I move:
That Seanad Éireann approves of the Health Contributions (Yearly Reckonable Income) (Variation) Regulations, 1980 in draft.
Health Contributions (Yearly Reckonable Income) (Variation) Regulations, 1980: Motion.
The present income ceiling on which the maximum level of health contributions is payable by an individual in respect of any particular contribution year is £5,500. The Health Contributions Act, 1979, provides that the income ceiling may be varied by regulations made by the Minister for the next contribution year after the year to which an income ceiling currently in force applies. The Act also provides that draft regulations providing for a variation in the ceiling must first be approved by both Houses of the Oireachtas before the regulations are made.
The draft regulations which are now before the Seanad for approval provide for a variation in the ceiling from £5,500 to £7,000. The latter figure is the same as that specified in the Social Welfare (Amendment) Bill, 1980, which has been passed by both Houses of the Oireachtas.
The collection machinery for the income-related health contributions scheme in the case of employees is integrated with the arrangements for the collection of social insurance contributions, occupational injuries contributions and redundancy contributions. All these collection systems are included in the collection arrangements made for the collection of income tax. When the detailed arrangements were being worked out it was considered essential that the inclusion of health contributions should not introduce complications that would interfere with the operation of the collection machinery for social insurance contributions and the collection of income tax.
It was decided that the best approach would be to arrive at a single contribution expressed as a percentage of an employee's income which would cover social insurance, occupational injuries, redundancy and health contributions. It was also decided that there should be a common income ceiling so as to simplify the administration of the collection machinery and also facilitate employers in the discharge of their obligations. It is therefore intended that the new ceiling for health contributions for 1980-81 will be £7,000, that is, the same level as that fixed for social insurance contributions.
In addition to employees, the revised ceiling specified in the draft regulations would apply also to all other individuals who are required to pay health contributions, including farmers and the self-employed. The rate of health contribution is to remain at 1 per cent. The maximum amount that would be payable by any individual in relation to the next contribution year which commences on 6 April 1980 would therefore be £70. In the determination of that amount all sources of income are taken into account.
I would now ask the Seanad to approve of the Health Contributions (Yearly Reckonable Income) (Variation) Regulations, 1980, in draft.
It is regrettable that in the presentation of this motion the Government have not yet faced up to the need for the introduction of a comprehensive health service for all our people. The raising of the income ceiling from £5,500 to £7,000 is not a raising in the real sense because due to the 1978-79 pay agreement the figure of £7,000 was agreed on. It is true that the ceiling of £7,000 was arranged with the voluntary health insurance people but from April 1979 the categories covered by the service had free hospitalisation and free health services. In taking into account the subsequent 16 to 18 per cent increase in the cost of living and inflation there is a factor here the Minister should have faced up to. He should have substantially adjusted it beyond £7,000. It is regrettable that it was not approached on the basis of introducing a full service for all.
Having regard to our population situation and the cost of hospitalisation and specialist services, never was there a greater need for this approach. It is evident that there are some pressure groups, small but immensely powerful and influential, who are holding back the introduction of such a scheme. At present the health services are costing in the region of £450 million per year covering approximately 85 per cent of our population. We must realise the mechanism by which the health services are operating, particularly since April 1979. Then, for the first time in our history, insured workers were obliged to observe a ceiling in their income for the implementation of free health services. We must bear in mind the massive volume of paper work that resulted from this decision.
Every public representative knows that from April last a tremendous degree of confusion has existed in the minds of insured workers and their families who heretofore were admitted to a hospital or a clinic or any health service and merely asked to submit their insurance number. A tremendous degree of confusion has arisen with the result that it is assumed that a very substantial number of insured workers and their families throughout the country are not covered for any health service. They have not been advised about the new regulations whereby they are obliged to fill in an application form for a hospital service card, collect a P60 form and submit both to the health board. That exercise is new to them.
The whole health service is blowing in a huge volume of paper work. The introduction of a comprehensive free-for-all health service to cover the remaining percentage of our population could well be financed by the complete elimination of the colossal volume of paper work involved in the health service. The Minister is meeting representatives of the ICTU shortly. They speak on behalf of a very wide spectrum of the population and they are sincerely urging the Minister to abolish the ceiling. We are well aware of what is happening, be it on a large or small scale. In today's health situation a patient approaching his doctor may be in need of urgent hospitalisation but may have to wait a number of weeks for a bed in a health board hospital. That patient may be told that a bed can be obtained immediately in a private ward. That patient, concerned only with his or her health and ignoring the financial circumstances, immediately may ask for an arrangement, not being conscious of what he or she is exposed to until some considerable time after he or she is discharged from hospital. There is room for a private service here but let that be for those who opt freely to avail of it.
