Dáil Éireann díospóireacht -
Thursday, 7 Apr 1938

Vol. 70 No. 13

Public Business. - Vote 44—National Health Insurance.

Mr. O Ceallaigh

I move:

Go ndeontar suim ná raghaidh thar £200,124 chun slánuithe na suime is gá chun íoctha an Mhuirir a thiocfaidh chun bheith iníoctha i rith na bliana dar críoch an 31adh lá de Mhárta, 1939, chun Tuarastail agus Costaisí i dtaobh Riaracháin na nAchtanna um Arachas Sláinte Náisiúnta, 1911 go 1936, agus na nAchtanna um Pinsin do Bhaintreacha agus do Dhílleachtaithe, 1935 go 1937, agus chun Ilsíntiúisí agus Ildeontaisí, ar a n-áirmhítear Deontaisí áirithe i gCabhair mar gheall ar Chostas Sochar agus Costaisí Riaracháin fé sna hAchtanna um Arachas Sláinte Náisiúnta.

That a sum not exceeding £200,124 be granted to complete the sum necessary to defray the Charge which will come in course of payment during the year ending on the 31st day of March, 1939, for Salaries and Expenses in connection with the Administration of the National Health Insurance Acts, 1911 to 1936, and the Widows' and Orphans' Pensions Acts, 1935 to 1937, and for sundry Contributions and Grants, including certain Grants-in-Aid in respect of the Cost of Benefits and Expenses of Administration under the National Health Insurance Acts.

The sum now asked for is to complete the sum of £300,124 required under the National Health Insurance Vote for 1938-1939. The figure covers the cost of central administration of national health insurance, and also the cost incurred for staff, etc., of the department engaged in the administration of widows' and orphans' pensions. It also includes the amount required for the Statutory Exchequer Grants for national health insurance, and expenditure in connection with the district medical referee service.

There is an increase of £4,400 in respect of the Statutory Exchequer Grants due to the increasing number of insured persons. There is also an increase of £4,014 due to additional provision for salaries arising out of the increased cost-of-living bonus and increments. Small increases under sub-heads AA, B and D are also shown. There is an offset of £2,898 under subhead H—Appropriations-in-Aid. The net increase in the Estimate as compared with the year 1937-38 is £6,040.

During the year 1937 the Unified Society continued its operations under the direction of the committee of management constituted under the provisions of the Act of 1936. The committee of management consists of a chairman, three trustees and three representatives of employers—all appointed by me—together with eight representatives of insured persons, of whom three are nominated by the Executive Council of the Irish Trade Union Congress and five are elected at an annual meeting of the electorate consisting of insured persons nominated by the councils of county boroughs and county councils.

I reappointed the Most Reverend Dr. Dignan, Bishop of Clonfert, as chairman and Dr. R. J. Rowlette, Mr. Thomas Foran and Mrs. Helena Concannon as trustees of the society. To the vacancy due to the regrettable death of Mr. Sean Noonan, of Free-mount, Charleville (one of the employers' representatives on the committee), I appointed Mr. William O'Callaghan, Lombardstown, Mallow, and reappointed Mr. John O'Neill, of Dublin, and Mr. William O'Meara, of Kilkenny, as the other employers' representatives.

In electing the five insured persons' representatives provision is made for two being representative of the province of Leinster, two for Munster and one for Connaught and part of Ulster. The persons elected in 1937 are residents of Dublin, Longford, Tralee, Mitchelstown, and Westport. All members of the committee hold office until the 31st July the year when new appointments and elections are necessary.

The membership of the society at the end of 1937 was about 580,000 and the number of insured persons in receipt of sickness and disablement benefits at 31st December, 1937, was 24,236, which is about the average throughout the year. It will be seen that the percentage of insured persons in receipt of those benefits is over 4 per cent.

The value of the contributions from employers and employees collected in 1937 was £703,000, an increase over the previous year of £28,000. The expenditure on benefits during the year amounted to £705,294, made up of ordinary cash benefits, £697,301; additional benefits, £7,993, showing a decrease from the previous year of £12,802 cash and of £20,453 additional benefits. The accumulated funds forming the assets of national health insurance amounted to £4,201,224, showing an increase of £258,984 during the year.

As I stated last year, it is proposed to have the whole question of the financial basis of the Acts investigated by the Actuary. The material for this investigation is under preparation by the Department and by the society. Although the contribution income is still increasing, I think that there is still considerable non-compliance with the provisions of the Acts. During 1937 it was found necessary to protect the interests of insured people by prosecutions of 697 employers. In addition, a sum of £366 was recovered from employers in respect of benefit lost by employees owing to the employers' failure to pay contributions.

