of the inflationary situation in which we live. When the health contribution services were first introduced they were fixed at £7 per year. They are now gone to £18 per year and that is a clear indication of the spiralling health costs which have occurred in recent times. It is a cause for anxiety and alarm that the health and hospitalisation services are costing more and more. We seem to be in a situation which is difficult at times to explain. We must realise that the health of our people is a priority and must always be so irrespective of a financial depression. Therefore there is an obligation on all Governments to provide adequate finances to run the health services.

One might be tempted to ask if the Minister believes he is getting real value for his money with regard to health services at the present time. We have an acute bed shortage in all our hospitals. He has made announcements that extensions have been given the green light and health boards have been authorised to go ahead with certain hospital extensions this year. He also said that new jobs would be created. New jobs would be very welcome at this time because of the high number of unemployed. Let us hope that positive efforts will be made to employ people who are genuinely on the unemployed list and that the additional money will not be absorbed through other contracting activities. Hospital extensions are badly needed at present and this must be pursued with vigour and energy. If we are ever to arrive at a stage where we can give first-class service to our people we must have first-class accommodation. I fully realise the enormous cost of hospital extensions and of hospital equipment because this is highly sophisticated equipment which is more costly than the equipment required in any other industry.

We fully realise that many problems exist but a positive effort must be made to proceed with hospital extensions. That is a positive approach towards meeting some of the demands of the people. It is an extraordinary situation where so many people still require medical attention. I do not know whether it is the age we live in, the time we live in or the environment. More and more people seem to be demanding medical attention than was the case many years ago.

I should like to see a situation where free medical services would be made available to all. We seem to be a long way from that goal yet. Let us hope that will be the aim of the progressive thinking in the Department of Health.

I wish to express concern at the necessity to increase the charges for hospitalisation in recent times. That has been brought about because of the high cost of maintenance of patients in hospitals. Those who will suffer are those without any benefits whatsoever. We still have people in the agricultural sector who are not covered by voluntary health or social welfare contributions or the health contributions.

I should like to ask the Minister for Health to ensure that the health boards make some effort to streamline their method of assessing those who should pay the health contributions and those who should not. A situation exists where health boards send out demands to people who have been dead for the past ten years and whose lands were not reregistered and have remained in the name of the deceased person. I feel there is a need for a follow-up and a thorough investigation. The health inspectors should be utilised to a greater extent. There should be more consultation between the finance officers and those health inspectors. If that was done a great deal of overlapping and of unnecessary writing and communication could be avoided.

Another common problem is that registered owners of small parcels of land who also qualify for medical cards are receiving demands for the health contribution despite the fact that they are covered for health services by medical cards. That is a reflection on the personnel within the health services and those employed by the health boards. I should like to ask the Minister to ensure that this situation be remedied because of the cost and the time involved in sending out reminders and passing them on to the legal advisers. It would not be complimentary to any health board to start suing somebody who had been deceased for ten years or a person who had been in receipt of a medical card or who had taken up insurable employment over the years.

All this can be avoided and a large amount of money saved by consultations between the finance officers and the local health inspectors. Social workers and local health inspectors have knowledge of every participant in the health services scheme. They also have ways and means of inquiring as to the source of income of individuals concerned. This is an urgent problem because of the amount of duplication and correspondence that takes place. I ask the Minister to contact the health boards and ask them to put their house in order and ensure that the method of collecting the health contributions will be simplified.

Mr. W. O'Brien

We all regret that this health contribution has to be increased. Unfortunately the cost of maintenance and hospitalisation in general has become excessive. I am not too happy about what is happening about prescriptions. A Select Committee has been appointed to deal with health services in general. I should like the cost of prescriptions to be included within their terms of reference.

I read a newspaper report recently in which it was alleged that a doctor operating on a panel was in receipt of £45,000 per year. This is at a time when many young doctors are unemployed. I am not convinced that any doctor should receive that amount of money. I am not suggesting there was anything wrong with the figure as far as that doctor was concerned. He had worked the hours involved, completed the services and carried out the visits. There is no reason to doubt his integrity with regard to that. I do not think any man should be asked to work such long hours at a time when three or four doctors could be carrying out his job.