The population should be afforded an opportunity of availing of a free hospitalisation service in public wards within our health contributions. This is a long standing aspiration and the cost is easily surmountable. It would create a mechanism by which our health services could be more easily, expeditiously and more economically arranged.
Earlier this year taxpayers received what appeared to be taxable demands in amounts running from £12 up to £50 or £60. On a number of occasions I was asked what exactly it covered and I said I understood it covered the new health regulations contribution, which it appeared to do. The question that I was not able to answer—I would like the Minister to take the opportunity to give us a better picture—is what this contribution covers, what facility it grants or provides for those who lie within the maximum level of £7,000 which is subject to a health contribution of £70.
I should like to ask the Minister about the cover the health contributions afford to the people who are paying. In the midlands at present there is tremendous unease about the hospital services. The Minister was quoted by Radio Éireann two weeks ago as asking for stricter criteria on the admissions of patients to general hospitals. There is a persistent rumour that as far as the Midland Health Board are concerned there is a proposal to send home all the old patients who, for a number of years, have had the health facilities of district hospitals or county homes. That would be a deplorable step backwards and the Minister should tell the House if he is going to bring in drastic economies. Surely the people who have served the country well for the past 75 or 85 years are not the people on whom either the health boards, or the Minister, should pick. Farmers receive six day and seven day notices from health boards because some of them have more than one valuation number in the council registers. The health boards even though this scheme has been in operation for a number of years, do not appear to have been able to classify or list the people who are entitled to pay. The Minister should avail of this opportunity to qualify what he was thinking about when he was asking to have the hospitals cleared out. In practically all hospitals there are patients now in the corridors, a deplorable situation. This regulation is varying the amount of contributions that practically everybody will be making towards the running of the hospital and the health services and it is appropriate that the Minister might clarify the points that have created so much uncertainty, especially amongst the older people.
I should like to support these regulations which are basically a tidying up operation but they do bring to our minds once again the enormous cost of health services and the near impossibility of meeting these costs in a way we would very much like to do. This is not a problem occurring in isolation here, it is an international one. As Senator Moynihan mentioned, we are spending something in the region of £450 million per annum. An enormous proportion of our budget is going, quite rightly, on health services. The problem is how to get the best value from it in money terms and at the same time remember that we are dealing with people. People are at their most vulnerable when they are ill.
The institution of the national health service in England was one of the great achievements of the immediate post-war Labour Government. One would have to confess, unfortunately, that the national health service, from having set a standard which we could all only desire to emulate, has nonetheless gradually deteriorated as effectively demand has been rationed. Now in England one can wait many years for very important operations. Indeed, the situation is arising in which people, often quite poor people, are spending their life savings in order to go to a private hospital and have operations such as a hip dislocation, done. That is happening because the national health service in England is overstrained and they are unable to find the finances for it. On the other hand, of course, there is the free for all type of medical service in the United States. There, too, ill-health can be a grevious burden on people who, through no fault of their own, through some sudden illness have found themselves and their entire family literally ruined for life.
We have tried, this and previous Governments, to steer a sort of middle course, with all the difficulties that involves. On the whole, we can be very satisfied with that. We do not fully realise just how good our health services are. I do not wish to speak on behalf of my own profession, but I can certainly speak in glowing terms of the other medical professions, the nursing and para-medical professions which we have. Often they are relatively badly paid and yet they give a magnificent service to patients, a service often far over and beyond anything they could be recompensed for. Long may this continue. I would hate to see health here ever becoming simply a matter of ideology, of one group simply pressing that we should have one particular type of health service because ideologically they wish to have such a service. I would hate to see any other group trying to prevent improvements in our health services purely on the grounds of their own financial well-being. I hope that never will be the situation here.
