I move:
That Seanad Éireann approves the following regulations in draft—
Health Contributions (Yearly Reckonable Income) (Variation) Regulations, 1989
a copy of which regulations in draft was laid before the House on 7th March, 1989.
Health Contributions (Yearly Reckonable Income) (Variation) Regulations, 1989: Motion.
For the information of Senators participating in this debate, there is not a limit on the time but that does not mean they may go on all evening.
Subsection (3) of section 9 of the Health Contributions Act, 1979, provides that the Minister for Health may vary the income ceiling which determines the amount payable by an individual, in a particular contribution year. Subsection (5) of section 9 of the Act requires that a draft of the proposed regulations shall be laid before both Houses of the Oireachtas and that the regulations shall not be made until a resolution has been passed, by each House, approving of the draft regulations. The draft regulations now before the House shall apply in relation to the contribution year commencing on 6 April 1989.
The income ceiling is at present £15,500, and it is proposed to increase this to £16,000. In determining the proposed increase in the income ceiling I have taken into account — as required by the Act — the most recent information available regarding the average earnings of workers in the transportable goods industries, since the last income ceiling was adopted. The latest recorded information on average weekly earnings in those industries relates to June 1988, when the average figure was £206.13, which was an increase of 4.76 per cent on the June 1987 figure of £196.76. When this percentage increase is applied to the current £15,500 ceiling, a figure of £16,238 emerges. I propose, therefore, to set the new ceiling at £16,000, an increase of £500 which is equal to the amount of last year's increase.
Following upon the increase in the ceiling, the maximum contribution payable by any individual will be £200 that is 1.25 per cent of £16,000. Persons with incomes of £15,500, or less, will not be affected by the increase. Those with income over £16,000 will pay an additional £6.25 in the coming contribution year.
The additional income which is expected as a result of the proposed increase in the income ceiling will be slightly under £1 million in the contribution year 1988-1989. Most of this will accrue to the Exchequer in the first quarter of 1990. Senators will be aware that a new assessment and collection procedure has now been introduced for the self-employed. Income tax, social insurance contributions, the employment-training levy and the health contribution are now being collected in one payment, based on self-assessment. This streamlining and integration of the arrangements for collecting the various receipts will lead to greatly increased efficiency and help to ensure prompt payment by all those who are liable for contributions.
As announced by the Minister for Finance in his Budget Statement on 25 January, the Government have decided to permit small-scale employers to opt for an annual remittance basis for PAYE, PRSI and VAT. Application of the new procedures will be at the discretion of the Collector General of the Revenue Commissioners but the procedure will be optional for the employers selected. Before 6 April next, I will be making an amendment to the Health Contributions Regulations, 1979 to give effect to this decision in respect of health contributions.
The Revenue Commissioners have been responsible for the collection of current health contributions from all sectors since 6 April 1984. The health boards remain responsible for the collection of arrears due from farmers, for periods up to that date. Health boards can retain these arrears as additional revenue for local health needs.
The total amount owed by farmers to health boards at 31 December 1988 was about £4.6 million. The amount outstanding at 31 December 1987 was £5.7 million. While the amount which is still outstanding is a cause for concern I am pleased that this amount has been reduced by more than £1 million in the past year.
The Health (Hospital In-Patient charges) Regulations, 1984, came into effect on 1 June, 1984. These regulations allowed for an admission charge of £100 to be levied on persons admitted for hospital in-patient treatment in a public hospital who were in arrears with health contributions. This amount was increased to £150 from 1 July 1986. This has proved to be quite an effective measure in inducing defaulters to pay their health contributions. However, it is important to mention that persons in arrears are not refused admission to hospitals, but the collection of the admission charge and the arrears is pursued later.
I am anxious that outstanding arrears should be collected as soon as possible as it is clearly unfair that those who do not honour their obligations with regard to health contributions should continue to obtain health services at the expense of others. Health boards are continuing their efforts to recover these arrears. It has been necessary for them to initiate legal proceedings in some cases.
I shall be reviewing shortly the income limit for free consultant's services. I am not, as yet, in a position to say what the limit will be.
I now ask the House to approve the regulations before it in draft.
These regulations vary the income ceiling which determines the amount payable by an individual in a particular contribution year. This is something that comes as a procedural measure before both Houses of the Oireachtas every year. It would be easy to accept this measure just as a procedure but at a time like this it is important that we should question the progress of the health services and by and large, see what exactly people are getting for their contribution and ask what is happening in our health services. I will very briefly do that.
The question is, how can our health services survive the present rate of cutbacks, the present restrictions. Indeed the restrictions have gone on for two years. While I accept that savings must be made and that the general policies that are being implemented now by Fianna Fáil are in line with the policies the direction of which we agreed in the Tallaght strategy — we know there is a need for savings — we would question the manner in which these are carried out.
In the context of those savings, those cut-back measures, we all need to assess how the health services are coping with them. There are a number of areas that cause concern, not least the lack of hospital beds in specific areas and the risk that involves people who are looking for hospitalisation, perhaps not as an emergency. The present situation in many hospital would unfairly, and perhaps dangerously, disadvantage patients.
