Seanad Éireann debate -
Thursday, 8 Mar 1979

Vol. 91 No. 6

Health Contributions Bill, 1978: Second and Subsequent Stages.

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

Minister for Health (Mr. Haughey)

The Bill is designed to give effect to the decision of the Government to replace the present scheme of flat-rate health contributions by an income-related scheme of contributions and, subject to certain specified exemptions, to extend the obligation to pay health contributions to all those who have an income and are over 16 years of age.

The principle underlying the new scheme is that the payments will be assessed on an income-related basis, where appropriate, and, in the case of farmers generally on a notional income basis using a multiplier related to land valuation. As compared with the flat-rate contribution system it will work out in a fairer way for those on low incomes and, in the case of farmers, for those with farms which are in the lower valuation classification.

A substantial group of the population will not be obliged to pay any health contributions, such as widows with social welfare pensions and others who are listed in section 11 (2) of the Bill.

Neither will persons with medical cards be obliged to pay health contributions but the existing liability of the employers of such persons to pay health contributions on their behalf will be continued. This employer's liability will also extend to persons with agricultural employees and to those who employ female domestics.

The decision to extend liability for the payment of health contributions to all those who have an income and are over 16 years of age, with certain specific exemptions, follows logically from the decision of the Government to extend entitlement to further health services to the community generally.

The most important of the new benefits is the right to free in-patient and out-patient services in public hospitals. This will include the services of consultants except where a person's income exceeds the ceiling, which for the year commencing next April will be £5,500. In addition, the benefits of the drug refund scheme will be extended to everybody. Those who have medical cards will, of course, continue to have medicines and drugs provided free. The regulations providing for the extended benefits will be made under the Health Act, 1970, and will be submitted to the House in the near future.

The ceiling for health contributions specified in the Bill is £5,000. That ceiling is identical with that fixed for social insurance contributions in the Social Welfare (Amendment) Act, 1978, as both ceilings must be the same to meet the needs of the collection machinery. The ceiling was recommended by an inter-departmental working party which investigated very comprehensively the problems associated with the introduction of fully pay-related social insurance, health and redundancy contributions. The figure was calculated on the basis of the latest information then available on the average earnings in the transportable goods industries, but using a multiplier of 1½ to arrive at an appropriate ceiling. The purpose of using the multiplier of 1½ was to ensure that the ceiling would encompass the earnings of the vast majority of workers. Certain changes have taken place in the average earnings in the transportable goods industries since the working party reported and, as I have already announced, I intend to make regulations after the enactment of the Bill to fix the ceiling at £5,500. The power to make regulations to vary the ceiling is contained in section 9 of the Bill. The ceiling will not be static and will be reviewed from time to time taking into account the latest information available regarding the average earnings of workers in the transportable goods industries. I wish to stress, however, that the ceiling which will apply from April next for the purposes of determination of eligibility for consultant services will be the income accruing in the year ending on 5 April 1979, and not in the year commencing on 6 April 1979.

The rate of contribution specified in the Bill is 1 per cent. With a ceiling of £5,500 this would involve a maximum contribution of £55 per annum. The present flat rate contribution is £24 a year. If no change was being made in the existing arrangements regarding eligibility for services and if there were no proposals for the extension of health benefits, the £24 rate would probably have had to be increased in any event to take account of the cost increases in the existing limited eligibility services. The new rate required would probably have been of the order of £32. The decision to extend liability to the community as a whole to pay health contributions and to provide further health benefits has a further impact on the amount required to be raised in health contributions. There have been substantial cost increases in other sections of the health services apart from the hospital services and the new health benefits will cost a substantial amount in 1979. The income related scheme will ensure, however, that where they have to pay, those on lower incomes will be paying less than they would have paid if the flat-rate contributions had been increased to take account of all the factors to which I have referred. Again, as I mentioned earlier, substantial numbers of persons in the lower income brackets will not be paying at all.

It is estimated that if the scheme of contributions provided for in the Bill had been in operation from 1 January 1979, the income that would have accrued over the whole of 1979 would be about £30 million.

As the scheme is not scheduled to come into operation until next month the total estimated income from health contributions for 1979 is £26.6 million, including about £4.1 million which it is anticipated will be forthcoming from the existing scheme of flat-rate contributions in the period from January-March.

It is estimated that further income totalling about £700,000 will be received as a result of raising the ceiling from £5,000 to £5,500. This addition would raise the estimated yield from health contributions in 1979 to about £27.3 million.

The additional revenue that will accrue in 1979 over 1978 as a result of the introduction of income related contributions will amount to about £10¾ million. While it is not possible to be completely precise as to the cost in 1979 of all the elements provided for in the range of extended benefits to be introduced from 6 April next, it is estimated that they will absorb practically all the additional resources which will become available.

The increasing cost of health services is, of course, a matter for concern. The problem is not peculiar to this country. All countries, whether developed or developing, face the same difficulty. Efforts at cost containment have been and will continue to be made, but much more is required. It is not only a matter of looking for solutions within the services as they are now organised with the main emphasis on curative aspects. A more radical approach is necessary not only from the economic viewpoint but in the interests of producing a healthier nation. A major contribution to improving the overall situation can be made by devoting ever-increasing attention to health education and preventive measures. We have made a significant start on these fronts but it is essential that the impetus of the campaigns should be maintained. There must be no let up in the efforts to persuade people that they can do quite a lot to improve their own health status.

Our health education campaigns have so far been concentrating mainly on controlling the abuse of alcohol, pinpointing the dangers of cigarette smoking and improving the standards of hygiene. We have also embarked on a major campaign to cut down on the use of drugs and medicines where they are not medically necessary. Many of the modern most lethal diseases have their origins in factors related to life style. Prevention rather than belated attempts to cure should be the guiding rule.

It is unfortunate that so many believe that drugs can cure almost every ailment. There is no denying that they have made highly significant contributions in support of the advance of medical science but resorting to them for even trivial ailments is both unnecessary, uneconomic and sometimes damaging. The amount spent on drugs and the volume of consumption is increasing annually at a rate that must be regarded as alarming. As I mentioned at the recent international symposium on "Alternatives to Drugs" it is estimated that we will be spending about £35 million on drugs in the health services in 1979. It has been shown that a very considerable amount of the drugs prescribed are not eventually used by patients. The wasted moneys could be put to far better use in other branches of the health services. I am arranging for a nationwide publicity drive in the media to focus attention on the situation and a commencement will be made in the near future. The wholehearted support of the medical profession has been forthcoming and I am confident that a sustained effort will produce worth-while results.

Returning to the question of overall costs and the need for the making of increased direct contributions towards the cost of services, I would point out that the Exchequer contribution towards the cost of health services in 1979 is about £419 millions—£79 million more than was provided for in the Estimates for 1978. The estimated total net cost of health services in 1979 is about £453 million. I have already mentioned that the estimated income from health contributions in 1979 is £27.3 millions. That figure represents only about 6 per cent of the total estimated net cost of the services in 1979.

The explanatory memorandum which was circulated with the Bill indicates that for the purposes of collection the community will be divided into three groupings. In the case of employees the collection of health contributions will be integrated with the collection of social insurance contributions through the PAYE system. It would be extremely wasteful to set up special machinery for the collection of health contributions separately from social insurance contributions. Employers will benefit from the system as administration will be simplified. They will also benefit in that the dangers in the handling and custody of insurance stamps, which included provision for the health contributions of employees, will be eliminated.

The Revenue Commissioners will also look after the arrangements for the collection of health contributions from the self-employed, from persons with investment income and from a limited group of farmers who have other trades or professions and who are directly assessable for income tax.

The Revenue Commissioners being so closely involved in the collection arrangements will have available to them considerable data regarding health contributions and the reckonable income, earnings or emoluments of individuals in respect of whom health contributions are payable. It is necessary that this information should be made available to my Department and to health boards as far as this is found to be necessary for the purposes of the administration not only of the Health Contributions Bill but also of the Health Act, 1970. Section 14 of the Bill makes provision accordingly.