It is an enormous problem and our new Minister for Health will have to look at this carefully. Instead of running over the old arguments of whether he should go on increasing the limits he will have to look to see if, perhaps, an entirely new form of health service is necessary. In the case of the elderly, for example, it is very difficult, appallingly difficult, to get a bed in Dublin, even if that person is severely ill. We are going to have to turn our attention towards a more selective type of health service, selective not in terms of finance, but in terms of giving priority to those who are most in need of medical care and in terms of giving more attention to preventive medicine. If in the process of this those who are well able to pay for day to day illnesses, have to pay for them and for the therapy and treatment relating to them, that is only fair. It is not fair that we should spend vast sums on health and at the end of the day the poor and the needy—our elderly people are poor and needy—should not be able to get medical treatment or should find it so postponed as to be almost meaningless. We must look at the provision of finances for our health services on an entirely new basis. There is no way in which we can continue on the present path. The sums involved are too vast and there is no way they can do anything other than increase unless we look a little more selectively at getting value for the money spent and seeing that it goes to those in most medical and social need.
Some speakers widened the debate a little and I move to offer some thoughts in the same area. I read a figure which is so large that it seems improbable—I do not think that it is wrong—that in Sweden 10 per cent of GNP is spent on the area of health in its widest ramifications. We see a situation where the calls for money are practically endless. It is true, as Senator Conroy said from expert knowledge, that there are immense creakings and groanings in our health system. It is often not good enough for those most in need and it is complex in terms of administration. While I cannot put my finger on where, I believe that there are areas where there is at least an expenditure that is not carefully adjusted to the objective of achieving the maximum result.
I agree completely with Senator Conroy about the quality of service in Ireland but it seems to be a quality that depends on the quality of people and not because we have a good structure or a good system. We have one that has been cobbled together over a long period in bits and pieces but we have extraordinarily dedicated, kind and warm people in that service. Indeed, it is the experience of the ill in other countries that, for example, Irish nurses are kind and warm as well as meticulous and efficient. We have to look at ways of improving the service without the cost going mad because any of us who have been involved in a budget process know that health can eat all the money anybody can provide and still not be satisfactorily done.
I am struck by the fact that in our society so much of the money desperately needed for the people Senator Conroy correctly identified as the poor, the needy and the old is going in other directions. Our expenditure has increased but our health does not improve. So many of the things that we see huge expenditures on are obviously preventable things. I would grind a personal axe as a non-smoker because I bitterly resent—if people want to kill themselves with cigarettes that is their right and I would not try to stop them—the loads that puts on to non-smokers in regard to the cost of health here. It is preventable, the knowledge is there and it is wilful. We have to think of differentials, so much as I dislike the idea of means tests, and of targeting to get the maximum benefit where there is the maximum need. I gave the example of smoking as one of many examples. I note the drives with a rather PR aspect to them about smoking and fitness. I hope that is the way to do it; it is an admirable thing to do. Obviously, in the area of prevention there are savings to be made which may in the short run involve extra expenditures.
Having agreed quite a lot with Senator Conroy I should like to offer a disagreement. The idea of a comprehensive health service does not seem to me to be an ideological one. It seems to be a basic demand of both equity and efficiency. What we are seeing now in Ireland and, indeed, what we are seeing in Britain with the great difficulties of the national health service, and what we are seeing more uniquely in the United States, is a vast differential in the quality of service depending on income, in other words service is for sale. It does not seem to be a matter of ideology but a matter of what one might call the availability of fundamental human rights, that access to health and treatment of illness should not be dependent, not even on the person's own earning power—it is usually on the earning power of some near relative—and in the case of a child it should not be dependent on the accident of the earning power of the father. We know that limitations exist in all these countries in this way. We know that service is a function of money.
In my view it is not ideology to say that that is improper. It is the putting forward of a basic human demand. We can have equality and, whether it is the Proclamation of 1916 or the Declaration on Human Rights in the United Nations, with differential access on the basis of income then those claims seem to me meaningless. I do not look on the demand for a comprehensive health service as a matter of ideology, I look on it as a matter of the asserting of basic human rights. What I previously said makes it clear that I am not starry-eyed about the difficulties of doing that and I appreciate the Minister's problems perfectly well.