There is a point beyond which you cannot go. The Senator is near to it.
I think what we are talking about is fairly general. We are talking about health contributions and the benefits. We had an example in Limerick recently with the ludicrous situation of one hospital being auctioned off in one part of the city while in the other part of the city there was an attempt to refuse admittance to all except emergency cases. There must be something manifestly wrong when this sort of situation develops.
It is worrying to find this type of policy in public health. If people, and indeed doctors, feel that there is no place for their health problems in the system, how can they cope, where can they go? In this category are people waiting for tests or investigation who are presenting symptoms. Will they go away and put up with discomfort and maybe even pain, helpless in the face of local difficulties? Certainly into this category would go people waiting for hip replacements. There are 8,000 people waiting for over three years for this operation. Children waiting for heart surgery would also come into this category. There is a way out, of course, but it is through private health care and many who cannot afford it must borrow to finance health costs if their need is great enough. This, however, is not an option for all.
Many of those now unable to get health care are the old who made payments for health benefits all their working lives. There is a tendency, whether we like it or not, to regard the health problems of the old as not a great priority. At present there is a crisis of accommodation for the old and dependent. Life can be good for the healthy elderly but when they get that they cannot care for themselves and begin to examine what are the options it can be a depressing picture. Because there is only a poor structure of community care in most localities here, such old dependents have to seek institutional care. The depressing reality is the cost of this care.
We have all seen the dramatic growth in the number of new nursing homes opening in the country. This trend has developed due to the numbers of young people who are moving away from the home environment and because they no longer want the responsibility of caring for their elderly parents. For this reason, substitute care has to be provided.
We need to monitor the regulations and legislation governing old people's homes and make necessary changes but we should also come to grips with the need for community care provisions. This is most essential to the proper and efficient operation of a health service. In every other European country the need for a community care structure is accepted. Not only is it accepted, but it is developed to a very highly sophisticated degree. I am thinking of one service I know well, the community health service in Holland, where the needs of the old, the handicapped and socially disadvantaged are looked after.
With the greatest respect, Senator, if I allow this to go on we will have a debate which should not take place. I am always slow to stop someone but the regulations before the House are quite specific and deal with increasing the income limit for the individual contributions.
I suggest that is relevant to anybody who is going to claim benefit under the health service. I know the Minister in his speech only dealt with a few headings but I suggest we need to——
I am not trying to upset the trend of the Senator's contribution in any way. However, I can only allow passing references; I cannot allow this to develop into a detailed hospital services debate. I am as aware of the problems as the Senator.
I understand and I certainly would not want to be out of order. I have very strong views about regulations. When they come before the House nobody can change them, they are there. I suppose this is not one that would be open to change. When we have regulations and there is no time limit on us in this House, it is only fair I think that we should discuss issues of importance to us. I will be finished in a few minutes.
It is not the length; it is the content, Senator.
It is important, as I am sure you will agree, to make a case for the old people and the difficulties they are experiencing. Most of the difficulties they are experiencing are directly due to costs and the unavailability of money at local authority level to develop community care or provide homes for them. They have done this in other countries and I have to say that our position is very regrettable. Too often, we forget about the old. I just want to put in a commercial here to suggest that there is a report available on recommendations from the working party which was given to the Minister in October 1981, dealing with the needs of the old.
Of course there are difficulties in many other areas of the health services. There are serious cutbacks in VHI, a crisis in the dental service and there is the fact that the recently extended facility for spouses of insured workers is not operating. I am not opposing these regulations, I should say; I am just using the debate to highlight a few areas which I feel quite strongly about. In this context, I have to look at the Minister's speech. Once again, he gives us information about the situation regarding the collection of the farmers' contributions. This came up again in last year's debate.
It is very regrettable that the health boards that have responsibility for collecting these arrears have not been able to recover them. We now have a situation where on 31 December 1988, farmers owed the health boards some £4.6 million. The amount outstanding on 31 December 1987 was £5.7 million. I think this is an absolute disgrace and I wonder if the Minister has some discretion to move to remedy this. It seems to me that it is at local level that spending needs to take place in a whole range of areas that could support and back up our health services. To think that £5.7 million is being withheld is disgraceful. Some machinery or means should be found, if the health boards cannot collect it, whereby central Government can go in and be as effective as they were in collecting the large income tax take they got last year.
We are not opposing this motion and I welcome the regulations.
This motion gives us the opportunity to look at the means by which the health services are financed. In 1970, the late Deputy Erskine Childers was Minister for Health and he brought in the Health Act. That Act was primarily concerned with the health contributions and it was believed by him at that time, and by many more in the Dáil, that this health contribution would figure significantly in the financing of our health services. Unfortunately, it made very little impact. We find that the health contribution and the proportion of the health services financed by it is ridiculously small.