Mr. Dockrell

I think we were told when the societies were amalgamated that the object of the amalgamation was that there would be a decreased cost in running the National Health Insurance scheme. The Vote is up for the present year, and the Minister more or less explains it by referring to the cost-of-living bonus. There are some other matters at which one wonders. How far was the amalgamation carried out, for whose benefit, and with what object? If one considers what happened in the past one will realise that there were certain societies which by very careful management got into a position in which they could declare very considerable extra benefits. There were dental benefits and various other benefits which those societies were in a position to give their members. When the amalgamation was brought about the Minister told us it was with the object of levelling up with the other societies that were not in a position to cater as well for their members as the more carefully managed ones, and it was hoped that they would be brought up in time to that level. For some years the additional benefits were continued for the members who had obtained them, but now all insured persons have been levelled down, and meanwhile the contributions have gone up.

There are several other unsatisfactory features in this whole scheme. It was represented as a transitory scheme, that a good deal more was going to be done in the way of medical benefits for insured workers. Whether one looks upon the insured worker as a machine, an insured person or a citizen, there can be no doubt that adequate and proper attention for him and his family is to the benefit of everybody. I personally, and I am sure all Deputies, would be very glad to see medical benefits in this country placed upon a proper footing. At present, if an insured worker feels ill, he has a choice of two things: he can continue working and possibly risk a very serious illness, or he can declare himself sick, take to his bed, and send for medical assistance. There seems to be no half-way house, and I think the time is over-ripe for a review of the whole question of medical benefits for insured workers. The Minister said nothing about it in his opening remarks, and apparently he is satisfied to let matters go on from day to day and from year to year. If, however, we look at what is being done for insured workers in other countries, we must realise that either we or they are fools. There can be nothing between the two. I urge the Minister to have a proper and comprehensive review of the entire question of medical benefits under the National Health Insurance scheme. It is overdue and everybody would welcome, even at some extra cost, the putting on a proper footing of the health of the workers in insurable occupations.

I have mentioned one anomaly—the choice of a worker to go sick or to continue at work, and his inability to get medical advice under the scheme— but that is only one of a number of anomalies which everybody would like to see done away with. What we would like to see is a proper and comprehensive medical service; in other words, value for the worker and for the country at large. I have not any doubt that the cheapest thing the country could ever do is to see that the people in need of medical advice should be able to get it at a proper cost under this scheme. We are going on from year to year while nothing is done, and I put that matter forward for the Minister's serious consideration. It has been brought up from time to time in this House, and on a previous Estimate the Minister gave us information about a great deal that was being done for the insane in the shape of curative treatment. In this case I have not heard any pious platitudes, but I hope that something real and concrete is going to be done towards a solution of this problem.

Mr. Hogan

We might talk for hours on this matter of national health insurance, and it is very doubtful if, after all the talk, we would have achieved very much. It is a matter the various manifestations of which one must sit down and work out in detail. The Government tried a very big experiment when they unified all the societies, and I think they chose a very bad halting point. They should have gone a step beyond unification and should have nationalised insurance. Deputy Dockrell has raised the matter of medical treatment. That, of course, is a very important point and one which demands almost immediate investigation. That investigation, however, will be a big investigation. We cannot compare the position here and in a neighbouring country because the medical services are so entirely different. We have a dispensary system here which, I think, does not operate on the other side, and if you are going to investigate the national health insurance medical services and treatment you have, of necessity, to include that branch of local government and see how it can be applied to the needs of insured people. That is a huge job, but because it is huge is not a reason for our not tackling it. I think the administrators of local government and the people generally in this country are sufficiently big to undertake that job and I think it ought to be undertaken to see how far it can be applied.

There is some grumbling regarding the results of unification on the part of some of the societies brought into that unification scheme, and I think some of them have a right to grumble. There were increased benefits in some of the societies because they were better managed than others. There was dental treatment in some that was not available in others. It was a question of some societies having very good committees of management who did the work very well and very effectively, and the members of those societies got the benefit of that work; but when all the resources of the societies were pooled it would appear that the deficits and deficient administration in some societies more than counter-balanced the efficient administration in the other societies, with the result that the Unified Society found it necessary to drop many of the benefits that were being given in some societies when they were single units of administration.

I do not want to press the Minister unduly in this matter. I know that a very big experiment was tried. Anybody who has had experience of the ramifications of national health insurance knows the difficulties that have to be encountered in the purely office work of national health insurance. Without wishing to press the Minister unduly, I think we have reached a stage now when we ought endeavour to find out whether some of these benefits cannot be restored; whether, in fact, these benefits ought not be levelled up instead of being, as they have been, levelled down. Standardisation upwards, rather than downwards, is what we want. I suggest that standardisation ought to be up to the level of the best societies operating before the unification took place. I think the Minister himself must feel that something should be done in that direction. If the Minister devotes even one day in the year alone to national health insurance, he will find that this is a problem that has to be faced immediately.