In the case of farmers generally the regulations to be made under the Bill will provide that the collection of health contributions will be a function of the health boards as it is at present. The amount of health contributions payable will be determined on total income from all sources, including farm income assessed on a notional basis using a multiplier related to valuations and the ceiling of £5,500. The systems in operation for the collection of contributions from farmers are being redesigned and strengthened with a view to improving the collection rate.

Senators will have seen the press notices, publicity and commentaries on the new schemes being offered by the Voluntary Health Insurance Board. I would like to draw special attention to the low-cost scheme for consultant cover which the board will be introducing as from next month to coincide with the introduction of the new health benefits scheme. This special scheme will be of particular interest to those who wish to avail of free maintenance at public ward level in public hospitals and who will not be entitled to free services of consultants. The scheme will provide for cover against the cost of consultant services associated with treatment at hospital level, maternity benefits, a relaxation of the existing rules governing payments in respect of day surgery and where miscarriages are involved, provision for special nursing and for cases requiring convalescent care.

The scheme will allow for a relaxation of existing entry restrictions regarding previous medical history. There will be no entry age limit or no waiting period as regards elegibility for benefits. The age loading for persons over 60 years of age will disappear. Provision will be made for payments by instalments.

The premiums payable will enable the biggest families to be covered for consultant services for somewhat less than £33 per annum which, for persons paying the standard rate of income tax, will mean a net payment of about £22. The cost for a single person will be less than £11 per annum, before allowance is made for income tax concessions. I should, perhaps, emphasise that this low-cost scheme for consultant cover will be available to the community as a whole.

I commend the board for the very attractive scheme they have produced, and I would strongly recommend the scheme to all those who may need cover for consultant services.

I might also point out should the circumstances in individual cases present difficulties the existing hardship clause will continue to operate.

I have dealt with the main elements of the Bill and certain other relevant matters associated with the new health benefits scheme. There may, however, be other matters which I have not dealt with on which Senators may desire to have information and which may not be covered in the explanatory memorandum. If so, I will give further explanations when replying.

I commend the Bill for Second Reading.

Mr. Howard

The Minister said that the income ceiling in this Bill is similar to the ceiling in the Social Welfare (Amendment) Act which we discussed here some time ago. I remember saying on that occasion that the principal advantage of that Bill was that it streamlined the collection of social welfare contributions. The same thing can be said in relation to the present Bill. It ensures the collection of more money from more people. This money will come into the Exchequer on a regular basis throughout the year, which is an improvement on the old system in which stamps were usually paid at the end of each year. The ideal would be to have a comprehensive national health cover for all our people. This Bill is a step towards achieving that objective, and I welcome it. It goes part of the way, but it does not go all the way. In so far as it is an indication that the Minister is working towards that ideal, I commend the Bill.

I have reservations about the cover that is being provided for some people. Three categories of people will benefit when this Bill becomes law. First, people with medical cards will qualify for free health services. The second category are those whose incomes do not exceed £5,500 per year and farmers with a PLV of less than £60 per year. Wage and salary earners will pay 1 per cent of their incomes to a maximum of £55 per year which compares with the existing flat rate contribution of £24. The people in this category will receive free maintenance but they must pay medical costs, consultants' fees and maternity costs. In relation to the first category, those who qualify for medical cards and pensioners, who are the weakest and most deserving of all, they are a steadily diminishing group. Is the Minister aware that several thousand people in the west have lost their medical cards in the past few months? The loss of these medical cards has, in cases that I am aware of, resulted in hardship and unhappiness for the families concerned. Is he aware that this campaign is continuing? Is it taking place with his knowledge, and will he accept that it is causing hardship?

If so, will he therefore assure the House that he will call a halt to this campaign for the removal of medical cards and ensure that borderline cases are treated with sympathy?

With regard to the second category of people, those whose incomes are less than £5,500 per year, in the past they had a limit of about £3,000. This limit existed for some time. At face value, it would appear that the increase to £5,500 is pretty generous. When account is taken of the effect of inflation on wage and salary increases and increased hospital costs, not many extra people will benefit as compared with the numbers that came into benefit when the £3,000 limit was originally introduced. Perhaps there are figures to show what the extra numbers will be in comparison with the numbers who benefited when the £3,000 limit was first introduced. For the majority of people within this income bracket the Bill represents an increase in the health contribution. Insured people have been paying at the rate of 50p per week, or £26 per annum, and all now earning up to £55 per week will have their contributions increased from £24 per annum to £55, which is at the top of the scale, more than double the contribution. Many of them will be paying an increased contribution and will not be receiving a corresponding increase in benefits.

One of the reservations I have in regard to the third category, those who earn over £5,500 per annum and farmers with PLVs over £60, is that their entitlement is limited to free hospital beds and maintenance. They must pay for all additional medical expenses, consultants' fees, maternity costs and so on. The ceiling of £5,500 is too low. When we see the 1979 wage settlements many manual and non-manual workers will find that they have passed that limit.

Mr. Haughey

They will not be affected by this provision. Income up to 6 April 1979 will govern eligibility for the following year.

Mr. Howard

When we come to the following year, is it the Minister's intention to adjust the limits? The figure of £5,500 will represent quite a sudden cutoff for some people. Could he not have considered a phasing or a grading at that point? Let us consider the case of two neighbours, one with an income of £5,499 and the other an income of £5,501. The man who has £1 over the limit and who is suddenly cut off is paying a severe penalty for a difference in income of £2.

The reservations that I have expressed do not mean I am not prepared to admit that there are certain good points in the Bill. I believe it represents a step on the road to the provision of a comprehensive health service for all our citizens. It now includes the non-manual worker who earns between £3,000 and £5,500 and it streamlines the health services.

In his speech the Minister referred to the enormous cost of our health services. I should like to conclude by again drawing attention to the fact that in 1979 something like £453 million will be spent in providing health services. It is a vast sum to service a vast machine but, of course, we are dealing with the health, well-being and the lives of all our people. Because of that we all accept that it is vital that this machine operates smoothly and effectively. It is vital that all involved in that service play a full and unstinted role. In the final analysis, the buck stops on the Minister's desk. The Bill represents a short step towards the provision of a comprehensive national health service. I wish it well.

Mr. Jago

I welcome this Bill and congratulate the Minister on the changes he has made, which are a step in the right direction. Firstly, we have the general change over several Bills in the pay-related payments which, in itself, should rationalise administration, save administration costs and make things easier for those who have payments to make. Secondly, I congratulate him on working out a system where there is more equalisation and fairer treatment. The pay-related system means that the burden of cost is spread more equitably in that it is partially taken off the lower paid and allows those more capable of paying to pay their share. The scheme will probably be simpler for hospitals because they will know that all patients are covered to general ward standard.

I support the Minister in his approach to preventive medicine, especially in relation to the use of drugs. I hope he is successful in pointing out that drugs merely treat the symptoms not the disease.

We already know that the VHI will cover consultants' charges for those who are not already covered and will allow those who wish to have semi-private and private accommodation to pay for the reasonable cost through the VHI. I have always accepted that the VHI is an excellent service. I have no doubt that it will continue to be so. I welcome this Bill and congratulate the Minister on his approach to this matter.

Mr. Moynihan

I am disappointed that the Minister adhered to a ceiling in the development of a national health service. The aspiration of the trade union movement and of the Labour Party is for a free national health service for every citizen. In the absence of such a service the two queues will continue—one for the national health service and one for the private service. This creates many problems of which, I am sure, the Minister is aware. Nevertheless, the raising of the limit from £3,000 to £5,500 is inadequate. The ICTU have been looking for a ceiling of £8,000 to £9,000. This figure creates problems for a substantial number of workers. During the existence of this State the insured manual worker and his dependants never had a ceiling in relation to free health services. For the first time this legislation is putting a curb on such people and will expose them and their dependants to consultancy fees when they exceed £5,500. This is a retrograde step in that their existing rights which they have carried will be terminated.