I did a study recently which revealed that the health services cost the average taxpayer in this country some £22.50 per week; that includes the health contributions. The Irish health service is only a free health service for 35 per cent of the population. In Britain, the cost is £23 for a full national health service. The Government are paying out enough money — more than enough money — but the service is not there. This is what we have to question. It costs the taxpayer in Britain £23 a week and they have a full national health service, free family doctor, free hospital service and all the other ancillary benefits that are available. Here it is £22.50 per week but we get very little in return for it. There is need for a public debate as to how the health services will be financed — maybe as an extension of this health contribution scheme — and also a need to examine how the money is being spent. Perhaps we could also establish new priorities in the health services, based on the financing of same.
It would be a unique role for the Seanad to hold public hearings on the health services and invite submissions, both oral and written, from various interest groups throughout the country, including the public in general. It could take six or 12 months to do this but I believe it would be worthwhile. We need to consider this seriously. I do not wish to step outside the limits here and I recognise your difficult role, a Chathaoirligh. I fully understand and sympathise with Senator Fennell in the problems she had.
There is something radically wrong because we are not getting value for health costs. It is not the State's fault because more money does not necessarily mean more health. If health contributions were doubled I am not sure it would necessarily mean a good service. I would say to surgeons, in particular: they do put people on waiting lists for operations which need not necessarily be done. I have talked to many patients, who have not gone ahead with their operation after my advice against it. These lists might be reduced considerably. When one reads about the long lists of people waiting for a long time for operations, it appears we are an uncaring inhuman society whereas, in fact, in many cases it might be in the patient's best interest not to have the operation. I say this as an aside to the consideration that when we are establishing priorities and establishing where the money is going we might be able to get better value for what is being spent.
Senator O'Connell has raised a few interesting points which open up the whole debate before us. I do not want to be out of order but I would submit that the Minister, in introducing the regulations dealt not alone with the raising of these contribution limits but with health contributions to health boards and the in-patient charges for hospital services which came into effect. That brings us to the question of what people who now pay this contribution are eligible for, what are they entitled to receive as a result of the increasing of the ceiling.
Senator Ferris, Dr. O'Connell's contribution was certainly absolutely based on finance.
Indeed this whole instrument is about finance. The Minister dealt with it by pinpointing what was outstanding by way of contributions to health boards.
Do not get me wrong. I feel as strongly as you do about health.
I intend to be absolutely specific. I am responding to the Minister's statement and to the motion. As a matter of principle, the Labour Party would have no objection to the raising of these limits but on this occasion we will have to oppose them because in every preceding year up to now, in line with the raising of the limits on ceilings for health contributions from PAYE workers and the self-employed, there was also a corresponding increase in the actual level of hospital services cards which were issued. The Minister said he was not yet in a position to notify us about the limits that would be set for hospital services card. I believe these two directly linked matters of contributions and eligibility are now being separated by the Government for some reason. That is why I will be asking that these regulations be rejected. These two limits have always been linked together.
The Minister said he would be reviewing the income limit for consultant services which brings us to the reason the Minister raises these limits. It means that the income limit at which the contributions taken from PAYE workers would stop has been raised by £500. I have no objection to it being raised further, because people would then know that by being within this ceiling limit or, indeed, paying a PRSI contribution towards the health services they would not be at the level at which they would be required to have VHI contributions.
In regard to what Senator O'Connell has said — that there were some consultants who were making arrangements and increasing waiting lists for people who did not require services — to whom can the consultants, or the Government, or the people who depend on professional advice turn to for decisions as to whether health services are required or whether operations are required for people? We are depending on the authenticity of opinion from consultants and medics to know whether a service is required, whether a prescription is required, whether hospitalisation is required or whether in the final analysis a full surgical operation or intervention is required. We must depend on somebody, and it is extraordinary that one of their colleagues in this House makes this statement. He would be considered by some people to have at least an opinion that would be closer to the real truth than anybody else. I will not say he has a vested interest, but there is certainly a conflict of interest as far as consultants are concerned. We have to take very seriously what he has said.
I do know that when surgical interventions took place in the past there was this procedure that consultants always insisted on seeing the patients two or three times after carrying out the operation. This in itself often put a strain on waiting lists at out-patients departments and indeed a strain on the provision of transportation for people in eligible categories back into hospitals to be seen by the consultants. That often brought about stresses and strains and, as chairman of the health board at the time, I suggested that people should see their own GP as soon as they were discharged from hospital and that if he considered it was necessary to bring that person back into the out-patients department with a consultant in the hospital, that should be the procedure. That would eliminate waiting lists with people sitting around for hours in queues in hospitals every day. Strain would not be put on hospital transport services which the health boards were unable to continue to provide. People in need of hospital transportation are now being debarred from it, particularly in relation to going back to out-patient departments.
