I am pleased to have an opportunity for the second time today to come before the Upper House of the Oireachtas and seek its support for the Health (Amendment) Bill, 1987, which provides for the amendment of section 56 of the Health Act, 1970.
This amendment would enable the Minister for Health, with the consent of the Minister for Finance, to impose charges in respect of out-patient services as defined in the 1970 Health Act. The Bill seeks the powers to enable the Minister for Health to make regulations setting out the charges to be made and the categories of people to which they will apply.
These regulations, when made, will be laid before the House. Today, I should like to set out what is proposed in relation to the content of those regulations.
As you see from the Bill, the following exclusions will apply:
1. Medical card holders and their dependants. Approximately 37 per cent of our population are holders of current medical cards and they cover approximately 1.2 million of our population.
2. Children suffering from diseases and disabilities of a permanent or long-term nature;
3. Children who require attendance on an out-patient basis in respect of defects which have been noticed at a health examination provided in accordance with the Health Act.
Also excluded by the regulation will be:
A. All women in respect of motherhood;
B. Infants up to the age of six weeks as already provided for under the 1970 Act;
C. Persons receiving services for the diagnosis or treatment of certain infectious diseases prescribed under the Health Act, 1947.
Finally, and most important, the chief executive officers of the health boards will have the discretion as provided in the 1970 Health Act, to exempt people where there would be an obvious case of hardship if the charges were imposed.
I would like to turn now to the circumstances in which the charges will be made. A charge of £10 will be made for all out-patient services but only for the first visit arising in respect of a particualr medical condition. That is to say, return visits in respect of that condition will not be liable for the charge. The £10 charge will also be made in respect of attendances at casualty departments of hospitals. I would like particularly to comment on that charge.
In all parts of the country it has been traditional for generations for people to use casualty departments of hospitals to receive treatment which could just as appropriately be provided by there general practitioners. As things stand at the moment, this service is being provided absolutely free of charge. There are two points I should like to make with regard to this situation.
First, I suggest that the use of casualty departments of minor ailments is a misuse of that facility. It is a misuse, because instead of these departments being allowed to gear themselves for the treatment of real emergencies, a very sizeable part of their time is being taken up by the treatment of non-emergencies. Anybody who has visited a casualty department will see ample evidence of this. The second point I would like to make is that, irrespective of a person's ability to pay for the services, these are provided as I said free of charge.
A visit to a general practitioner at the moment costs in the region of £10, so charging a person £10 for service in a casualty department, given the exemptions I have already mentioned, has to be regarded as reasonable. The House should also note that the £10 charge will be made only in respect of the first visit arising from a particular condition.
The House should be aware that for some time now a number of health boards have been collecting contributions from patients in respect of out-patient services. I have had personal experience of this myself. These contributions are being made in respect of every visit. In my own health board, the Western Health Board, I have had the experience of visiting the out-patients' department of the Roscommon County Hospital where I was charged for 12 visits at the sum of £5 a visit which was quite reasonable. Over the last few days some people have made quite an issue of the charges now proposed. Those people seem to have conveniently forgotten, or perhaps were not aware, that similar type charges are being made in a number of areas at present. Therefore, the proposed arrangements cannot be seen as something totally new and unacceptable. I wish to clarify that there is a £10 charge for a particular ailment. The situation is that if somebody has an accident and breaks an arm the treatment for that breakage would be covered under that £10 charge on an out-patient basis. He or she would not have to pay a further £10 for each visit.
I should also like to make it clear that in applying the new arrangements, a person presenting for out-patient services suffering from more than one condition will be liable for only a single £10 charge. Likewise, a person who at the first visit requires an X-ray or pathology service will also be liable for a single £10 charge only, which includes the X-ray and the pathology service.
These then are the proposed arrangements for making charges for out-patient services. The House must agree that in drawing them up, the Government have been extremely conscious of the need to ensure that the vulnerable and disadvantaged will be exempt from the charges. I believe this has been comprehensively achieved.