In regard to non-manual workers, public service workers and so on, there was the system of voluntary social welfare contributions. I should like to know whether this legislation proposes to discontinue the services to which these people had an entitlement from the contributions they were making. I am sure some unions have been in contact with the Minister in relation to this matter. This is of major concern to many trade unions, especially the unions that cater for non-manual and public service employees who had exceeded the ceiling of £3,000 and opted for voluntary contributions.

In regard to the figure of £5,500, there is no flexibility for the single person or the family with 10 children. All have the same level of dependency. Therefore, if the person with the higher number of dependants exceeds the ceiling he is exposed to consultancy and other fees.

The Minister should consider the responsibility of the family doctor. I am sure the Minister has, as has every public representative, received representations in regard to substantial bills from private hospitals for patients who were entitled to health authority hospitalisation. We should feel proud of the standard of service of our health boards. They are capable of dealing with every situation that arises in our health services. Family doctors still think that better treatment can be obtained in voluntary and private institutions that do not accept patients as health authority patients. While this option must remain the right of every citizen, family doctors should advise patients of the financial impact should they choose to enter a private hospital for treatment.

About two weeks ago an unfortunate medical card holder was presented with a bill in excess of £500 for a period in hospital. I asked him to get an explanation from his doctor for the charge. He said the doctor was unable to get him a bed in a cardiac intensive-care unit in one of the health board hospitals. On a subsequent checking with the hospital in the area I found that this was not right. At the time of illness patients or their relatives should be advised of the impact of such charges. It is wrong that people are exposed to these costs. They seek help from their public representatives and the health boards who cannot do anything to reduce or even eliminate the cost.

There is ignorance of the rights of the community to the free health services. In hospital waiting rooms, public libraries and all public institutions, either by leaflet or poster, full publicity should be given to entitlements, and the consequences of choosing private hospitals. The family doctor should be responsible for advising patients in regard to hospitalisation. Much emphasis has been put by the Minister and others on the contribution of voluntary health in the advancement of the health services. One problem with the VHI is that they refused admission to people with medical and psychiatric problems. This is a very serious omission on their part. A medical or psychiatric history can have a tremendous impact on a person's income. I am sure he will continue to review the situation in regard to the lifting of these ceilings and have a further look at the position of the insured worker to date and what his position will be after 1 April. I should also like the Minister to have a look at the position of the people who have opted for the voluntary social welfare contributions, which was a tremendous way of continuing the social insurance factor in our health services.

Mr. Connaughton

I welcome the Bill. I should like to take this opportunity to congratulate the Minister on doing his very best to ensure that people will look after themselves. That is the essence of all health preventive measures: it is much better to prevent it than to cure it in a more costly exercise afterwards.

This scheme is like all other schemes, it is good and bad, but in my opinion it is more good than bad. A bigger number of people will be much happier once 1 April comes. It brings us nearer to the situation where there will be more people eligible for free hospitalisation, which is a good thing.

I should like to raise a number of points which the Minister might clarify. First is the application of liability to persons from 16 years upwards. Obviously, a lot of young people at that age would not be earning very much money and one would have hoped that the system we now have under which persons who are not employed between the ages of 16 years and 18 years automatically get medical cards would apply to lower paid juvenile workers. There would be a fair amount of hardship on a large family with persons in that category. Admittedly, in any family you would probably have only one or two in that category, but where you have a big family, the cost will be more than heretofore.

Another point worth mentioning is that all income earners, irrespective of whom they are, will have to contribute. That is fair in so far as the free hospitalisation scheme is being spread to that category, but manual and clerical workers earning more than £5,500 will not receive a return for their contributions other than the free hospitalisation and drugs refund and so on. This brings us to the point that has been mentioned here before, that they may have fairly considerable consultants' fees. Anybody in that category will not like that angle of the scheme. Given the restraints on the budget, we cannot legislate for everybody, but at the same time I am happy to see that the drug refund scheme is an important factor in this area.

Another very important factor is the whole position of medical card holders. I represent a western area where there is a higher number of medical cards per thousand of the population than anywhere else. I understand from a Dáil question that 24,000 medical cards were withdrawn in the period from July to September 1978. That is a remarkable number by any standards. A very hard look must be taken by the Minister and the health board at the eligibility pattern for medical cards, taking into account inflation and the cost of living. There is a big difference for a small landholder with a £10 or £12 valuation and a county council worker or a forestry worker earning £47 or £50 with a young family. A very hard look must be taken at this in the light of 1979 family costs. There is severe hardship in some cases and this is something I spend a lot of my time with. If you take a farmer with £12 or £13 valuation with five or six young children, with the standards as they now are, it is quite possible that he will not be entitled to a medical card.

While I am on this subject, I should like to ask the Minister what health contribution would a farmer on £12 valuation have to pay? How is it assessed? It is a very important point. When you consider that a recent farm management survey by the Agricultural Institute found that 25 per cent of farmers had an income averaging £1,500 a year or £30 per week, one can see immediately that it is vitally important the medical card scheme would be extended in line with inflation costs and so on. There is a certain period in the life of any family when they want the greatest help and that is when the children are small, whether in town or country. The family doctor could cost £2, £3, £4 or £5 per visit. Prescriptions to the chemist, even for a child, might be anything from £4 to £6 or £7. There is no way that people on that type of income can put up with that. I ask the Minister, through the Department and the health boards, to take a long look at the eligibility threshold for medical cards.

In all matters dealing with health concerning the low income groups, it is vitally important that at the stage when the family budget is most expensive every possible help in medical terms should be given to them.

I notice that the ceiling of £5,500 has been calculated at one-and-a-half times the average industrial earnings at a certain date. I assume that that is a fair and reasonable way to do it. I also notice that the Minister is putting a fair amount of emphasis on the fact that this ceiling will be reviewed as the years go by. That is very important because, if the wage demands being looked for are to be met in the next few months, that figure will be much higher this time next year.

The position of fee paying patients getting priority over non-paying patients is something which we come across as public representatives quite often. There are a great number of people who believe that to be true. I should like to hear the Minister's comments on this, because if any educational exercise is to be undertaken there would be a major plank on this: that if you are entitled to a certain thing, you will get it and it does not make any difference who is paying for what.

Another important point I would bring to the Minister's attention is the collection of the contribution from farmers. This will be a very difficult thing to do, but I must say that since the £7 health contribution scheme was introduced in 1972 many people did not know whether they had a statutory obligation to pay it. It turned out that a lot of people paid it the first and second year, but for some unknown reason they did not pay it thereafter.

I would make a suggestion to the Minister that just might work. We have rate collectors in every county and by virtue of the decision of this Government to abolish rates they have not an awful lot to do. From the introduction of the new health scheme on 1 April it should become clear through the media by the health boards and the other bodies concerned, that a certain section of farmers are included, people who are ineligible for medical cards and so on. I find a fair amount of ignorance among the farming population as to what they are supposed to get or to what they are supposed to contribute. It is something like what Senator Moynihan was speaking about a few minutes ago.

At this stage an unusual problem has cropped up now for the health boards, particularly the Western Health Board with which I am most acquainted. It is that many farmers have "copped on" to the idea, and "copped on" the hard way when somebody belonging to them was hospitalised and they were billed for it but they had not medical cards. A number of those people incurred arrears over the years. The Minister has mentioned the figure of 70 per cent intake. I would not have thought it was that high. I would have thought that it would have been far less than 70 per cent. If it is possible within the law, a deal should be made, as is their right, that they pay their contribution through the rate collectors as from 1 April and that all the arrears that might have been there before will be scrapped. It should be a statutory obligation if a person fails to pay he would be in serious trouble. A few thousand pounds might not be collected, but most people would pay and they would be much happier to know that they are actually covered for their hospital bills. It is something the Minister might look at. The arrears, though not high, represent a stumbling block and the health boards are inclined to say: We will admit you to the scheme but you must pay for the years you did not pay for before now. Maybe with a new sheet and ensuring that everybody pays would be better for the Exchequer.