Reference has been made to VHI. I should like to know why a patient in a hospital, when having his final visit from his doctor, should be asked if he is a member of VHI. I am worried that the VHI Board are being fleeced. Many of us are paying VHI subscriptions and are not too happy; we are paying dearly for an in-patient service. I suggest there should be a third party involved when the bill is being paid. The Department should take a greater stand and ensure closer scrutiny. A copy of such accounts should be sent to the Department. I raise this because of the many people who have mentioned it to me in the past and, to clear the air, something will have to be done. I have to be critical of all health personnel. When one is critical sometimes one is speaking in their defence, casting any doubts from people's minds that the doctors of this country are vultures. I am not saying for a moment that they are. Every protection should be afforded health personnel, the hospitals, the boards and the Department in general. There is in operation in hospitals the private bed's system—a doctor is allocated so many private beds in a hospital. When I queried this with the Mid-Western Health Board I was informed that it was an incentive to a doctor to take up the position. We have many fine Irishmen in England who I am sure would take up such positions, particularly at a time like this when we have a bed shortage in the mid-west, when it is absolutely impossible to get a geriatric patient into hospital—perhaps somebody who has been living alone, in spite of the kindness of the home-help, the district nurse and who needs further medical attention and care.

It is now impossible to get a patient into a hospital in Limerick. For that reason I make the suggestion that the Department, through the medical boards, should pay a salary to such consultants. I am not convinced nor happy that any consultant should be allocated a number of private beds in any institution. I hope the day will come when the consultant will have to be paid a standard figure, the same as anybody else. Very often constitutents will come to you and say: "I cannot get a bed in such a hospital" and, at the same time such constituents will tell you that somebody else has gone in there because he or she is a patient of Doctor X or Doctor J as the case may be. One is inclined to think that deep down in her mind she is convinced that money is playing a major part in the health services. I never want to see that happen.

Reference was made to health cards. I am thankful to the chief executive officers and to the Department that they have increased the ceiling to £34, which is fairly reasonable. In a case where any hardship is involved the boards are always prepared to act on the humane aspect.

The cost of services are rising and prescriptions particularly at an alarming rate. Let us consider people with medical cards. The same applies, only in a different form, in regard to the Exchequer. Today we find that we have to raise our charges for hospitalisation. If we keep on going as we are we could be like America some 20 years ago when it was cheaper to die than live. Some stand will have to be taken. I have been frustrated, annoyed and worried about what I have seen about a doctor drawing £45,000 a year. I do not believe any doctor should draw such a salary.

Minister for Health (Mr. Corish)

I am grateful for the contributions made by Senators Keegan and W. O'Brien. If anything emerged from this short debate it was the anxiety of Senators about the rising costs in the health services. Needless to remark all parties in the House are concerned about rising costs just as I am. It would be no harm if I gave figures for the rising costs in the last five or six years. In 1972-73 the amount met from the Exchequer was £76.7 million. That increased in 1973, 1974, 1975 and 1976 until today non-capital expenditure, I should stress stands at £299.7 million. If one adds £16 million for capital works one gets a figure of £315 million.

It is indeed a formidable amount to be spending on our health services but we must all take a share in the blame for this—whether we have been in Opposition or not but particularly when we have been in Opposition. Whilst I heard in the other House anxiety about rising costs I well remember and know, that every single day practically, when I answer questions on health these questions amount more or less to a demand for more and more services. There is no doubt in my mind that the services have improved and improved very much in the past four years. Not alone —and I do not say this as the absolute criterion—are we spending something like £315 million but employment in the health services has risen from 43,000 in 1972 to 55,000. That is an increase of 12,000 jobs. The fact that there is such an improvement and increase does in itself show that the health services have indeed been improved in various ways right across the board over the last four years.

Senator Keegan spoke about value for money. We made the initial start in that regard last year when we allocated to the health boards and to the voluntary hospital boards amounts which disappointed them to say the least of it but, when the notifications were made all the health agencies were exhorted to ensure that economies be affected. Despite the furore we had in the beginning of the year from health boards and from members of the Oireachtas it was found at the end of the year that the health services did manage to stay on par, so to speak, with the services as provided in 1975. I believe that many economies can be made. They were described as cuts; I refer to them as economies. I still believe there is room for more economies without any disruption of the services.

