We are now on to the Adjournment and I understand Senator Doyle is taking the matter on the Adjournment for Senator Nuala Fennell.
Adjournment Matter. - Health Benefits for Insured Workers' Spouses.
I thank you for affording me the opportunity of raising this matter on the Adjournment. This debate, regarding the extending of certain health benefits to the spouses of insured workers is a debate that goes back over many years. In the main, the advocates for this extension have been women and women's organisations. The reason for this is that we have a very high proportion of women in what are officially termed "home duties". In this group there are women who, when they have children, have to give up their jobs and stay at home to look after them. This is a free, personal choice made by the couples in question and it is generally believed to be in the best interests of children. The thinking among women individually at all levels in women's organisations and in trade unions is that society should recognise the contribution made by these women. They should not be penalised for the decision taken to be full-time mothers and homemarkers. But the reality is that over the years they have been very severely penalised for making the decision to stay at home. They lose out on an independent income, on health benefits and on personal pensions.
Very early on it was recognised that there were certain fundamental needs that should be negotiated for women in the home. Paramount among these has always been the need for dental and optical care. As far back as 1975 this issue was debated and submissions were made to various Governments and the Department of Health outlining this need. Nobody ever disputed the justice or the rightness of this appeal. It has taken a long time for us to get to this stage. It has taken several general elections to get the dental benefit for spouses from election manifesto into reality.
In the report of February 1985 entitled Irish Women Agenda for Practical Action, a recommendation was made in chapter 4.40 that, as a first instance, this benefit should be extended to pregnant wives of insured workers. To quote from that section:
The question of extending Dental, Optical and Oral treatment for spouses of insured persons has been a source of considerable debate in recent years, in particular among groups representing Women's interests. Because of the cost associated with dental care particularly, there is evidence that the wives of insured workers tend to neglect the care of their teeth. It is known also that pregnancy can take a heavy toll on mother's teeth. In particular during pregnancy the gums become softer and can be easily injured by food particles and once they have been injured it is easy for infection to be introduced and established. Pregnacy is therefore an important time to have any gum condition treated and to receive advice from a preventative point of view.
The recommendation in that report, at chapter 4.44, reads:
In principle for health reasons the spouses (were mainly wives) of insured workers should be brought under the present insurance-based scheme. A number of options can be considered in relation to the inclusion of spouses which should be pursued in the light of the prevailing public finances situation over time.
In the following year the Coalition Government extended the benefit in the budget to include pregnant wives of insured workers. While this has been seen as an inadequate response to the total demand by many organisations, it was welcomed and taken up. Everyone welcomed the announcement in October 1987 by the present Minister for Social Welfare, Deputy Michael Woods, that the full benefit was to be extended to the 330,000 dependent spouses. It was interesting at the time to consider the contrast between the response of the opticians and the response of the dentists. The Irish Dental Association at that time boycotted the scheme and indicated they would refuse to treat spouses. By the following year it was obvious that the Irish Dental Association were quite adamant in their refusal to co-operate with the extension of the scheme. In a proposal to the Minister around that time the Dental Association suggested that the scheme should be amended to make it means tested and that those insured people whose gross income is above the limit for a hospital services card should receive only a dental examination free of charge and would pay for other treatments. The Minister rightly opposed this recommendation saying that it would be a major departure from the whole principle of an insurance-based scheme. All benefits are given as right without a means test. It was indicated that only 1.7 per cent of those covered by the scheme had gross incomes of £2,000 or more
In the intervening time the debate has staggered on with considerable bitterness and with no signs of resolution. There have been changes in the fees in the benefit scheme in that time and they include the following: 2.5 per cent increase in all fees backdated to 1 October 1988; 10 per cent on full dentures and repairs and 20 per cent on partial dentures. For extractions an additional £3 for a second tooth extraction in the same section of the mouth. A new fee of £12 has been provided for panoramic X-rays.