In regard to the statutory instrument before us, if we take it that that income limit is increased it means that PAYE workers will have to pay on a further element of their salary but it does not include a corresponding increase on the hospital services card. The hospital services card is requested by the surgeons in order to determine whether they can now charge the patient a special fee over and above what is paid to them by the public service for their consultancy work in the hospital, which averages out about £50,000 per annum. It now indicates to them that there are people in categories over certain income limits who are now required to pay them. That is why people when they get their P60 have to get a hospital services card. I today do not know whether the limits are going to be tied or whether they are going to be different.
I am worried about the public perception of the hospital services card, now that it is pretty useless, because basically it entitles you to none of the things it entitled you to when this Government came to power. Hospital services cards in the past ensured that people who paid contributions under PAYE and PRSI were covered for all hospital in-patient and out-patients services, including consultants, hospital, nurses, food and every other aspect. That is what the hospital services card and the PRSI contribution were for but this Government changed all the rules in relation to people's entitlements in hospitals. It means that people who do not have a medical card but who do have a hospital services card and are under these limits now set by the Minister for the payment of health contributions now have to pay £10 a day for the first seven to ten days. They have to pay £10 for out-patient visits, which the Minister has referred to in his speech.
Not alone is the hospital services card becoming completely irrelevant, it is also now being perceived to be an element of double taxation. The health contribution section of PRSI is taken for one's gross pay, as is PAYE. Therefore, the health contribution element is now double taxation and those paying it are receiving less for their contributions than they did in the past.
Whereas Senator O'Connell worries about the Government putting more money into the health services, what we are suggesting from this side of the House is that people who are working and contributing out of their weekly pay packet, people who have no opportunity to evade their health contributions or anything else, are now paying on a larger salary but are getting less for what they are paying. Not alone are they getting less, but they are faced with major cutbacks in the health services, in the units to which they are asked to go, in the hospital beds and wards in which they need attention, in the hospital surgeries where surgical intervention is required to be carried out as instructed by a consultant. That is what they are getting simply because there is an increasing amount of money being taken from working people for the service. yet a lower level of service is being provided by this Government.
If they cannot rationalise this problem to ensure that the service is there for people who pay for it and are entitled to it, then, in regard to health they are shirking their national responsibility to people. This Government have closed hospitals throughout our region in Munster. They have closed hospitals in Tipperary, Waterford, Limerick, Cork, Kerry, Clare, they have closed them all over the place. In my town of Tipperary alone Fianna Fáil members of the health board closed the district hospital to which this hospital services card would be applicable and where people could get a service at the lowest sub-acute level. They removed it by one vote proposed by a Fianna Fáil member and in fact——
Senator Ferris, you know you have travelled miles away from the motion.
That is what we are getting for the increased limits on the health contributions and we do not even know yet what we are getting by way of a hospital services card. All I am saying is that the availability of the services is beginning to falter. The Minister for some reason has kept the limits secret from us today, because they were always linked together. We now do not know at what level a person on PAYE will be asked by the consultant surgeon to pay an additional fee in addition to this money he pays through the tax system. In another place in the Oireachtas they were not allowed to debate this subject. I am going to avail of the opportunity to debate it because this is the House of the Oireachtas where these matters should be debated.
The public are entitled to know what they are getting for their contributions or indeed when this new demand will be made by consultants for additional income. This means that more people could be forced into the VHI system. People who are already in that system are complaining to me that, in spite of of having VHI contributions, they are now being asked by some consultants for additional payments over and above all that. otherwise they will not get into a hospital for an operation.
The Senator is well aware that this is not a full and detailed debate on health.
Why did you not inform the Minister? If this statutory instrument was confined to just the figures he mentioned, why did he talk about an increase to health boards in respect of health contributions, which are not involved in the instrument? Why was the Minister not asked why he talked about the proposed additional income to the Government from this and what it is being used for? Why did you not ask the Minister not to refer to the income limit in relation to consultant services, because he mentioned all of that in his speech?
Senator Ferris, I am not responsible for what the Minister says or does not say. All I am doing is ruling on what is before me.
I am elected here to discuss items put before me by a Minister and it is my right to do that.
I have the right to rule on the debate. You or the Minister may make mistakes, but I am trying not to make them.
I am sure the Minister does not need you or me, a Chathaoirligh, to protect him in any way. The Minister made statements——
I am not protecting any Minister.
The Minister made statements and I have the right to reply to them. I am dealing specifically with the items he did raise in his contribution. Unfortunately, the Minister linked them to the Health Contributions (Yearly Reckonable Income) (Variation) Regulations which are before us. You cannot separate the two. The Minister mentioned that by raising the limit he now raises the contribution to £200. I am suggesting that for that £200 people are getting less by way of health services than they did when they paid less. There is nothing unfair about spelling out the truth in this House or any place else in regard to the serious decline in the health services and the initiation of a two-tier system. If the Minister has not seen fit to tell us at what limits the consultant services payment comes into play, then surely we are talking about a two-tier system of health care?
Now, Senator, you are well aware that you have gone far wide of the subject matter of the motion.