I am glad to know that the Minister said there was to be an actuarial examination of the inside position of national health insurance. That is very necessary. Before the Minister can move, he must know the resources. It is obviously necessary for him to know what are the resources he has to work upon. I want to urge the Minister to consider the position of people who were in a much better position before the amalgamation took place than they are at the moment so far as benefits are concerned. I want him to consider whether in their interests alone, not to speak of the interests of all the members of the Unified Society, something should be done. There is just one other matter that I wish to put to the Minister, and that is whether a pensions scheme has been prepared in respect of the officers of the Unified Society?

Mr. O Ceallaigh

Yes, it is in operation.

An Ceann Comhairle

The Minister to conclude.

Mr. O Ceallaigh

Deputy Dockrell referred first of all to the cost of administration. I am not quite sure whether he meant the cost of the administration of national health insurance, so far as it affects the Department of Local Government, or the cost of the administration by the Unified Society. Probably, as he was looking at the Estimate, he meant the cost of administration by the Department. Well, there has been a considerable reduction in the cost of administration by the Department, so far as headquarters are concerned, as compared with the last year, under the old system. We have had a considerable reduction. This question of the amalgamation or unification of the national health societies or the benefits or otherwise arising from amalgamation has often been discussed in this House. Some Deputies, including Deputy Dockrell, need to be reminded of the fact that the possibility was that if the old system were allowed to continue the bottom was going to fall out of national health insurance. Probably Deputy Dockrell knows that as well as I do, but it does not suit his case to admit it. That, however, is the fact.

The only drawback now with the system, as Deputy Hogan says, is that it is not going the whole road. Getting the societies unified was going a useful part of the road. In the old days, at the start of the national health societies, there were some societies that were in a position to give medical, dental and hospital benefits. No society could give all these benefits but some societies gave one benefit and some societies gave another or two other benefits to their members. That certainly was not in any of the cases due to good management. It was due to other things. Where these benefits were given it was because the society was fortunate in the type of members it had. As a consequence of the type of members a society had, the calls on its exchequer were not as high as in the case of other societies. Deputy Hogan knows very well that some large and well-managed societies were unable not alone to provide additional benefits, but were financially in a very dangerous position because of the type of member they had. They refused nobody in the ordinary way. They admitted every applicant associated with their line of work, the old and the young, the infirm and others. They took them all in a humanitarian spirit. Consequently, such a society could not compete with a society that could select its members. The result was that some of those large important societies were in a financial position that required immediate attention. That is why unification was brought about. Now all insured persons are treated alike. They have been levelled. Deputies Dockrell and Hogan say they have been levelled down. That was necessary. We need a period of conservation and retrenchment so as to try to put national health insurance on its feet before we can start the type of development that everybody who is interested in the subject would like to see — progressive development in national health to make it really what we aim to make it. National health is not a system that was devised by ourselves. It is a system that was devised in another country and suited to the people of that country but not suited to the conditions here. We are actively engaged through the actuarial staff in the Unified Society and through our own officials in the Custom House in dealing with the present position and the future prospects, financial and otherwise, of national health insurance.

During the last year the Government has taken up the question of the consideration of medical benefits. As Deputy Hogan, who knows the subject well, suggests, it is a very thorny and difficult problem. One cannot devise any quick method of putting medical benefit into operation as long as we have the present poor law medical system in operation in the country; there will be modifications, perhaps, a complete change. It is a very big subject, and one that requires long and detailed examination before any change is made. But that examination is in progress. I am interested in seeing, not alone medical benefits, but a variety of other benefits that should be associated with and made a part of national health insurance, introduced, and benefits given to the insured persons, even though it may cost more. When the time comes to bring before the Dáil the enlarged scheme that those who are most progressive in the matter and who have given long study to the subject would like to see put into operation, it will be found that this will lead to increased cost—increased cost on the employer and increased cost on the insured person. Deputy Dockrell encourages me by saying that he does not mind the increased costs. I hope he will remember that when the actual proposition does come up in the House, and when he is faced with the Vote on the subject and with the increased cost that the employer must necessarily bear. Deputy Hogan was anxious to urge on me the necessity of reviewing the position. I can assure the Deputy it is hardly necessary. It is a matter in which I am interested. It is a matter also in which the Unified Society and its committee of management are deeply interested. At fairly frequent intervals they have had discussions with me about this matter. It is being actively discussed, canvassed and considered, but we cannot do anything in the way of a definite substantive proposition until we have the result of the actuarial and other investigations that are now proceeding.

Vote put and agreed to.