Can anything be done from a price control point of view about drugs? As an ordinary paying citizen I am amazed at the difference in prices of drugs between one place and another and indeed the price of drugs in one place at different times. I often wonder why in a consumer age, when so many people are so price conscious, it is not possible that the Prices Commission or an allied body of some type to inquire into this whole area and perhaps control prices. I do not believe for a moment that drugs should be as costly as they appear to be. Maybe it has something to do with wholesale and retail trades. The Minister would be doing the people, and indeed his Department, a great benefit if he could stop profiteering in the drugs business, that is, if there is as much profiteering as I think there is. I must compliment the Minister on his fitness-for-all programmes. That is a very good development. As he has been quoted as saying, people are unaware of the aids that can be used without drugs to make them feel better, to work better and feel happier. It is important that health programmes be launched on television and radio. It is important that a greater emphasis be placed on the things we have for free in this country, such as our clear air and our methods of leisure and so on, so that we can become a healthier race. I congratulate the Minister on the line that he has taken on this, and hope that in the future people will be able to look after themselves better and not have the State doing it for them.

I welcome the Bill, and it is a good Bill. There are things in it I should like to see changed. I ask the Minister again to take note of the medical card situation and particularly the farmers' contribution.

Professor Conroy

I should like to join in the general welcome which this Bill seems to be so rightly getting. I congratulate the Minister on the Bill and on his general approach to the problems of health.

The principle of the Bill is a worthwhile one. It proposes to change the whole system of flat rate contributions to an income related scheme of contributions, and accompanying them with some important and necessary safeguards. This should make the scheme a great deal fairer in its impact generally on people, allowing for the fact that you have these very proper exemptions for some people, such as widows and social welfare pensioners and so on.

The ceiling which has been set is in present circumstances a reasonable one. I am sure we should all like to see it a good deal higher but one has to decide on some figure; and this, using the one-and-a-half multiplier, seems to be a reasonable one. Perhaps even more important is the fact that the Minister is taking the power in section 9 to make regulations to vary the ceiling. This means that one has very effective control and will be able to increase it when necessary, if and when it is possible to do so.

The yield from this Bill however, is not likely, despite all this, greatly to contribute to the costs of health services. We talk a lot about the large figures involved and yet I do not think we fully appreciate just how enormous they have become. It is, perhaps, the enormity of the figures which begins to leave us totally uncomprehending: demands for another £400 million or £500 million almost seems to be incomprehensible. In simple terms, the figure which we have here of £459 million is four and a half times what the entire budget for the country was a short number of years ago. It represents an enormous percentage of total Government expenditure in the current budget. If you run through the various items of account which we looked at earlier, there are two figures which by their enormity dwarf all the other figures in the budget. One of these is social welfare and the other the health budget. Unfortunately there is no way in which the amounts required for health can be effectively reduced, nor would we wish to do so, because if there are methods of treatment, personnel and so on available which would increase the health of our citizens, we would wish to avail of these to the maximum extent. As the Minister has suggested, the escalation of health costs is a problem which not only poor countries find difficult in coping with, but for which even the wealthiest countries have not found an effective answer. Nor is there likely to be a full answer in the immediate future, because the scope for increase is openended whereas the revenues and the means to pay those increases are strictly limited.

So it is a question of getting the best possible value we can out of our health services. Unfortunately, for many years this has been not just a problem for this country but a global one, and by and large the attitude of Governments has been to try to limit expenditure and to cut down expenditure in various ways, as Senator Moynihan implied, often in ways which bear very hard on particular sections of the community. In effect, people are rationed, and inevitably such systems can cut very unfairly on individuals involved.

I greatly welcome this, in effect, new approach of the Minister, a greatly neglected approach until now, of trying to emphasise health education and preventive medicine. It is not the whole answer, but it goes a long way towards providing part of the answer. Many of our ills are self-inflicted, and a relatively tiny amount of money can do much good in preventing illness, by keeping people healthy instead of trying to lock the stable door afterwards. This is an enormous advance, and one which I welcome and which is very important.

The second aspect is to try and get the best value we possibly can when we are spending money. Here again the Minister has brought in a new and much needed approach, looking at these things on a sensible financial basis and seeing where the maximum benefit can be got for the expenditures which, vast though they are, nevertheless are limited. We cannot spend money on everything. We have to select and try to get the best value possible.

One of the lines which the Minister is using is in relation to drugs. One welcomes his campaign but in some ways one would be inclined to wonder if it could not go a little further. As the Minister rightly stated, many drugs are not used, many are used for trivial purposes. I wonder should the health services, the State, be providing free drugs such as tranquillisers—a very large proportion of the health budget goes to these types of drugs. It seems to be a pity that we provide free drugs of that nature, on which very considerable sums of money are spent and yet we are finding ourselves limited in regard to much more vital and beneficial aspects of the health services. One would like to see this at least considered, even if there are difficulties about this.

Senator Moynihan referred to a particular case. I hope he would agree that by and large, doctors, and in particular family practitioners, most of my colleagues who are in family practice, give a great deal of care and attention to their patients. In many cases they go perhaps beyond the call of duty in consideration of what the financial impact will be of the advice they are giving. Many of my colleagues take a great deal of trouble to see that the financial impact of illness on their patients is limited in so far as they can advise or help. I would like to pay a tribute to our family practitioner services. We get very good value for money there. We have very good and devoted doctors, nurses, medical laboratory workers. Generally it is one of the things we are very lucky to have. I am sure it makes the Minister's difficult task a lot easier that he has such good backup by the people involved in delivering the medical services.

I am very glad to see that the Voluntary Health Insurance Board are bringing in this new low cost treatment benefit scheme. I welcome it very much. I am glad to see VHI has taken a very enlightened attitude and I hope that anything that can be done by the VHI will be supported by the Minister so that it be done on a cost-conscious basis with the object of getting the maximum benefit to the patients.

Mr. Harte

I welcome the Bill as a step in the right direction—that of providing fuller health servies. Access to the health services at present is that 40 per cent of the population are covered by medical cards. About 85 per cent are covered by limited eligibility for hospital services. That situation has given rise to a lot of anomalies and inconsistencies in the area of manual and non-manual workers. In effect, we had a barrier raised against a very large number of the population who were not in a position to pay privately, and this possibly resulted in a lot of people not having sought public medical treatment because they could not afford to do so. We talk a lot about education and prevention, but this situation has to be guarded against: we must take the steps quickly to avoid a development of that situation. This Bill will help to prevent further such anomalies developing.

On the question of eligibility limits the Irish Congress of Trade Unions felt that £9,000 would be a much more realistic figure. They probably based that on their assessment of the total situation. It looks as if they are arguing that the amount be almost doubled. I know the problems that lie in that direction, but overall I am wondering if the suggested increase in the limit would affect any more than 35,000 more people. What would the cost factor be in that situation? I do not think if the eligibility limit could be raised it would have any effect on the VHI new low cost scheme. There would still be a substantial number of people who would have to take advantage of that scheme.

The Minister is the type of person who would like to see a strategy in the development of free health services. I know this is not possible at present and a lot of people would rather see a situation of contributions to these services. In the long term it could mean the beginning of a strategy towards the implementation of a free health service, a free drug service and a free GP service. At this particular time I do not think that this is a realistic proposition, but in the long term it could well be, if other factors were taken into consideration.