I have one technical thought to offer. One sees the tidiness of the system of deducting a sum of money that covers a whole lot of things, social insurance, occupational injuries, redundancy and a health contribution. It is easy to compute and it is easy to deduct. It is a nice system from the point of view of those people who get their money and who can budget on it. However, what is calculated on the tax form is 1 per cent of the person's income. That changes continuously. Every rise in a person's income is reflected in a rise in the contributions there and then, whereas the ceiling is not continuously adjusted. I like the idea of it being adjusted by this mechanism because we get a chance to talk about it; it is nice that it comes before the Oireachtas but when I see an increase of the order of approximately 27 per cent, from £5,500 to £7,000, it makes me think that the thing is not intended to be done annually but to be done when it gets so glaringly out of line that the clamour becomes incapable of being resisted, by politicians anyhow.
That means that while the contribution is currently adjusted automatically since it is a percentage not of the wage but of the total income from all sources, that the ceiling is not automatically adjusted. This year we do not know whether inflation will be 18 or 20 per cent but it will be in that order of magnitude. This increase is more than that but it will be substantially less than two years inflation unless something extraordinary happens. I do not say that with any sense of glee. I have had my own experiences of inflation from the Government side and I also know the constraints the Minister has. However, it is too much for one year and it is not enough for two years. The Minister, presumably, will not be coming back in 12 months time but will have to come back to make good something that will already have started getting out of line two years from now.
I would like to see a mechanism whereby there would be two separate processes. As people get richer—we are getting richer most years; we are not guaranteed a rise in GNP, or a rise in the income of any particular sector every year but it is happening that most years we get richer—it seems likely that our spending on health will increase at least pro rata with our income. Therefore, the idea of an indexing of a basic kind annually seems to me a reasonable one. Then if one wants either to increase the proportion of GNP that goes to health or if one wants to alter the proportionality in any way it can be done by a mechanism like this or it can be done as part of a larger budget mechanism. It seems to me that what Senator Moynihan referred to is made likely by this mechanism. Every public representative hears many people ask, “Are we in the ceiling? Are we out of the ceiling? Are we free or are we not free and would it be better to by-pass the insisting on our rights and get treatment quickly?” And so on. That limit is being hopped up and down all the time because while you do not have indexing of the statutory £5,500 going to £7,000, you do have a continuous change in wage levels not just by annual agreements but sometimes by cost of living allowances built into those agreements that come into force at particular times and by the process of wage drift, so that it seems to me that this mechanism does not keep the limit at the same place in reality. The fact that it runs for two years will bring down the limit sharply at the end of those two years. If it is put up again by £1,500 or £2,000 it is lifted again.
Would it not be better to have a mechanism that kept approximately the same proportion of the population having this right at any given time, instead of having a percentage band, perhaps 5 per cent on each side of borderline cases, who provide not alone a lot of work for public representatives but provide a lot of work and a lot of headaches for people who are employees of the State and who are already overworked, as are many people in the health services, and who could very well be employed in doing work that contributed more directly to the wellbeing of the people in their charges. I do not like the mechanism, in other words, by which you have a 1 per cent of a wage or a total income which continuously varies but you have a limit which is only tweaked at certain intervals. I wonder if the Minister would comment on that.
I think we all would agree that the task of our Minister for Health and Social Welfare is an enormous one. Enormous sums of money are involved, the services are very widespread and affect every man, woman and child in this State. We wish the Minister every success in the enormous task that is his.
A factor that prevents the smooth operation of the health services and, indeed, of the social welfare services also, is the fact that so many people do not know either what they are entitled to or how they should look for their entitlements. To deal with the health service alone, because that is what is before us today, I came across a very distressing case recently. It concerned a man who had to be taken to hospital very quickly because of a most violently painful, acute infection in one of his eyes. He did not know, nor did his wife know, exactly what he was entitled to and when they reached a certain hospital an argument ensued, while the man was in a state of collapse from the violent pain he was suffering, as to what should be done and what should not be done. While he was in that distressful condition it was pointed out he would have to pay for the services of a specialist and so on. I got an awful shock when I heard of the case. I made inquiries and everything is smoothed out now but all that would have been avoided if everybody knew exactly what he was entitled to and what he should do to assert his entitlement.
I would make this suggestion: as soon as possible a simple straightforward booklet or pamphlet should be issued to every household in the country and more booklets should be available either through the Government Publications or through ordinary bookshops to cater for cases in which books are lost. In these books, I would suggest, people's entitlements to the various services should be stated briefly and clearly and also, of course, what they are expected to pay. Indeed, the same could be done in respect of social welfare arrangements. Pamphlets and papers have been issued from time to time but at the moment there is a great urgency to have these updated. If the Minister could do that as soon as possible in 1980 I am sure it would help considerably to ease the stresses and the strains such as those I indicated in the case I was speaking of.
