I feel I was entitled to regard the present legislation with some suspicion even when Sections 22 to 28 had disappeared from it, because there is the same Taoiseach under whose auspices the legislation in 1947 was brought forward. He was again Taoiseach when the 1952 Bill was introduced. In 1947, Dr. Ryan was Minister for Health. Again, in 1952, he was Minister for Health. He has presumably the same Department of Health officials around him as he had in 1947. There is the same Attorney-General asthere was in 1947, the Attorney-General who said that these sections were all right. I presume he gave the same advice in 1952. When Fianna Fáil speak on this they say that the Constitution is there for the protection of the community. There is, in particular, Article 45, the directive Article of the Constitution. Do not forget that the Constitution was there in 1947 and the directive Article on social policy was there, too, Article 45.
I wonder what the present position is. Have these sections been completely abandoned without any possibility of their return? I find that Section 4 says as clearly as words can say it that this legislation is to be free. There is to be a free choice. The Minister has interpreted that in these terms: it is free as far as the doctor is concerned because he can come into the scheme, if he wishes, or he can stay outside; it is free as far as the applicant is concerned; it is free as far as institutions are concerned.
Our attention was directed to Section 18. A little later we got a new Section 18 thrown at us by way of amendment. As far as certain sections of the public are concerned I think I am not wrong in stating that the Minister's new Section 18 is causing considerable anxiety and great scruple amongst the nuns who run our secondary schools where day pupils are attending and amongst Catholic headmasters running secondary schools where day boys are attending. I do not know if the Minister will say I am going beyond what is in the Bill when I state that, as far as religious communities of nuns responsible for the education of children are concerned, they have indicated that they will not allow this section, if passed, to operate in connection with their schools. The Catholic headmasters dealing with day pupils in secondary schools have indicated their complete objection to this section and have gone so far as to say, as far as I am aware, that they will not allow it to operate if it is within their power to prevent its operation.
The Minister has said that in Section 4 everything is open to choice and there is free choice. I wonder what other errors might be hidden in thisparticular piece of legislation now that we know how free the choice really is. Objection was taken to the 1947 Act on general principles and not so much along certain sections. The phrase used was that the Bill in principle was contrary to Catholic teaching, the rights of the family and the rights of the Church in connection with education and to the rights of the medical profession and of voluntary institutions. It is noteworthy that in that context the rights of the family come first. We know that since the legislation of 1947 many well informed members of the Church and many learned men have directed their comments, without directly aiming at the Government or individual members of the Government, towards this legislation. The one fundamental objection they have to this legislation is summed up in the phrase that it deprives the community of their responsibility and deprives fathers of families of their responsibility to educate their children, physically as well as mentally.
Objection was made that if this legislation went much further and there was much more in the way of State control, that inevitably must have the effect of weakening self-reliance and breaking down the moral fibre of the community. Yet, we get this piece of legislation welcomed, as it was in this House, in the phrase that it represented egalitarianism, and that was apparently something to be proud of. Consider the egalitarianism that is in this measure. It is equality at the lowest possible level. The one phrase that has been repeated by the Minister for Health over and over again in the course of this debate is that those who want to avail of this and the free services provided under it must avail of them in the public ward. That is equality at public ward level. The Bill specifically prohibited any provision being given to people who take treatment in private or semi-private homes. In that respect it is a great contrast to the British legislation. As if he delighted in it, however, the Minister harps on that again and again. If there is equality in this measure it is equality at the lowerincome group, and not even at the level of the middle income group. It is equality at the level of those who are described in the Public Assistance Act as folk who, by their own industry or lawful means, cannot provide their own essential medical services.
In the light of that, we gaily set forward, leaving clerical objections out of it altogether, on this voyage towards social betterment, and the improvement of health services and the level of social betterment and improved health services is treatment in the public wards. I should have thought that if there is anything to be improved in social conditions here on the health side it would have been our ambition to work upwards from the public ward situation and to get away from that atmosphere altogether. If lack of medical staff, lack of sufficient nurses or lack of buildings meant that for some time, at any rate, we had to continue with the public wards in our hospitals it should be our endeavour to ensure that they would not be crowded with new applicants and that the horrors of the public wards would not be extended for a wider circle of the citizens than those who qualified for public assistance and were forced to put up with these rather shocking conditions. When the Hierarchy did condemn in 1947, in the letter to the Taoiseach, and when later the blundering of Deputy Dr. Browne brought the fullest possible condemnation from them, they did not confine themselves to a negative approach to this matter. In one of the letters that they wrote, dated 5th April, 1951, this sentence occurs:—
"The Archbishops and Bishops desire to express once again approval of a sane and legitimate health service which will properly safeguard the health of mothers and children."