In 1975 the Labour Party did an estimate and they reckoned that a phasingin of a free national health service would cost about £75 million at 1977 prices. I do not know how accurate these figures are. This would mean spending about £12,500 million each year, in the phasing-in period. It does not seem all that improbable in the very long term. I think this is the desire of most people; it is not an idealogical matter.

The fundamental objective should be the establishment of a free comprehensive system for all citizens, free of discrimination, and we have discrimination at the moment. Health care is a fundamental human right and there should not be any situation where cost prevents people from availing of health care. The development of the medical card scheme alleviates things a great deal, but I still think that health problems can cause financial stress for a lot of people, having regard to the ceiling of the income relating to medical cards. As a test whether or not people are being discriminated against and whether people can avail of the health services, it might be a good idea to see if the health standards of our society are equal. An exercise was done in England and it was found that health standards were savagely unequal. It is likely that we could have a similar situation here, which I do not think the Minister would want.

Over the next 30 years the health services should continue with the collection of compulsory contributions through the employer, but with an overall working towards the objective to narrow substantially, or eliminate, the gap in health standards between both parts of Ireland and between the social classes. In present circumstances I am not quibbling, and neither is anyone else, about payment. At the moment the quibble seems to be that there are not enough people brought into the hospital services.

Getting back to the point about whether there is discrimination, the mortality rate is usually a good indicator with regard to health standards. In the area of infant mortality, we might find that discrimination manifests itself in the sense that the infant mortality rate is much higher in the lower paid income groups than in the other social classes. There is not sufficient information available on mortality statistics generally, and there should be. What is the distinction between the mortality rates of the various social classes? Probably the only way this exercise could be done would be to work right through all the age groups up to 65 years and see what the position is.

In Britain, where most of the people are working class, government is by a system rather similar to our own. A survey in Scotland over a 50-year period showed that there was a big distinction between the medical and health care services given to the different social classes and that there was no narrowing of the gap over that 50-year period. When we consider that this survey was done at a time when the national health service and the welfare state were in existence, it is something worth thinking about. I wonder if a similar survey would not reveal defects in our system.

In my view educational programmes cannot, of themselves, prevent self-inflicted ill health. In this area, I must compliment the Minister on his initiative in making people more health conscious. I agree with Senator Conroy that there is a lot more to be done, but there has been a beginning, and that is a good thing. I hope the legislation meets with the success it deserves. We need more information. There may be intolerable differences, but if they lie deep in the fabric of the society in which we live, then we must not accept this situation and must come up with remedies. If we find, for example, that problems are caused by poverty or by environment, we must look at the whole question of how we can provide the service, what the necessary contribution must be and what action may be needed to eliminate some of the existing problems. A lot of research has been done on the medical side but we do not seem to get benefit from it: what problems cause health difficulties and so on and what kind of service can be provided to overcome that?

I compliment the Minister. The idea of health education and prevention of ill health has been developed by him. He should get the reward he deserves for taking this initiative, it is not an easy job. Do health and occupations come into it? What are the factors? The initiative taken by the Minister must be supplemented by other research, particularly in the area of the patients' needs and away from the doctor's needs. Research at present is directed more towards hospitals, but there is no effective research that I know of on the cause and effect of occupational diseases, for instance. However, I am open to correction on that. I do not mind being corrected if in fact some research has been done.

We are still dealing with the area of prevention, education and so on. If the GP's area is too remote, how does his service connect up with the hospital services? Is the kind of work the GPs do too narrow? Are their surgeries adequately equipped? When we are talking about prevention, we must look at these things. What type of consultations are given? Are they too short? Are the GPs not good contributors towards the health services? After all, we are talking about contributors in more than one way. We are talking about people who contribute to a good service by actual deed and by their reaction to the realities of the situation. It is not just about people who pay for the service. On that side of it, can we get any information from the GPs' records that would help on the question of prevention and health education? This is relevant, because we are talking about a free hospital service, about prevention and about the whole question of good health habits and making people less dependent on the health services.

Very substantial revenue accrues from compulsory contributions through employers. I have, however, one question on the income limits and it is this. When contributions are subject to an income limit does this make the financing of the system less equitable than taxation? If it is not equitable with the taxation system, how can you avoid the unequal distribution of resources and establish priorities? I welcome the initiatives the Minister has taken and hope the specific steps taken in the Health Contributions Bill will be developed and that supplementary research will take place.

Finally, my reading of the Bill may not be correct, but I see a problem where people are on early retirement and do not receive any unemployment benefit, where they sign for credits but are in receipt of a pension from their company, I assume that, since they were contributors under the old system, they will come under the new system. Will they have to pay contributions out of their pension from the company in order to pay for the improved health standards? It is important to have this information because these people might have to join the VHI scheme for further services.

Mr. Governey

I want to make some comparisons between the health services at present and how they will operate when this Bill becomes law. As we know, medical card holders make no contribution to the health services at present but are entitled to all health services free of charge. At present, under the Health Contributions Act, 1970, the middle income group make a contribution, the self-employed pay £24 per year and an insured person pays 50p per week. Under the new Bill, medical card holders will make no contribution as heretofore, but people whose incomes do not exceed £5,000 a year will contribute on the basis of 1 per cent of their earnings. They will be entitled to free hospital services, hospital beds, hospital maintenance and medical, surgical and consultants' fees. Taking into account inflation and the fact that the cost of hospital services and maintenance has increased tremendously over the past few years, the increase here from £3,000 to £5,000 is small and it will not bring many extra people into this scheme. In the case of people whose earnings are more than £5,000 and of farmers who are over the £50 valuation, these farmers will not have to pay any more than those on £5,000 income.

Mr. Haughey

It is £5,500 and £60.

Mr. Governey

They will qualify for hospital beds and maintenance, but will now have to pay their own consultant.

The Minister, in his reply, might be able to set my mind at rest on one point. During the term of office of the Minister's predecessor, the then Minister for Health tried to introduce a scheme of a free-for-all health service, but was told by the consultants, at that time, that it could not be operated. The major reason given on that occasion was that there would not be enough hospital beds available. I wonder if the Minister is satisfied that there are now enough hospital beds available to operate this new scheme, or has the position changed dramatically over the last 18 or 20 months? I think people earning £2,500 at present are being asked to pay a little too much. By today's standards, with the present cost of living, £2,500 is not a very considerable amount of money. I do not know if anything can be done about it but the contribution for that income seems to be a bit out of line.

I now refer to something which has been spoken of in both Houses, which is the question of medical card holders. We all know the health boards review income limits each January, but those in operation, even since last January, are far too low. A married couple earning £40.50 per week are entitled to a medical card, but a married couple earning £41 per week are not so entitled. The Minister, who takes such an interest in his Department and who is so concerned with the health of our people, would agree with me that a married couple earning £41 a week who suffer illness during the year and need the attention of a doctor cannot afford to pay for this service, pay their rent and get the bare necessities of life. I know the income limits are decided by the CEOs of the health boards, but I would strongly urge the Minister to give a directive to those CEOs to have another look at this limit and to increase it to a more realistic figure.

I refer to the case of a married couple, but I am just as concerned about the single person living alone. All the income limits are far too low. At a meeting, about a month ago, of the Southern Board, of which I am a member, we sent a resolution along those lines to the Minister for Health. I would ask him to consider it very sympathetically.

An Cathaoirleach

I think the Senator is going too far off the Bill in regard to medical cards. It is slightly outside this discussion.

Mr. Governey

I apologise. I thought it was relevant to this Bill. Up to now, a manual worker earning more than £3,000 was not covered but one earning less than £3,000 was covered. Now, people earning more than £5,000 are not covered for consultancy fees, but those earning less are eligible. In the case of a husband and wife who are slightly under the £5,000 limit, they will be covered for consultancy fees, for maternity, for everything under this Bill. But in the case of a husband and wife with a family who are earning more than £5,000, they will not be covered for consultants' fees and, if I am correct, they will not be covered for maternity fees. That is something which the Minister might reconsider.