I realise, also, how money is eaten away in our health services but I should like to make just one suggestion to the Minister. There has been always a long waiting list for beds, in many instances for beds for urgent cases. I believe that if in every city and town and in the country villages there was set up a community centre with one professional person looking after that centre where people who are elderly, people who are chronically ill, but not severely ill enough to be in hospital could be taken care of during the day but who would go home at night, a great deal of money would be saved. Apart from the money point of view, it would be much more preferable for the patients. They would continue to be still part of the family life.
This is a limited motion and I think the Senator is moving slightly wide of the motion.
In determining the incomes of farmers under these health contributions regulations, I should like to know from the Minister what the multiplier will be for the year 1980-81. It was 92 for 1979-80. The other brief comment I want to make is that notwithstanding the criticisms that have been made as regards documentation for a farmer who applies for the health contributions hospital services card, it is a good idea to have a card which states for what period the holder is entitled to these services. I agree entirely with the speakers who mentioned that services should be quite clearly defined but it would be helpful for a person to have a hospital services card which would state exactly for how long that card would be valid and to which services the person is entitled.
All public representatives are aware that in the past bills have issued from the various health boards in respect of arrears. Those arrears are often a burden on the son of a farmer, or maybe on another relation who was not aware that those bills had to be paid. It is a good idea to have one's hospital services card and to have the contribution fixed for that particular card and for that particular year.
I should also like to support what has been said as regards directing the health services towards the needy and the less well off. We all know that it would be very admirable if we could have a full medical service and if everyone had what we call the medical card to cover all the health services. In a situation where that is not possible the system of health contributions based on a percentage income is a system that has helped and has resulted in people knowing exactly for what period they are entitled to these benefits. I should like to support the speakers who asked about the entitlements.
I am always concerned when I hear of indexation being built into formulae for funding or formulae for income increases. There are certain areas where this is a good idea. In the case of this one where in principle a certain percentage of one's earnings goes towards financing health services, if one's income increases then one would expect that there would be a pro rata increase. Against what Senator Keating said, I do not agree that the limits should also be indexed because it is good periodically to have a milestone point where you stop and take stock, have a look at the system and see if it is working well. The fact that we are having a discussion here about the financing of the health services at a point where there is no major change in hand in itself seems to me to be a good idea. What the Minister is doing in making his shift at this point and giving us a chance to talk about it is the right way to deal with it.
The trouble about indexing as a way of dealing with the problem of inflation is that very often it becomes a crutch for inflation. Building up people's expectations that inflation is going to be at a certain level will almost ensure that that high level of inflation will be reached.
The other point I want to make is that working as I do in the inner city where something like 12 per cent of the population are over 64 years of age compared with the average for Dublin, which is something like 4 per cent, I find that the poor, the needy and the deprived are not getting the attention that is required. I again take this opportunity of saying to the Minister, whom I know understands this situation, having worked closely in community areas for some periods, that the necessary changes will not happen just because you change the system. They will not happen just because a piece of paper arrives at the door of the older person. They will only happen if people arrive at the door. What I am making a plea for is more concern by people for the elderly and that concern can be shown only by contact.
Our bureaucracy and our Oireachtas Members may at times be consumed with this notion of proportionality of application of resources, that all across the country and in all categories of people, people must get their proportion. The principle must be to everybody his need or her need rather than to his or her proportion. In an area like the inner city, about which I can assure the House more and more will be heard, where the elderly are congregated their problem is compounded by the dimensions of the deprivation that exists there. Such problems as violence, traffic problems, housing problems, social structure problems taken together make any one of them in itself less tolerable. I make a plea to the Minister that more effort, and not just funds, in terms of attention by people to the needs of the elderly is required. What Senator Goulding said was apt and needed saying. It is a suggestion that the Minister should take into account.
I find it very difficult to relate the Senator's remarks to what is in the motion.
We are talking about expenditure and health services and I suppose we are entitled to raise the question of where the expenditure goes.
We are talking about raising the limit from £5,500 to £7,000.
Take my indexation point, then. On that basis I stand corrected. The Minister heard what I said and I leave it to him to take it into account.