I did submit to you initially, a Chathaoirligh, that as the Minister had broadened the scope of this debate to cover these aspects it should be appropriate to respond to them, because there is definitely a feeling abroad that, no matter what working-class people pay by way of contribution, under this new variation clause they will not get the service. They are getting less service, but they are being asked to pay more by regulations which the Minister himself referred to. That was the In-patient Hospital Services Charge Regulations of 1984, which imposes a £100 charge on people who do not pay their health contributions but which also charges people on a daily basis even if they are paying these health contributions. That is a change and people know it is a change.
I know it is embarrassing for the Government to have it repeated that it is a change, but it is a diminution of people's rights in this most important area of health care and what it costs. We are not talking about the limits for medical cards. You could say that 48 per cent of the population now have medical cards. We all know how difficult it is to get them: it means that up to 48 per cent of the population are almost in poverty, because now you almost have to be in a poverty trap before you can get a medical card.
I am not dealing with medical cards. I want to confine myself specifically to what is here in front of me. I am suggesting that there is something happening between the relationship of the income limit for consultants and the raising of this ceiling. The Minister will have an opportunity at the end of the debate to reassure me that my fears are groundless in this regard. I cannot understand it. Is there some problem now with consultants that they do not want to be linked to this particular income limit being set by the Department, which, as Senator Fennell said, was sort of index-linked every year? I said initially that we had no objection to that principle. As a matter of fact, I would advocate that most people should be given the opportunity to pay a health contribution. It tapers off at a certain limit — it is now £16,000 — over which people will be required to have VHI cover.
I have told the House of the difficulties of people in that category who now cannot even get service at that level because of the closure of beds and the lack of hospitalisation, the lack of consultant services as close as possible to the people. Surely we are not heading back to the Fitzgerald Report, which advocated the provision of three or four major hospitals in the country where everybody could go if they wanted or else could stay out of them?
Now, Senator Ferris, if you continue to proceed with the debate as you are going you are going into a general debate on health. I am as well up in the health field as you are. In fairness, you have said what you have to say. If you are going to continue to keep repeating it and if you arrive at the Fitzgerald Report, my blood pressure shoots up. You will have to confine your remarks or resume your seat. I feel as strongly as you do about the health service but I have before me what is before me and that is where I have to make my ruling. If the Minister puts something in the speech that has annoyed you, I am quite sure he is more than capable of answering in his reply. While your contribution is being made I have to insist that you keep to the motion rather than a general debate. That is why I made my ruling in a less harsh way to Senator Fennell, hoping that this would not develop into a general debate on health services, whether we have or not have them.
Thank you. At least we are on the same side about the Fitzgerald Report.
I was always on the same side as you on that.
I am surprised you did not draw the same inference from my speech as you did in regard to Senator O'Connell, who dealt with the health services, their funding and the services provided——
To get back to Senator O'Connell, I am absolutely fair in this House.
I am not worried about how you deal with other Senators. I want to make as clear a contribution as I can.
I am concerned about a reference you have just made. In regard to Senator O'Connell's contribution, I was certain he was on finance. In fact, I let him drift a little because I thought his suggestion was worthwhile for this Seanad perhaps at a later time to take up. But, so be it. He did not go off on a general health discussion on our services and all the loopholes in it. I hate interrupting you Senator, but at the same time I cannot have a general debate on the services, whether they are right or wrong at the moment. That is all I am asking of you.
Thank you. I will continue. Regarding the contributions from the self-employed referred to by the Minister where he points to an outstanding deficit at the end of 1988 of £4.6 million owed by the farming community, he suggested that in 1987 that was £5.7 million and he looks upon that as an increased income of £1 million. I am suggesting that the people included in these draft regulations have no opportunity whatsoever of opting out of their responsibility or of paying at the end of the year or four or five years down the road.
I acted responsibly when I was involved in a health board until the present Government removed me from that office — but that does not worry me either; we just carry on regardless. Irrespective of that, I had meetings with the farming organisations to explain to them the importance of ensuring that their arrears, if any, which they may not have disputed legally or otherwise, should be paid in the overall interest of the health services. I would say I was responsible for negotiating with the then Minister for Health the provision that the Minister now refers to — that any money outstanding under these headings could be retained by health boards for the internal revenue of the boards. I would claim responsibility for having done that, and it was a welcome breakthrough because health boards were at their wit's end to try to maintain the service. The Department were at their wit's end trying to collect this money refered to in these regulations and trying to distribute it, along with further taxpayers' money, to ensure that the health service continued.
Farmers did object to the method which the Department had initiated, which was that they would pay health contributions, health levies, youth employment levies and other such levies out of gross income before account was taken of capital investment. I tried to show that PAYE workers also paid their health contributions and PAYE on their gross income before any deductions were made. There was also a corresponding equivalent appropriation by the Department of what income should be determined for health contributions. Unfortunately, it was difficult, if not impossible, to convince some farming organisations that this was a fair way and they wanted health contributions to be equivalent to income tax, which is a tax on income, while a health levy is not a tax on income from the point of view of the self-employed; it is a tax in another form, not necessarily on income which is subject to taxation.