Senator Keegan also raised the question of additional money and said that he hoped it would not be eaten up by administration or, in some other way, to the detriment of the provision of jobs. I should like to assure him in that respect that the Government allocated an extra £10 million, not alone in order to improve the health services but to create employment as well.

Of the £2.7 million spent on the commissioning of units which we could not open last year and in respect of units that will be opened this year, there will be the creation of something like 920 jobs, which is no mean contribution. Whilst it does appear big, that is the amount required for the commissioning of these units. There is also a sum available to me of £16 million for capital projects. Of this, I think £6.8 million has been earmarked for new capital works. That would apply to capital works that could go ahead immediately whether they be the building of units or in respect of any other capital project. That is estimated to yield something like 700 jobs. Again that will mean an improvement in the service because it will give new facilities and consequently more jobs. Approximately £7 million is also being allocated for the improvement of the services. This improvement will go right across the whole health scene. It will not be confined to consultants, doctors and so on but will mean the provision of jobs for all types of people, whether on modest or small salaries.

Senator Keegan also raised the question of the identification of those entitled to limited eligibility. It is fairly clear as far as social welfare contributors are concerned; it is clear as far as the people whose income is £3,000 or under are concerned. The difficulty appears to be in the identification and collection of the contribution from those farmers who have £60 valuation or more. Senator Keegan spoke about a lack of communication so to speak between the health boards and those who would be over £60 valuation. In that respect that there can be some errors.

Mr. Keegan

Under £60 valuation, not over.

Mr. Corish

I am sorry, under £60. As far as these are concerned, there can be errors but I do not think they are widespread. The criticism I would have is that there are some who are not paying at all. The health boards would be well employed to ensure that these people would pay their rightful contribution. I know people also are annoyed when they get these bills. They are not obliged to pay. But in any case this would be a matter that would be considered by the Select Committee to which I have referred in this speech and in Dáil Éireann.

Senator W. O'Brien talked about prescriptions and their high cost. I think we all agree about this. We are so concerned that we established a working party on prescribing a couple of years ago. As a result of that, certain recommendations were made. I could not say at present whether these recommendations have borne fruit but doctors have been advised about their prescribing methods. With the pressure from the Department of Health and the health boards we must have favourable results soon. Drugs cost an enormous amount. Anything we can do to reduce their cost will be very beneficial and I suppose in many cases would be beneficial to the health of many patients. I do not mean that as a reflection on the doctors but we seem to have become very drug/pill conscious at present.

Senator W. O'Brien also raised the question of voluntary health insurance and said that patients, when they present themselves to hospitals, are asked if they are covered by voluntary health insurance. I am certain that is not just a fiddle or try-on to ensure that the maximum will be got because the VHI are very careful in the advice they give about cover, the advice they give in order to ensure that a man and his family, or any person who is insured under VHI, will pay the amount required for hospital maintenance, no less and no more.

Mr. W. O'Brien

The reference I made was to the doctor; when your account is being furnished you are asked: "Are you in the VHI?" I fail to understand the relevance of somebody being asked that question. I want to know what difference it would make to the account. It should not make any difference.

Mr. Corish

I do not see what difference it would make. I would say this, that generally as far as the VHI are concerned they try to give the best cover they can for all emergencies and different cases.

I do not think very many more points were raised. I dealt with the prescriptions. I could add to that by saying that not alone have doctors been advised about prescribing but in the Select Committee of the Dáil the terms of reference are sufficiently broad to allow them to look into this matter.

Senator W. O'Brien also referred to doctors earning up to £40,000 a year in the general medical service. This arose recently in the Southern Health Board. The Senator has a point in that the board could allow more doctors into the scheme in areas, say, where through overwork a doctor is earning a large amount of money. But if the doctor earns too much through over-visiting, in a normal panel of patients, there is machinery, as the Senator knows, for inquiry into that sort of allegation and, let me say, imposing a penalty on the doctor if it was found that there was a question of over-visiting. Again I am grateful to the Seanad for their quick despatch of the Second Reading.

Question put and agreed to.

Agree to take remaining Stages today.

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

The Seanad adjourned at 5.50 p.m.sine die.