I should like to thank the Senators for their wide-ranging contributions and I appreciate their general interest in the service. Though the matter under discussion is very simple and direct on the question of raising the ceiling, I accept the points made and I will try to deal briefly with them.
Senator Moynihan and a number of Senators stressed the fact that they want to see a comprehensive health service. Senator Moynihan had his figures very accurate currently in the sense that it is true that 85 per cent of the population are covered presently. He outlined the system of application though some other people felt that the system of applying is not widely known. I doubt if the question of eliminating the paper work which he mentioned would really bring in the sort of money that we would need but the move which was made last year to tie the contribution in with the other contributions for social welfare purposes will simplify the contribution element very considerably. I would hope, too, that it would have some beneficial effect on the total amount of paper work but in addition I certainly would be anxious to ensure that the bureaucracy was as far as possible removed or reduced. The Senator mentioned also the question of the possibility of getting a bed only in a private hospital and said that this can often be a point that is brought to a Deputy or a Senator in representing people locally. Of course there are 20,000 public beds and there are 1,000 private beds in hospitals, that is leaving out nursing homes. We can appreciate that the number of public beds is very far in excess and so in terms of providing beds the beds are provided. There is a major programme under way currently to provide a great increase in the numbers of beds in hospitals. While one may come across individual cases, I can also quote cases like the one cited, when taken in the context of the overall provision, it will be seen that the State has provided and is continuing to provide the beds.
The point I wanted to get across was that the patient was not advised beforehand in the matter of the financial consequences of the decision he was asked to make.
I appreciate that. The question of people knowing what is happening was later raised by somebody else in a different way and I shall come to that. It is something I would be concerned about.
Senator Brugha raised the question of clarifying exactly what people are covered for. I accept that with the changes which have been taking place and the interim arrangements which were made as part of the national understanding one can be somewhat confused about the exact entitlements but the factual situation is that the ceiling is being raised from £5,500 to £7,000 by this measure. This will ensure that 85 per cent of the population will be covered by the scheme.
The income in this case is the income for the previous year. Therefore, it is better than one might think in current terms because the 1979-80 income will be derived up to 5 April 1980. One then gets the P60 form which gives details of one's income clearly and with that form a person so entitled may get his hospital services card. For those earning less than £7,000 there is full entitlement to all services, to maintenance, drugs, medicines and consultants, in public wards. If someone opts to go to a private ward there is a contribution towards that but the full coverage is there for anyone earning up to £7,000. The statutory position up to now was that the ceiling was £5,500.
For those earning more than £7,000 there is entitlement to all these services with the exception of consultants' fees. As far as consultants' fees are concerned it is relatively inexpensive to provide cover through the voluntary health insurance scheme and this is what is normally done. To take a husband, wife and three children and allowing that premiums can be set against tax, the cost works out at a net £21 total for that kind of coverage. That would not represent a great burden on anyone. However, if an individual wants cover for a private or semi-private ward there would be an additional charge on voluntary health for that.
The cover is quite comprehensive and in that sense we have a comprehensive health service. We have a mix of voluntary and State services which is a valuable resource nationally. Most of the Senators will appreciate the contribution of the voluntary hospitals and of the mix we have of voluntary and State services. It is a very excellent service and, as Senator Keating said, a warm service. There is very considerable courtesy and kindness in the provision of the service and I hope that this is something we can retain. It is one of the distinguishing characteristics of the service which is provided and it is something that we should be very careful about in any changes or alterations so as to ensure that that kind of service is maintained.
So far as the voluntary organisations and voluntary hospitals are concerned, they are a vital element in our social policy. I will do all I can to encourage communities to involve themselves in the welfare and the environmental and cultural and other activities to create a sense of community at local and national level. The voluntary organisations have a special importance in the services for the elderly. The active interest of the younger members of the community is essential for the success of programmes aimed at helping people to live out their lives in comfort and security in familiar surroundings for as long as possible.
As Minister for Health I intend to do all in my power to support voluntary bodies involved in health and welfare activities. These voluntary bodies make a major contribution to the development of a sense of community and to a caring and responsible community. I will endeavour to arrange that the voluntary community organisations will not be put at an unreasonable disadvantage in 1980 because of the general financial constraints that are necessary in the public services as a whole. I wanted to say that in order to reassure Senators who have raised points in relation to that particular area.