Up to 6 March of this year a total of £1,700,826 was paid in respect of claims from dependent spouses of insured persons to the 184 panelled dentists who at that time had signed agreements to provide treatment in this category. It is very regrettable that the victims in this debate are mostly women who have few enough rights, because they are out of the workforce, compared to their counterparts in any other country. Of course, it would have been much more helpful if all the questions now in dispute could have been resolved before the announcement was made to extend the scheme fully. This would be desirable, but, because I have been rather more closely involved with the question over the years than most, I appreciate the difficulties that the Minister must have experienced.
I have to lay the blame for the present situation clearly at the door of the Irish Dental Association. They have taken an ungenerous and arrogant approach to this whole matter. Indeed, far from it being a matter of them boycotting the scheme, I would suggest that couples should consider taking action of their own and boycotting dentists who have refused to extend the operation to wives working in the home.
It seems at present that there are 189 dentists fully co-operating with the Department and giving full cover to the insured persons and their spouses, while 630 dentists are dogmatically refusing to co-operate. In their opposition to the scheme, the Irish Dental Association have indicated that they seek to ensure there is good quality of service available to insured people. I do not doubt the sincerity of that claim, though one would not be so naive not to realise that the main motivating factor behind their action is money. It seems that the Minister has gone as far as he can in increasing fees, and the dentists must realise that they cannot be exempted from the overall policy of restricting public expenditure.
I am happy that the scheme is not under-funded and that the dentists are not exploited for the work they have done. Fees are paid on a fee per item basis. Typically, dentists involved will earn around £30,000 per annum from the scheme, and this excludes their private fees on top of payments from claimants.
This is a very fundamental issue in the context of reflecting the needs of nonworking wives in relation to basic health care and extending to them some of the entitlements of people in the labour force. I absolutely agree with the statement made some weeks ago by the Congress of Trade Unions in which they called on the Irish Dental Association to co-operate in the new scheme. I would ask the Minister to continue to take any possible action he can bring about a satisfactory solution. However, I would earnestly call on the Irish Dental Association to become involved in this scheme so as to give the people I am speaking about the dental care they urgently need.
The Minister for Social Welfare, Deputy Michael Woods, has asked me to deputise for him. The Minister is in Sligo for the official handing over of the new pension services office but will be back later this afternoon. He has asked me to apologise that he could not return in time for this debate and to deliver his speech on his behalf.
I very much welcome the opportunity to make a statement to the House this evening clarifying the position with regard to the extention of dental benefit to the dependent spouses of qualified insured persons. The treatment benefit scheme is a good scheme. It provides a very valuable service to the 350,000 PRSI workers and their dependent spouses who benefit from it each year. In addition to extending it in October 1987, the Minister made considerable improvements in the scheme last March along the lines suggested by the Irish Dental Association.
There is a clear recognition in Europe of the need to protect the social insurance position of women who leave the workforce to work in the home. By extending this scheme to dependent spouses we were giving a lead in this regard. Since the Minister extended the dental benefit scheme to dependent spouses of insured workers, mainly women working in the home, some 40,000 dependent spouses have claimed under the scheme.
Some 7,500 of these made claims since last January. The number of dentists who have signed new agreements to operate the extended scheme continues to increase and is now 190, despite the fact that the Irish Dental Association has strenuously opposed the extension to spouses.
It is important to put the dental benefit scheme in perspective in relation to the present difficulties. Dental treatment has been available to insured workers, subject to the statutory contribution conditions, since the inception of social insurance in 1953. Each year over 350,000 persons receive treatment under the scheme. I would prefer to have more dentists operating the extended scheme for dependent spouses, particularly in rural areas, but the extension has been of major benefit to some 40,000 spouses mainly women in the home.
I regard the extension of dental, optical and aural benefits, which is now operating for 19 months, as an historic achievement for this Government. It is a measure which has the support of all parties in both Houses of the Oireachtas. It has opened up access to the treatment benefit scheme to dependent spouses, mainly women in the home, on the basis of their spouse's PRSI contributions. There has been considerable demand for this extension over the years and the Minister was very pleased to have been able to introduce it.
The number of beneficiaries under the optical benefit scheme — almost 52,000 since the extension was introduced — reflects great credit on the opticians who welcomed the new scheme and who put it into operation without delay. I would like to take the opportunity to pay tribute to them for their co-operation and also to those dentists who are treating dependent spouses.