I am satisfied that there would be a certain amount of goodwill if it were explained properly to the farming community. I look forward to the day when the outstanding money, if still legally due, will be paid to the health boards to help them overcome some of their problems. The figure is running at about £1 million in the South-Eastern Health Board, and this year they have been told by the Minister that they will have £2.2 million less to spend on health services. Here we are today increasing income limits to get more money from people and yet there is a smaller allocation in the health estimate for the South-Eastern Health Board. I am concerned about that as a representative for that area.
I represent people in that area who are in need and who are bringing to my attention on a daily basis the lack of services provided by the Government. I would not mind increasing the ceiling if there was a contribution from people in reasonably high income brackets provided that the health services was intact and available. Whether the Government like it or not, it is true that the health services have degenerated into a two-tier system irrespective of whatever changes are made in the limits for consultant services which the Minister is going to announce.
I should like to ask the Minister if discussions are taking place with the consultants about the income limits in respect of people who do not have VHI? If their income is over the limits specified here, or the limits to be announced by the Minister, will they then be faced with bills from consultants? Those are the questions we want answered. The Minister has raised these questions today. I need to be informed, because when I attend my clinic next Saturday what do I tell my constituents — that the Cathaoirleach would not allow me to ask these questions. I do not think they would live very long with that kind of attitude. I need to know and I am entitled to know.
Before I start would it be possible for me to ask the Minister to outline to the House the entitlements under the health contributions?
The Minister has already made his statement, the debate then takes place and the Minister replies. We are not on Committee Stage.
To be helpful to you and to myself, in view of the rulings you have already made on contributions, it would be easier for me to make my contribution within the limits if I knew what the limits were. If the Minister could tell me what the contributions entitle one to, then I would know whether I could talk on specific matters.
The Minister has said what he had to say in his speech and when the contributions are made he will be concluding. It is not like Committee Stage.
I understand that, but my reason for doing that is——
If that had been the way I think I would have had a much easier time in the last half an hour.
It would make it easier for me——
I do not like making things easier for you at times.
My understanding of the health service is that it is threefold: the medical card, the hospital services card and others. I wish to examine within my area, which is the only thing you have left me to do, a Chathaoirligh, what services are available to the people in the North Western Health Board and, more specifically, in County Donegal. Like Senator Ferris, my party in County Donegal was ousted from all health boards and from the health committees when they existed. The net effect was that there was not one Fine Gael representative on the health committee in Donegal, which was a despicable situation, but perhaps not as despicable as the fact that there is no longer a health committee there at all for anybody to make a contribution to. Had I been on that committee I would have been expressing my concern to the Minister about the situation that exists at present in three places: in the General Hospital in Letterkenny, in St. Conal's Psychiatric Hospital in Letterkenny and in Fanad dispensary. With regard to the general hospital——
Do you know what we are discussing, Senator?
Yes, I do.
We are not discussing the hospitals in Donegal.
We are discussing places to which those contributions entitle one to attend and I would submit, therefore, that they are within the debate. Or do they entitle one? That is what I wanted to ask the Minister to outline to me. Assuming that they entitle one to attend the General Hospital in Letterkenny and St. Conal's, what I want to say to the Minister is this: could he give me an assurance in this House or in writing at some future time that Letterkenny General Hospital is not being downgraded? It would appear to me and to many others that Sligo Hospital is being upgraded to the status of a regional hospital. I do not mind what happens to Sligo; I would like to see it and other hospitals upgraded.
Senator Loughrey, I love when you play innocent or ignorant and you want my advice and the Minister's answers. You know well that he does not have to tell you in this debate what hospitals might close or remain open and I am not going to ask him to. I am not protecting him because he is the present Minister; I am protecting him because it is my duty as Cathaoirleach to do it.
Could you indicate in what debate I might ask the Minister to indicate what he intends to do about the downgrading of Letterkenny General Hospital?
It is certainly not my job here this evening. We are discussing health contributions.
In fairness, and with all the ignorance I may plead, we are talking about a contribution that entitles people or does not entitle them to certain services and we are entitled, therefore, to discuss those services. There is nothing contrary in what I am doing. If I disagree with increasing the contributions, as I do, it is only because they do not entitle the people I represent to avail of the services it is suggested are available to them. The services that this £500 extra limit might make available to other persons in other parts of the country are not available to the people in County Donegal because of the downgrading of Letterkenny General Hospital and the imminent closure of St. Conal's Psychiatric Hospital. If there is a contribution to be made by somebody living in Fanad Head or Malin Head and if at the end of the day that person has to travel outside Donegal to a hospital in Sligo that is being upgraded, then surely I, as a representative of that area, can put on record my disagreement with that policy.
We have a situation in Letterkenny General Hospital where wards are closed and people are lying in corridors. Is that what the contribution entitles one to? We have a situation where the Chief Executive of the North Western Health Board, Mr. O'Shea, in response to suggestions that the closure of St. Conal's Hospital in Letterkenny was imminent, said no, it was not, because he had not the money to close it. He had not got the money to close a hospital, he had not got the money to provide a service in the community that would be necessary as a result of the closure of the hospital, despite the fact that it is not yet known with any degree of certainty that community psychiatric service is the appropriate service. He was saying that if he had the money he would be closing St. Conal's Psychiatric Hospital in Letterkenny.