Senator McDonald said I was quoted on radio as saying something. I was not quoted because I did not say what I was supposed to have said. A Deputy, during the debate on the budget, said he had heard somebody say that I had said something. That was the basis of that and it was quite incorrect. I do not know how the question arose but the point that was made in that statement on radio was that drastic economies were being applied all round, that the old people would suffer as a result of this and that I was getting on to the hospitals to tell them to push all these old people out as quickly as possible. That is not correct. We are concerned to ensure that elderly people can stay in the community as long as possible and we will be developing community-based facilities to keep elderly people in the community. That is part of our policy and our programme. That policy will have the indirect effect of relieving some of the pressures on hospitals. From dealing with these elderly people I know that the vast majority of them, except those in very acute need of hospitalisation, want to stay at home if possible and, if not, within the community or as near to the community as possible. This is what I will be encouraging and it is the only reason I can think of for the misrepresentation to which I have referred.
On the question of drastic economies, there are economies and there is the question of budgeting and of keeping the total cost under control. Senators have in their own way accepted that need.
Senator Conroy raised what I think is important in relation to the level at which our services are pitched. We have a very good balance in the way in which our services are provided. That is not to suggest that I do not consider that they can be improved but this is something which we must work on continuously. The Senator suggested that we had something like a middle course in providing both the services and the eligibility for people. We are inclined to complain a great deal about delays in the provision of services but I was shocked recently by the kind of delays I saw within the system in the UK, to which Senator Conroy referred. Extraordinary delays have developed under the system they have created there and I think we have nothing like that kind of problem. I think the Senator made a very important point in that connection. Here, we certainly want to make sure that the service is improved and we will do all in our power to achieve that.
Senator Keating was concerned about creakings in our system and in that sense I think that certainly the system is under strain because more people are demanding services and they are looking for more specialised services. A great deal is being done in relation to this. There has been a very considerable improvement in the provision of services and in addition there has been a very big improvement in the numbers of people receiving out-patient service which, of course, saves confinement within hospitals. So, there is a great deal of modernisation which has been going on in recent years and which is continuing within the hospital service. I have been around a certain number of the hospitals and other institutions recently and the more I see of them the more I am convinced of the high quality and standard of service which is being provided compared to anything outside.
We have a major programme under way and that programme will be continuing. I accept what Senator Keating has said—that, in effect, the system is under strain from increased pressure and more people wanting more services.
Senator Keating raised an important point, the question of smoking putting massive loads on to our hospitals. This is something of which all the medical profession are very conscious. He said that he has noted the PR drives on smoking and fitness. We have decided to tackle the problem by trying to encourage people to look after their health in a positive way in the belief also that this will relieve the pressure on the services in due course. The Senator did not suggest any particular remedy for this situation in the shorter term and he seems to accept that the line which is being taken currently is a reasonable one.
Senator Keating also raised the question of how this particular measure is being implemented—we are rising now from a statutory limit of £5,500 to £7,000. He seemed to suggest that this is more than the increase in the consumer price index or the increase in wage levels over that year. I agree with him; it is greater. But it is greater so that from the point of view of the statutory provision it increases the number of people who are provided with the complete, comprehensive free service from 83 to 85 per cent of the population and it does not keep ahead of the wage increases in that period. That is what it is intended to do and it is also intended to adjust it annually. He seemed to think that it might be something that would be adjusted just now and then on an irregular basis but, certainly, as far as I am concerned, I would regard it as an adjustment which would come about annually and in line with the other developments within the services in social welfare and health.
I think what he was suggesting was that since incomes go up in between there should be a means of getting some extra income for the hospitals during the year. This is not so simple in an administrative sense. I think the annual revision with an opportunity to debate it—I think Senator Mulcahy welcomed the opportunity to discuss and debate it here in the Seanad and, of course, in the Dáil also on an annual basis—is sufficient. That is the system that is being operated currently and I think it is quite a good one. In effect by working on the previous year's income, you are providing a fairly sure and simple approach; you know for the year ahead how you stand. You can have your hospital services card and you know what you are entitled to and that is settled for the year. I really think that this is a better way to have it. Certainly, while I would like to see more money coming in in relation to the provision of hospital services I think that administratively it would cause far too many headaches. I think the provision will be reviewed at regular intervals as he was suggesting.