Finally, I refer to what was said in the Minister's speech about the low-cost treatment benefit scheme being offered by the Voluntary Health Insurance Board. This is an excellent scheme and I take this opportunity of paying a tribute to the Voluntary Health Insurance Board for the courtesy and help one always receives when dealing with any section of this board. The Minister might clarify the following point for me. Previously, if people suffered from recurring illness before they entered the voluntary health scheme, they were not covered by the scheme for that illness. Do I take it that, regardless of past medical history, people will be accepted under this new low-cost scheme?

Mr. Haughey

Yes.

Mr. Governey

That is a welcome addition to the scheme and I would congratulate the Voluntary Health Insurance Board on it.

These are a few points that I wanted to make and I should be glad if the Minister, in his reply, would comment on some of the items I have raised.

Business suspended at 1 p.m. and resumed at 2.30 p.m.

Mr. McGowan

I join other Members in welcoming this Bill. It could best be described as another milestone in the advance of the health services and I am sure that the Minister and the Department would be the first to accept that it is hardly the last Bill that will be necessary to streamline the services provided to the public. The health service has changed tremendously in the 20 years during which I have been associated with the provision of health services to the public. With the change from the local authorities to the health boards, the whole structure of health administration has changed, and this is probably the biggest leap forward that we have taken so far.

The public will realise that this Bill is necessary because we are reaching the stage where a vast amount of money is being spent on health, and all of us realise that the money must come from somewhere. Somebody must pay for it at the end of the day. The Bill goes a good part of the way towards regularising the health service. It clears up the position where some sections of the public were entitled to free medical service while certain income brackets had a grievance and sometimes had to pay large amounts for medical service.

I welcome the provision whereby we will have specialist services available free. That is really a tremendous step forward. Any family who have incurred medical expenses realise that this can be the biggest financial burden on a family. Almost all citizens are now absolutely assured that financial difficulties will not prevent them from getting the best treatment.

I would say to the Minister that when the provisions of this Bill are being implemented all the machinery of the State and of his Department should be organised to eliminate waste at every level, whether it is excessive charges by specialists, waste of drugs, or involved with the storage or administration of drugs. All of us realise that only by so doing will further advances be made in the health services.

The Minister is to be congratulated and commended by all the people. Those who may not support him politically have applauded him for his great crusade in the interest of the health of the country as shown by the nonsmoking campaign. I would like to see the Minister start another crusade against the over-use of drugs and the use of drugs where it is unnecessary. We as a nation must not copy other nations who have almost destroyed themselves by the use of drugs. The public should be advised to guard against the over-use of drugs. Secondly, there will be a saving that will help to extend the benefit of the health service to those most in need.

If our forefathers could see the advances contained in this Bill they would find it hard to believe that the country has come so far in such a short time. We are offering a very elaborate medical service to nearly all our people. I am delighted that the public are made aware that there has to be a contribution. I was very interested in the medical services introduced in the past in Britain and in Northern Ireland. Those medical services did not call for a contribution. The prescription cost at that time was one shilling. However, those who introduced that type of medical service quickly realised that they made a serious mistake, because the amount of money wasted through abuse could not be calculated. This is a totally different approach. It is a planned approach because we realise that we have to plan our budget and our expenditure to get the best results.

This Bill is very commendable and a great step forward. There are just a few areas I hope the Minister would consider. At the conclusion of his speech he said that there are areas that he will look at further. Where people are hospitalised for a long time consideration should be given to their relatives. Facilities should be improved for relatives where there is a problem of transport. If somebody from my county is in a Dublin hospital, transport to and from the hospital and accommodation are a major problem. That is one aspect of the health services where I should like to see an advance.

I join other Senators in complimenting the Minister and I wish him success. It is evident that he is one of the most successful Ministers for Health this country has had, but the onus on him is great because the public have come to expect, perhaps, a bit too much. The Minister has the backing of the vast majority of the people in his present campaign and we accept his balanced and reasonable approach to health services. I would encourage him to keep up the good work.

I would like to see him start another campaign or crusade to prevent the over-use of drugs and to prevent doctors from over administering drugs. The price of drugs is now enormous. All too often there is lack of control. GPs do not need to keep a strict record of how they prescribe drugs. I do not know how best to approach this, but the Minister would be well advised to keep a very strict check on the use of drugs, even through some of our best GPs. That would be a major contribution to the health of the nation. I think that is the Minister's intention. I see this as a good Bill and a step forward.

Mr. A. O'Brien

I join in the tribute to the Minister in so far as the Bill sets out to provide more medical care for a greater section of the people. That is desirable and everybody is in favour of it. Whatever limitations there may be are necessary because we are controlled to some degree by our wealth-earning capacity as a nation. If we develop production and make more money for ourselves as a people, it is to be presumed that the limits with regard to health cards and so on will be raised.

Without going into the maximum figure under which health cards are allowable, I would make a special plea to the Minister to ensure that there is a liberal interpretation of limited eligibility clauses. We all know of people who are just beyond poor law valuation or just beyond the upper income limit and when they are confronted with a long period of illness it is more than they are able to bear. Every effort should be made to be as considerate as possible in extending their eligibility.

I should like to pay tribute to what the Minister has done in launching what I might term a crusade to get people interested in their own fitness. As the Minister said, prevention rather than belated attempts to cure should be the guiding line. But there are many fields in which the Minister for Health will want co-operation from other Ministers if he is to get his message across.

There is widespread recognition of the fact that there is an over-consumption of alcohol. That is made easy by the ease with which people can get bar extensions in hotels. Extensions are given for the most flimsy reasons. A high percentage of our young people go to these functions, to which the admission charge is about £1.50. They often indicate that they do not want to take a meal and they are then admitted to these bars on payment of £1. That simply means that they have two or three extra hours for consuming alcohol.

Recently a very prominent medical practitioner in this country drew attention to the fact that it is the concentrated drinking over the weekends from Friday to Sunday that has resulted in an enormous increase in the number of people being admitted to psychiatric hospitals for treatment of illnesses brought on by over-consumption of alcohol. The regulation as it stood with regard to the meal provided at these functions was that a substantial meal costing not less than 50p should be served. We all know how substantial a meal at the present time costing 50p would be. My opinion is that the regulation should demand that a meal costing in the region of £2 should be served during these extensions. This is a matter that has been referred to by health boards all over the country and medical people and parents are very concerned at the ease with which these bar extensions can be obtained. That has resulted in a great growth in the number of people being admitted for treatment in the psychiatric hospitals. It has resulted in absenteeism from work on Mondays.

An Cathaoirleach

The Senator may be going a little beyond the scope of the Bill.

Mr. A. O'Brien

Quite recently the manager of a factory told me that there were more rejects from the work done on Mondays than on the other four days of the week. Therefore, every effort the Minister can make to control that situation will be very welcome and will contribute substantially to an improvement in the quality of our life.

The Minister also said that he has embarked on a major campaign to cut down the use of drugs and medicines when they are not medically necessary. Quite recently at a budget day meeting of the North Eastern Health Board attention was drawn to the fact that the cost of drugs was escalating rapidly year after year, and the Minister also draws attention to that. I believe that there is an over prescription of drugs and that people have come to think that a drug of some kind is a necessity. At one end of the scale they want pep tablets; at the other end it is tranquilisers.

Quite recently I heard of a case where in the senior final of a primary schools' competition a boy playing at centre half back, who had been a commanding figure in all the games up to the final, was suddenly found to be off form. He was running all over the field. He did not advert to the fact that he should keep his position. He was making an attempt to feel the ball when it was still some feet away from him. When the trainer of the team had a talk with him at half time as to the sudden cause of the deterioration in his form he was told by the lad that he had taken four pep tablets so that he could put on a class performance. It had the opposite effect. The point I want to make is that even at 13 years of age youngsters think that pep tablets will have a good effect. At the other end of the scale there is the fact that after any exertion whatever a tranquiliser is thought to be necessary.