Having explained what is involved in this legislation, I should now like to go on to make some comments on why it is considered necessary to introduce these charges. Everybody is aware that the cost of providing health services in this country has risen dramatically in the last decade or so. For instance, from 1974 overall expenditure on non-capital health services rose to the order of £1.3 billion, or approximately 7.5 per cent of GNP in 1986.
In that period there has been a significant improvment in the standard and quality of care which is highly desirable. However, we have now come to the situation where we must take stock of the reality of the current economic position. Within that, we must assess what should be expected from our health services, the cost of that expectation and how the costs should be funded. This reality has been made perfectly clear over the past few days. It was made clear without any of the fudging which was a hallmark of the previous administration.
As far as the health services are concerned, this reality means that the resources that can be made available to them from the Exchequer, that is through taxation, will be limited. Given that limitation we have to ask ourselves the question: how do we maintain the essential levels and standards of care required?
One option is that we simply cut the services to meet the available resource. Another option is to find alternatives to Exchequer funding to alleviate the consequences of limited resources. This Government consider that such a course of action is perfectly justified in the present circumstances. Therefore, it has been decided, in certain circumstances, to impose a charge for the delivery of certain services. But within that the underlying principle must be that only those who can reasonably afford to make additional contributions should be expected to do so. Conversely, this means that those who cannot afford to make such contributions should not be expected to do so, and will not be expected to do so by this Government.
That is the basis of the Bill before the House for the imposition of out-patient charges. The same basis will apply in relation to the imposition of charges for in-patient hospital services which have already been indicated. Even in respect of those people who will be required to pay both out-patient and in-patient services, arrangements are being made with the Voluntary Health Insurance Board so that they can insure themselves against charges at minimal cost. Negotiations are at present taking place between the VHI Board and my Department regarding the bringing forward of a very attractive scheme which I believe will be supported by the people in the categories which will be affected by the proposed out-patient and in-patient charges and will impose no hardship whatsoever on them.
Since the intention to introduce out-patient charges and in-patient charges was announced, there have been a number of quite misleading comments made on the proposals. It has been alleged that the charges are aimed at the most needy in our society. It has been alleged that they are going to cause considerable hardship. I must say that I find these comments, particularly when they are widely reported, especially disturbing. These comments are being believed by many people who are very worried as to how the proposed measures will affect them should they fall ill. I have already detailed the categories of people who will be excluded from charges. I will repeat that only those who could be expected to pay without hardship will have to pay. I am personally very concerned to get this message over and allay people's fears.
I will also continue to point out that the measures which we are proposing are infinitely preferable to the kinds of charges which the previous administration threatened to impose. In particular, a charge on prescriptions for general medical services patients was proposed, at the rate of £1 per perscription, which would have imposed tremendous hardship on the least well-off members of our society, the present medical card holders, 37 per cent of the population or approximately 1.2 million people who benefit from the conditions applicable to holders of medical cards. We are exempting them from what we regard as a very heavy charge in respect of that service. This would be a charge on those people who, by definition as medical card holders, cannot provide services for themselves or their families without incurring hardship. It would be incomprehensible that, when they are in most need, they should be faced with that kind of savage charge.
There is no doubt but there are difficult times ahead as far as the health services are concerned. The level of resource which we would all like to have is just not available. I am sure there will be many demands for increased funding, just as there will be similar demands from other sectors. But, in making these demands, people must ask themselves where the additional funding is going to come from. Are people prepared to face a considerable further increase in taxation across the board? I would not think so. Therefore, it is necessary that all our people consider carefully what they expect from a health service; to what extent they are prepared to pay for that service; and especially how they would wish to have the service used. The Bill before the House today is just one measure being proposed to protect the fabric of our services. I believe it is a reasonable measure.
This Government have taken a very courageous stand since the introduction of the budget. The Government had no alternative but to introduce such a budget bearing in mind the very difficult position with which we were faced when we assumed office some weeks ago. We are prepared to take hard decisions for the sake of our people. We are prepared to grasp the nettle, to take unpopular decisions, because, if they are not taken by us then they will have to be taken by others on behalf of our people. We are not prepared to accept such a scenario. Fianna Fáil, in Government will take the right hard decisions.
I commend the Bill to the House.