Senator Cranitch was particularly concerned about the issuing of booklets on entitlements and the fact that people do not understand them as clearly as they might. I can appreciate that, with the changes which have taken place within the last year and with the national understanding coming through in July and having its own impact on an interim arrangement, there would be some confusion among people generally in relation to that. The booklet which issued as a guide to the services last year is a very comprehensive booklet on entitlements but we will be issuing a new guide to the services shortly and I will ensure that this guide will cover the entitlements. Senator Cranitch asked if we would cover them. It will cover the entitlements but I will also ensure that it outlines the mechanism which is to operate, particularly the question of getting your P60 and getting the hospital services card and knowing your entitlement for the year ahead. As he has asked, we will make sure that that is done.
Senator Goulding pointed out the importance of keeping people at home or as out-patients and of developing in that area. I think I mentioned that already. That certainly is something which is vital to the whole health services structure and if we do not do that I think we will find ourselves getting into problems similar to those being experienced elsewhere. So, it will be a major part of our programme.
Senator Kitt asked about the increase in the multiplier. It increases from 92 to 117 as a result of this change. There is an agreed formula by which it is calculated and that formula would, in effect, mean that the multiplier will increase from 92 to 117. He felt that the hospital services card was a good system and I think coming into this year we will see that it can be a good system because we will be dealing with a whole year in which you can have certainty and clarity for the full year.
Senator Mulcahy preferred to have an opportunity in the Seanad to discuss the motion and to put views on it annually and I think that opportunity will be there. He was particularly concerned, as I understood it, that people on lower incomes or in deprived groups should get better consideration and a better service. He felt that the service should be there for them and that this will require more direct contact with the people to ensure that they know what services are available to them and that they are given the proper opportunity to avail of them. As far as hospitals, specifically, are concerned we recently published two booklets advising particularly on this aspect of trying to ensure that incoming patients are informed of their entitlements. The booklets followed work done by a working committee of people within the service. They looked at what was being done and what needed to be done and I hope this will be of some help in that area. I accept the point that he is making. Certainly it is one which I will note and we will try to ensure that the service in that respect is improved.
I would say that the Senators had a reasonably wide-ranging discussion on the services to be provided here. I believe that this step will bring in a somewhat higher proportion of the population on a statutory basis. We had an interim arrangement from July but this brings cover on the statutory basis to 85 per cent of the total population. I think that given all the circumstances the scheme is a good one.
Senator Keating raised the question about the public purse and its support. I think it is important to bear in mind that the public purse supports all the medical teaching hospitals where the highest standards currently prevail. There are, needless to say, high standards in private hospitals as well but the major public hospital standards are certainly very high and the whole community is entitled to avail of these services under the scheme. I believe that this is a valuable step ahead at this time.
In thanking the Minister for his reply, may I ask a question? The Minister did say that up to £7,000 meant full entitlement in a public hospital or public ward. Two questions arise: is there any entitlement above the £7,000 and are the old categories of the white collar and manual abolished?
Yes, there is full entitlement above £7,000 to maintenance in the hospital, to being in the hospital and to the cost of residence in the hospital—the maintenance charges— and to the drugs and medicines and treatment within the hospital in a public ward. What confuses the issue is that people very often want to go to a semi-private ward and they find the entitlement is slightly different and they get confused about the situation. But the position is very clear. All the population are covered in effect. The entire population is entitled to hospital services other than the consultants. All the services are available free of charge on the same terms in public wards. Everybody is entitled to that—that is quite clear-cut. Consultants' fees that were covered under £5,500 on the statutory basis are now covered up to £7,000. Above £7,000 you make your own provision, presumably through the Voluntary Health Insurance Scheme, which is a very popular one. This just raises the point that there has been an increasing demand on the Voluntary Health Insurance Scheme which, of course, means that people are using it perhaps to avail of semi-private wards or beds after that. In 1975, 524,000 persons were covered by Voluntary Health Insurance. That is the total number of people covered. In 1980 the figure is 840,000, or 25 per cent of the total population, so that in effect there are 300,000 people below the £7,000 limit who still retain their Voluntary Health cover. I think that this is indicative of a desire on the part of the users to have certain freedom in what they do. But, of course, it does cause confusion in relation to what is there. I hope I have made the point clear that the entire population of 3.36 million are entitled to hospital services on the same terms, free of charge, in public wards, excluding the consultants. The consultants are covered for people under £7,000 and above £7,000 you make your own provision for consultants.
Question put and agreed to.