I am concerned for the people in Fanad Peninsula who have a dispensary in the village of Tamney in which there is no toilet. The health board decided some time ago to build a new dispensary——
Do not go into detail. Is the Senator asking the Minister where the health contributions go?
Yes.
Then stop generalising about hospitals, wards and corridors. Just ask the Minister a direct question.
Surely I am entitled to know whether these specific places will remain open?
If you have a direct question to ask the Minister as to where the health contributions are being spent then ask that question. It is not fair to come into the Seanad and start flying kites about——
No kites.
Ask the question in your contribution and stick to the Health Contribution Regulations, 1989. You must be for or against them.
I will be for them, or at least I will not oppose them if I consider that the contributions that will be paid by people of my area will entitle them to use, in the first instance, a dispensary that has a toilet, that is warm, clean and cared for, that in the second instance will entitle them to attend a general hospital without having to lie in the corridor of that general hospital, a general hospital where the nurses will not openly be complaining — and nurses do not normally complain — of being run off their feet, or should patients become psychiatrically ill that there will be a hospital retained in the county where they may attend until such time as they become well again, or if they have a problem like alcoholism that there will be a hospital they may attend. If the Minister can satisfy me that the people in my county will have all of those services, then I will be happy not to oppose the motion.
The remarks made by Senator John O'Connell were very profound in the sense that he said it was not a question of money alone and that money would not do the job. I accept that and I understand it. In regard to the question of the provision of hospital services, I appreciate that the services can vary from one region to another. It is very likely that if the right type of research were done we might find that somebody died in one particular area which somebody in another area in similar circumstances was saved because the services were properly organised. I can understand Senator O'Connell's concern as a doctor and as a legislator. He said something very profound indeed and it opens up the whole question of the health services as a whole being debated.
If you come into a factory and start closing it down or bringing somebody in to do a hatchet job without examining the consequences or difficulties that may arise, then you can run into all sorts of problems. I can understand how Senator O'Connell feels and I also understand that we cannot go into a very wide debate on the question of the health contributions. I understand the depth of feeling that arises as a result of the way the health services are being tackled and I understand why people raise these issues, particularly when it affects their own areas. I accept that the Cathaoirleach must try to keep the debate in order, that the Minister has to present his case and the Senators have to try to argue the question of the health contributions. We cannot start arguing from the general to the particular point of view in a debate like this and, therefore, I am not going to abuse the privilege.
I would like to ask the Minister whether he considers he has made sufficient advances in getting the arrears that were due under the health contributions since 1966. As I understand it, the arrears have only been reduced by £1 million since then. I would like to know how the charge of £150 to people who are in arrears with health contributions is working. Has the Minister got accurate figures on it or is it just a generalisation in his statement that it is working better? These problems are relevant to the health contributions and do not take away from the argument I made earlier that giving a good service is not all a question of money.
An Leas-Chathaoirleach
Before I call on the Minister of State to reply, I would like to take this opportunity to extend a very warm welcome to a distinguished visitor, Senator Paul Sheehy from Massachusetts. You are very welcome and we hope you will have a pleasant vacation and will enjoy St. Patrick's Day. I hope the weather will remain as it is today. Your friend, Senator Hogan, might like to say a few words.
I would like to thank you and the House for allowing me the opportunity to extend formally a céad míle fáilte at this time of the year leading up to St. Patrick's Day to Senator Paul Sheehy, to his wife, Molly and Ray Shea of Lowell, Massachusetts. They have been tremendous friends of the city, county and people of Kilkenny for the past number of years. I wish to thank them particularly for the hospitality I received when I visited their country. I am glad the Seanad has recorded formally its céad míle fáilte to our visitors on this occasion and I wish to thank you, Leas-Chathaoirligh, for your courtesy.
I would like to be associated with the words of welcome from the Government side of the Oireachtas. As a Member of the Lower House I would like to say I am delighted to see Senator Paul Sheehy, his wife Molly, and his colleague from Massachusetts. They are very welcome. I hope they will enjoy St. Patrick's Day and their stay in our great country. I would like to thank the Senator for all the work he has done for us in the United States.
I wish to thank the Senators for their interesting comments during the debate. I will respond to each one separately. In relation to the general discussion, what we are talking about here is the actual contributions to the health services. As far as hospital service cards are concerned, we will discuss that again. I would like to give an example of the relevance of the health services and to be positive for a change. Quite a number of people tend to be negative.