We are being conditioned into the frame of mind where we believe tablets of some kind are necessary for everything we undertake. In the old days there was a belief that sometimes a general practitioner who knew people well gave them a bottle of coloured water and the psychological effect of taking that home and drinking it, thinking it was medicine of some kind, worked wonders. Nowadays it must be a tablet or drug of some kind. Whatever can be done by the Minister to educate the people to get them to rethink on this situation will be very useful and valuable.

In conjunction with the Minister's crusade to win people away from excessive drinking, excessive smoking and excessive eating, we should have a greater drive for savings, though I know this does not come under the Minister's Department. One of the bad side-effects of inflation was that people felt that putting money aside was no good, that in three to four years' time the devaluation of the £ would mean that the savings would not be worthwhile. Concurrently with the Minister's drive to cut out these abuses, we should have an intensification of the savings campaign.

An Cathaoirleach

The Senator is going slightly off the mark again.

Mr. A. O'Brien

With due deference, it is interrelated with everything that the Minister has said with regard to the over-consumption of drugs, alcohol and so on. The attractive alternative would be to get people conditioned into thinking that some of the money should be left aside rather than spent every weekend. That would help to achieve the Minister's goal.

We have reached the stage where we have a shorter working week, but we are not trained how to use our leisure time beneficially. The result is that we crowd into public houses with all the consequent evils to society. That is aggravated by the fact that we have the "hire purchase" mentality. Young people now, instead of saving for the future as the older generation did, believe that when they embark on marriage everything will be made easy through hire purchase.

An Cathaoirleach

I again remind the Senator that this is not relevant to the Bill.

Mr. A. O'Brien

I will finish shortly. Our young people have turned away from the idea of providing for the future.

I should like to join in the tributes paid earlier to the VHI for the great improvements recently introduced. This organisation have done tremendous work. I hope that the operation of this Bill, together with the operations of the VHI, will result in better treatment for a wider section of our population. I fervently hope that efforts being made at health board level and by the Minister to cut down on the use and prescription of drugs will be successful.

Minister for Health (Mr. Haughey)

I want very sincerely to express my appreciation to Senators for the welcome which they have afforded this legislation and for the constructive comments which have been made on all sides. I am very interested in the points made by Senators arising out of the legislation and in regard to the health services generally.

The Bill, as a number of Senators have pointed out, can be regarded as a step forward. It is a major improvement in our approach to health and to the administration of the health services. It will go a long way towards providing in our community a reasonable satisfactory and comprehensive health service. I would hope that by the time the Bill is fully in operation, allied to the attractive package which the Voluntary Health Insurance Board are putting forward, there will not be anybody in our community who will hesitate to seek any medical attention they may require because of their inability to pay for it. The provisions which we will have made when this Bill is implemented will be comprehensive and will cover all sections of the community to the extent that is necessary to ensure that ideal. As a number of Senators have mentioned, nobody will be compelled to forego necessary health treatment or medical treatment because of financial and economic circumstances.

I will now deal with some of the points raised by Senators and with the queries which have been put to me. I will deal with them more or less in the order in which they were made during the course of the debate rather than attach particular importance to one point over another.

The question of the information of hospital patients is a very important one. It is something to which I have been giving attention over the past 12 months or so. Most Senators agree that for many people to be admitted to hospital is an intimidating experience, particularly for old people. For most ordinary citizens to be removed from their home environment and taken into hospital—an institutional setting—can be intimidating. It is very important that every effort be made to ensure that patients being admitted to hospital are reassured to the greatest extent possible and treated with kindness and understanding.

A more important aspect than any of these is that they be fully informed of exactly what their condition is. We all know the trying experience it is to be left in hospital without any information as to what is going to happen or what treatment is to be received or what the programme is for the individual. There is a small working group looking into this matter and they have now submitted a report to me. As a result of that report we are now preparing in the Department of Health a booklet which we will be issuing in a matter of months to all health institutions and hospitals on the subject of providing the maximum amount of information and reassurance for patients admitted to hospitals.

Some of the debate has centred on the question of the ceiling and there are a few points which I would like to make about that. First of all, it is a movable ceiling. When the Bill was prepared the figure of £5,000 was mentioned, but I indicated that before 6 April a final decision would be taken and the ultimate ceiling would be fixed by regulation. That is still the position. Since the Bill was published we now have access to the figure for the average industrial earnings which was published in March 1978 and on the basis of that, using the same one and a half calculation, it is clear that the figure should now be somewhere around £5,200. The ceiling for both the social welfare and the health sides should be somewhere in that region. There have been very strong representations from the trade union movement and from others that we should put the ceiling up as far as we can. In response to that and in an endeavour to go some way towards meeting those representations, it is proposed to fix the ceiling at £5,500. That is more than would be indicated by the calculator of one and a half times the average industrial earnings. It will take in the vast majority of wage and income earners.

One of the limiting factors is that we have to have the same upper limit, same ceiling, for the new social welfare payrelated contribution system as we have for the health contribution. Otherwise, there would be an enormously difficult collection system. One of the big advantages of the changeover we are making is simplicity. We are introducing on the social welfare and health sides a major degree of simplification. In future, both these systems should be able to be implemented and operated with the minimum of difficulty, complication and bureaucratic and official problems. That is the limiting factor. But, weighing up all the factors, I think that £5,500 is a reasonable ceiling.

I mentioned by way of interjection to the Senator that, in considering the level of the ceiling we should bear in mind that it will always be operating retrospectively. In other words, it is a person's income in the year ended April 1979 that will be the basis of eligibility for 1979-1980 the following year. There is that further element of extension in the upper limit of the ceiling. The ceiling will move up in accordance with the movement in wages and incomes. Fixing the new ceiling will be an annual exercise. It will have to be the same ceiling for social welfare and for health, because that is one of the great advantages of the whole process.

I want to avail of this opportunity to commend the new Voluntary Health Insurance package to Senators and, through the Seanad to the general public. I am very pleased that so many warm tributes have been paid to the Voluntary Health Insurance Board during the course of the discussion. They are very well merited because the Voluntary Health Insurance Board are one of the great national successes of our health service. They have established an excellent reputation for efficiency in their approach to the whole matter of health insurance. They have, at my request, adapted themselves and their schemes very quickly to the new proposals. The package they are offering to the general public fits in exactly with what we are proposing on the official health administration side. I want to urge all who are likely to be affected, particularly higher paid workers, to really find out for themselves what the Voluntary Health Insurance Board are now offering to them and to favourably consider becoming insured under VHI. The package is a very attractive one. Any worker who is moving up towards the limit of £5,000 or beyond would be doing himself and his family a very great service if he got in touch with the VHI and investigated how the schemes would suit his family.

The VHI are introducing a number of improvements. Some Senators asked about the modifications in the new schemes. There were some questions asked about this in the Dáil, and I would like to avail of this opportunity to reiterate what the exact position is. The main thing, of course, is that the new schemes will be available to the public as a whole. They will be of particular interest and benefit to higher paid workers, particularly higher paid manual workers. The schemes will be of general application to the whole community. The important changes are that provision for maternity, for instance, is being brought in. The previous illness conditions which have existed up to now are being done away with. In most cases the age limits are being done away with. Provision is now being made to pay one's voluntary health insurance premium by instalments if one so wishes. A number of the restrictions that have existed up to now have been abolished.

I ask the full co-operation of Senators in drawing attention, particularly of the vocational organisations with which they are associated, to these new provisions, and preaching the gospel and getting across the message that family men and women should find out for themselves what it would cost them to join VHI, what benefits they would derive and how it would affect them.

Some Senators spoke about medical cards. While medical cards are not affected by this legislation, except in so far as the provision whereby a medical card holder does not pay a health contribution is being continued, nevertheless it is an important matter because medical cards and their availability affect in a real and vital way many of the lower paid families.