The Minister met the Irish Dental Association before Christmas to discuss the issues involved in their present action and to explore the possibility of getting the association's co-operation on the operation of the extended scheme. Arising from that meeting a package of proposals for improvement was put to the association for their consideration. Unfortunately, it was rejected by them. Officials of the Minister's Department have had further meetings with the association since then.
The changes which the association are seeking in the scheme would involve a major increase in expenditure from the Social Insurance Fund or substantially increased contributions from certain people entitled to treatment under the scheme. The association want to restrict the application of the present scheme to medical card holders. They also want to introduce new arrangements for other insured workers under which dentists would be free to impose additional charges, without limit, for most items of treatment on top of the fees paid by the Department. In other words, the Irish Dental Association want a two-tier system which would undermine the present scheme. The Minister wants to make it clear that he is not prepared to accede to changes in the scheme along those lines. It is a fundamental feature of the scheme that treatment is provided on the same basis to all persons covered by the scheme and he will not depart from that. Furthermore, basic items of treatment must continue to be provided free of charge to insured persons and their dependent spouses and where charges are applied in certain cases in general they would have to be subject to a fixed upper limit.
The Minister has indicated to the Irish Dental Association on a number of occasions that, while he is opposed to the introduction of a two-tier system, he was prepared to consider improvements to the existing treatment schedule, including improvements raised in the context of the discussions of the joint working group who reported last year. The improvements he had in mind were those designed to meet specific suggestions from dentists over the years. He is not prepared to dismantle the present scheme or impose considerable extra cost on insured workers, as the Irish Dental Association want him to do.
In the light of the rejection by the association of the Minister's proposals and their demand for fundamental changes as a prerequisite to operating the extended scheme, he decided to implement a package of improvements with effect from 1 March 1989. Details of these improvements have already been announced and have been sent to all dentists participating in the scheme. The main features are as follows:
(1) 2.5 per cent increase in all fees backdated to 1 October 1988.
(2) Examination fee interval reduced from 18 months to 12 months.
(3) 10 per cent increase in fees for full dentures, repairs, etc. and 20 per cent increase for partial dentures.
(4) 10 per cent increase in fee for single filling.
(5) Acid etch fillings allowed on all teeth; new fee of £18.00 (£10.50 for single fillings) will apply with a maximum patient contribution of £2.50.
(6) A similar arrangement to apply to pin-retained fillings, endodontic treatment and apicectomy.
(7) Additional £3.00 for a second adjoining tooth extracted in the same section of the mouth.
(8) New fee of £12.50 for panoramic x-rays.
(9) Normal examination fee (instead of a reduced one) will apply where the patient does not return for treatment.
(10) New fee for obturators.
The cost to the Exchequer of this package of proposals is £870,000 in 1989. Dentists' earnings from the dental benefit scheme average out at between £25,000 and £30,000 per annum when those earning less than £10,000 a year are excluded. At the top end of the scale the highest earners receive between £90,000 and £100,000 per annum from the Department. Dentists, of course, also have earnings from their private practice. In general those earning low amounts from the Department concentrate mainly on their private practice. Even those on the higher levels are performing some private dentistry.
Recent media attention in relation to the dispute has concentrated on the decision by the association to instruct their members not to undertake certain items of treatment under the scheme. The items involved are root canal treatment, dentures and extractions. A small number of complaints in this regard have been received by the Department and these are being investigated at present. Where the Minister is satisfied that the complaints are substantiated he will have no option but to regard the dentists concerned as being in breach of their agreement with him to provide dental treatment. That agreement provides for appropriate sanctions under the contract which is signed by each dentist operating the scheme including withdrawal of the contract.
The Minister wishes to assure Members of the House of his concern to have the present difficulties resolved as quickly as possible. He was very glad to have been able to introduce the extended scheme and is determined that it should operate for the benefit of all dependent spouses seeking treatment under it.
I hope I have explained the position to the House and I assure you that the Minister will do what he can to resolve the dispute.
The Seanad adjourned at 5 p.m. until 2.30 p.m. on Wednesday, 26 April, 1989.