I will give you a personal example of how the health services are working for the average person. On Monday, 13 March my own brother had a serious accident at his home. He was brought within 30 minutes to our local county hospital in Roscommon. He was treated extremely well by the consultant surgeon, Mr. Michael Relihan, by the anaesthetist Dr. Maura Casey, by Dr. Slevin, the radiologist, by the radiographers and all the staff who treated him in a proper fashion. As the situation was serious he was transferred to an orthopaedic hospital yesterday morning and he was operated on today. He went to Merlin Park Hospital under Mr. Kelly. He has a hospital service card and he is getting excellent service from the State. This is the positive side of the health services.
We always hear the negative side but we are providing a health service second to none. Nowhere in the world, I believe, is there is a health service equal to what we are providing here in Ireland. We should be proud of what we have achieved and we should stand up in the Oireachtas and other places to commend those in the health services who are providing such sterling service. The maximum charge with a hospital service card is £100, that is £10 a day for ten days. That is the maximum charge that can apply. If you had the equivalent treatment in the United States you would find that an enormous amount would be required. That is just a very personal response to some of the points which were made.
Referring to Senator Fennell, the arrears from the farmers are being collected, if necessary by legal action. The difficulty is that much of the £4.6 million outstanding refers to very old accounts going back to 1971 in many cases. Indeed, many of the farmers involved are unfortunately deceased. I would like to stress, however, that the health boards are making every effort to collect the arrears. It is in their best interests to collect the arrears because we, in Government, have decided to allow all the arrears collected to go towards local health services in each health board area. I would appeal to those who have outstanding accounts to come forward and make payments.
Senator John O'Connell raised the question of efficiency, savings and value for money. The Government are making every effort to encourage innovative, practical and cost-saving initiatives. The Department's costs containment unit has been studying more effective ways, in liaison with the health boards, in relation to efficiencies and purchases and supplies. Senator O'Connell also raised some general issues regarding the role which the Seanad could play in debating health service issues. This is a matter primarily for the Seanad.
Senator Ferris also referred to the health contributions. The health contributions we are debating here to day do not confer any entitlement whatsoever to services. They are simply a contribution to the health expenditure. He also referred to the June 1989 eligibility limits. They were introduced at a later date in June to give employers an opportunity to issue the tax documentation to employees. This system is for when they apply for hospital services cards. You must remember also that eligibility limits use a previous year's income and this is a further advantage to a person seeking a hospital service cards allowing for payment of £100 per year maximum for the services in hospital and also £10 for outpatient treatment when required. We receive excellent service in the public hospitals and again I would like to compliment all the consultants and the staff for providing the services at these hospitals.
Health contributions will bring in about £113 million in the current year and may form an important element of the health services financing. Just to elaborate further on that, the post budget non-capital provisions for health is £1,251.4 million. The budget adjustments account for about £9.1 million made up as follows: £8 million in lieu of income generating measures through increased charges: £1 million to allow a 3 per cent increase in cash allowances to disabled persons etc. with effect from July 1989; £0.1 million towards the agreed restructuring of the Dublin Rape Crisis Centre. The Exchequer contribution included in the overall provision amounts to £1,109.9 million and Appropriations-in-Aid account for the remaining £141.5 million. The provision for health services expressed as a share of total funds for non-capital supply services has increased in 1989 over 1988. This represents a clear recognition by the Government of the high priority of our public health services.
The Exchequer provision for capital expenditure in 1989 is £35 million. The non-capital provision I have just outlined will support a net expenditure of £1,256 million. When account is taken of local income of £107 million available to the health agencies, the total expenditure of £1,363 million can be generated. This level of expenditure will allow for the continuation of key services at existing levels and provide for the phased introduction of some major new facilities in the acute hospital areas.
Senator Loughrey raised many issues some of which I have dealt with already and some which I feel would be more appropriate in some other debate possibly in the Seanad as well.
Senator Harte spoke in relation to Senator O'Connell's suggestion that it might be appropriate to bring up a wide-ranging debate on the health services in the Seanad. As I mentioned earlier, the Health Contributions Regulations would not seem to be the appropriate debate because we will not be in a position to respond to all the contributions.
Every effort is being made by the health boards to collect the arrears and indeed people who are members of health boards can play a role in this. It is vitally important to ensure that those contributions are made. Regarding further charges for non-payment, I will not go into much details about that because generally I think I have outlined exactly the situation regarding the collection of funds.
I could make a very long contribution in relation to the health services but the situation is that this debate is not the opportunity for that and at a later date if these points are raised in a debate we will be in a position to respond. I commend the motion to the House and seek its acceptance.
In view of the fact that the Minister declined to respond to my specific queries will he accept them as representations made by me and respond to them in writing in the normal way?
Yes.
An Leas Chathaoirleach
Is the motion agreed?
No. I indicated initially I would object to it for the reasons given.
An Leas-Chathaoirleach
I am putting the question, "That the motion be agreed to." I think the question is carried.
Vótáil.
The question is "That the motion be agreed to." Will those Senators calling for a division please rise in their places?
Senators Ferris, Harte and O'Shea rose.
As fewer than five Senators rose in their places I declare the question carried.
Question declared carried.
The names of the Senators who stood will be recorded in the Journal of Proceedings of the Seanad.