I will deal briefly with the situation in regard to medical cards. It is wrong to be too disconcerted by reading or learning that so many thousands of medical cards have been withdrawn in a particular period because that is not the figure that counts. The figure that counts is the balance between the medical cards withdrawn and the number of new ones issued. There will always be movement in the numbers and the important thing to ensure is that, as far as possible, everybody who is entitled to a medical card gets one. There should be a minimum of delay and bureaucratic frustration in this situation.

A number of Deputies and Senators are concerned that in some of the health board areas, medical cards seem to be withdrawn to a greater extent than previously. I assure the Seanad that there is no policy directive of any sort involved in this situation. As far as I am concerned, I am anxious that all members of the community and families entitled to medical cards get them with the minimum of interference and delay. If there is a problem the benefit of the doubt should be given to the particular families. The guidelines were revised on 1 January by the chief executive officers of the health boards and the income limits were increased. They are not by any means generous limits, but they have been revised in line with increases in the cost of living. I recently had a meeting with the chief executive officers on different matters and I availed of the opportunity to discuss with them the question of the issue of medical cards. We understand each other's position. The chief executive officers are fully aware of what I am anxious to achieve in this situation—that the guidelines be fairly, impartially and flexibly enforced.

As regards the hardship provisions in the Health Acts, a chief executive officer always has the reserve power to provide assistance in any case where an individual or family would be involved in hardship in the provision of medical attention. Senators should not hesitate to drawn the attention of the officials, or ultimately the chief executive officer, to this provision and seek to have it invoked in any case where it appears desirable that it should be invoked. We will keep the situation in regard to medical cards under review but, in so far as the population as a whole is concerned, the percentage of the population covered by medical cards remains relatively stable. I imagine that in some cases the withdrawal of a number of medical cards might be due to the fact that people during 1978 secured employment. There was a fall in the numbers on the live register. Apart from that, there was a considerable increase in the numbers employed. That would be reflected in the medical card statistics.

I assure the House that there is no question of the Department of Health, the Minister or anybody at any level, giving instructions or directives that medical cards are to be restricted or that there is to be any tightening up or anything done that was not part of the Minister's machinery before. I will continue to keep an eye on the situation and will keep in touch with the chief executive officers of the health boards.

Senator Harte raised a number of interesting points. He was inquiring about the amount of research being done into mortality rates. I am speaking from recollection at this point, but there is no great valuable breakdown of mortality rates as far as social classes are concerned. The Medico-Social Research Board are at present engaged in a hospital in-patient survey. We will get a fair amount of information from that. The information we have is on the basis of age groups and not social classes. The Senator raised the question of whether or not morbidity and mortality figures can be related to social classes. We might get some surprising results if we had such a survey. I imagine that, in so far as a lot of modern diseases are concerned, the statistics might show that they are more closely related to affluence in society rather than to deprivation. But, unfortunately, as of now, there is no valuable or important research information available to us.

A number of Senators spoke about the importance of preventive medicine and health education. At the risk of being a bore on this aspect, I reiterate the fundamental basic importance of preventive medicine and health education. The most precious asset an individual has is his or her health. It means more to the individual than it does to anybody else. An enormous amount can be done by the individual to maintain and preserve this vital, valuable asset which he or she has. As Senators know, we are trying to do a great deal in the field of health education and are trying to get across a number of important messages. We have had a number of successful campaigns and will be continuing with them. Senators mentioned most of the important points; cigarette smoking, alcohol—and not just alcoholism—but the abuse of alcohol—the over-use and misuse of drugs and the importance of diet and physical exercise. We need constant educative programmes on these so that they will have an impact on the general public.

Every time I go to a meeting of Ministers of Health in Europe the debate is always the same: what can we do to control the escalating cost of the health service? The wealthier the countries are, the more they are concerned with escalating costs. The cost of the health services is one of the most vital factors in health. Any sensible person looking at the situation will see clearly that the ultimate way of keeping the health services within our capacity to pay for them is by a positive approach to preventive medicine and health education. If we can prevent people from becoming ill, we can use the money we have available to provide far better services for those who are ill. It is as simple as that.

One Senator mentioned the question of the co-operation and assistance from the radio and television authority. I must confess that I have mixed feelings on this score. One would think there could not be a more desirable function for a national radio and television service than to be fully committed to promoting positive health and preventive medicine. I have been making determined efforts to seek the co-operation of the RTE Authority in this area and I have met with some success, but I have also been meeting with quite a deal of disappointment. As Senators know, we launched a national no-smoking day on Ash Wednesday. The general public were interested in that and I know from my own contacts that there has been quite a good response to that campaign. I went to a great deal of trouble to facilitate the radio and television authority by doing a programme, which was to be transmitted on the evening before Ash Wednesday, to try and focus public attention and get the maximum public involvement in and support for the national no-smoking campaign. Despite that I, to my dismay, found that, even though we have made the programme, RTE for some reason of their own decided not to use it. I still do not know to this day why they did not use it. In so far as they discussed the no-smoking campaign at all, their attitude towards it was negative and unhelpful. I am sorry I have to say that but it seems to me quite incredible that programmes of a health education nature would not be enthusiastically accepted by the national television and radio authority. We have been meeting, at certain levels, with a great deal of co-operation from the Authority in certain areas. However, there is a great deal of room for more comprehensive and enthusiastic co-operation by the national radio and television authority in this area.

Mrs. Robinson

The Minister got his picture in every paper.

Mr. Haughey

I am talking about radio and television. I am just making the point that, even though I made a programme at the request of the Authority for this particular campaign, they decided for some reason of their own not to use it.

A Senator mentioned the price of drugs. That is something which needs constant attention. By and large, we are fairly happy in the Department with the situation regarding the price we are charged for drugs in the health services. We keep an eye on the situation and monitor price movements in other countries. We have constant dialogue with the industry about the prices that were charged. We are having discussions with individual companies in relation to particular preparations where prices seem to be out of line. That process will continue. The big improvement must come about not merely in the price of drugs but in the use of them.

There must be a sensible, moderate approach to the use of drugs. We are in very close co-operation with the medical organisation about this matter. If one looks casually at the figures in the general medical service one will see that the amount of drugs dispensed is out of all proportion to what should be dispensed. It is a complex and difficult situation and one should not come to any facile solutions and opinions. Both the Department of Health and the medical organisations are concerned to constantly try to improve the whole system of prescribing drugs. We have now brought out a formulary which lists the basic ingredients and which should be of enormous help to the medical profession to prescribe economically. We will continue our efforts to try and ensure that valuable and beneficial drugs are only used to the extent and in the manner that they should be.

The same thing applies to that section of the Bill which is not covered by the general medical service. One Senator mentioned that there seems to a fairly general opinion among the public that if one goes to a doctor one must come away with a prescription for a drug. That is totally wrong. More and more doctors are preaching the message that they can be of far greater service to their patients in many cases if they do not prescribe anything at all. It is an area in which an enormous amount of effort and education is required and, ultimately must be governed by what the patient regards as necessary and desirable and the clinical judgement of the doctor. We on the administrative side can only go so far. We cannot interfere with the liberty of the doctor to prescribe for his patient as he sees fit nor can we intervene in the clinical relationship between doctor and patient. Doctors are just as concerned about over-prescribing and about the use and abuse of drugs as we are in the Department and afford us full cooperation in our efforts to bring about an improvement.

I have dealt with most of the points raised during the course of the discussion. The debate, as usual, has been informed and constructive. Very good points have been made by different Senators, perhaps not with great relevance to the legislation, but nevertheless important so far as general administration of the health services is concerned. It has been a valuable discussion so far as I am concerned. I was glad to get the views of the Senators on these various matters. I greatly appreciate the constructive welcome which Senators afforded the legislation.

Question put and agreed to.

Agreed to take remaining Stages today.

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