At the end of that letter this sentence occurs:—
"Accordingly, the Hierarchy have firm confidence that it will yet be possible, with reflection and calm consultation, for the Government to provide a scheme which, while it affords due facilities for those whom the State, as guardian of the commongood, is rightly called upon to assist, will none the less respect, in its principles and implementation, the traditional life and spirit of our Christian people."
In a letter dated 8th March, 1951, from the Archbishop of Dublin, this phrase occurs:—
"I welcome any legitimate improvement of medical services for those whose basic family wage or income does not readily assure the necessary facilities."
A second paragraph follows:—
"And if proof be needed of my attitude, I may be permitted to point to many actions of my Episcopate, in particular to the work of the Catholic Social Service Conference founded by me, more especially to its maternity welfare centres."
Towards the end of a letter dated 10th October, 1950, this sentence comes in:—
"The Bishops are most favourable to measures which would benefit public health, but they consider that instead of imposing a costly bureaucratic scheme of nationalised medical service, the State might well consider the advisability of providing the maternity hospitals and other institutional facilities which are at present lacking and should give adequate maternity benefits and taxation relief for large families."
I want to stress these sentences because of the dishonest criticism that has occurred with regard to the efforts of the Hierarchy to perform their teaching office in this community and because of the efforts to misrepresent that attitude and to make these people appear as if they were anxious merely about taxation, that they had no care for the poor and certainly saw no necessity for improving the health as well as the social services for those who could not provide these things for themselves. At a meeting of the Government to which I belonged, on the 7th April, 1951, this decision was taken:—
"...that in the light of the Government's conviction thatmothers and children should not be deprived of the best available health care by reason of insufficient means, a scheme or schemes for a mother and child health service should, as soon as possible, be prepared and undertaken which would
(a) provide the best modern facilities for those whose family wage or income does not permit them to obtain, of themselves, the health care that is necessary for mothers and children and,
(b) be in conformity with Catholic social teaching,..."
Immediately after that decision was taken and for a brief month or two there was, for the first time since inter-meddling with health affairs happened in this country, a period of co-operation in which the professional men outside—the doctors—met with the professional men—the doctors—in the Department of Health and with others. That co-operation was enthusiastically given by the professional men, both those in the Department and those who were outside. Their enthusiasm was to provide a real scheme which would have benefited everybody because the principles were good, the extent was no way meagre, the methods adopted would have ensured smooth working and got a scheme that could work and be made work because the profession were behind it. Now, after all the years—notwithstanding the warnings that were given to the Taoiseach in 1947, notwithstanding the many warnings and the effort to correct and the efforts to guide that met with such lamentable ill-success in the case of Deputy Dr. Browne—Dr. Ryan, the Minister for Health, apparently finds himself in exactly the same position that Deputy Dr. Browne was in about two years ago. Again we have the tactics of suppression. Nobody knew anything about the letter of October, 1947, addressed to the then Taoiseach until it was disclosed in the Dáil Debates that took place and Deputy Dr. Browne did what was called here "make a sacrifice" but which I have heard phrased differently—"had a sacrifice imposed on him."
According to the Taoiseach's statementearlier this afternoon the Minister for Health is now conducting the business of the Government in the ordinary way. The ordinary way, apparently, is to take steps to have the publication of a letter at least delayed—a letter which, incidentally, was not addressed to the Government specially, a letter that was addressed to the community, a letter which was intended to be for the guidance of the community and which, I understand, is founded upon the teaching office of those who composed the letter. So far the publication of that letter has been suppressed even though it is addressed to the community and is for the guidance of the community. Again we have the same difficulties. Is there the freedom that a Catholic community should have? Is the responsibility left to parents—fathers and mothers— within a Catholic community which, according to Catholic teaching, ought to be left to them? Is that the position or has it been found that again there is a breakdown and that another Health Bill will have to be scrapped entirely or will have to be amended so completely that it will be very far away from the piece of proposed legislation that got the acclamation of certain peculiar odd people in this House in the past ten days? Has the Minister amendments that he can speak of when he is replying to this Money Resolution? Will we know before the Money Resolution is passed what the money is required for? Is it for something that now lies under condemnation or is it for some new scheme that the Minister will have hurriedly to think up? That is one of the ghastly parts of this. I myself did not consider it credible, in view of the warnings given in this earlier correspondence, that any responsible person entrusted with preparing health legislation could have neglected to have association with those who composed these letters. I believe he had that association and that he had that association over many months. I believe also that recently when this matter was mounting to a climax here and outside, the Minister was visited by at least one member of the Hierarchy, who, I am sure, gavehis best in the way of advice and offered him his best in the way of guidance out of the embarrassing difficulties into which he had landed. Do not forget that this legislation, this Estimate for the Department and this Money Resolution have been before the House and the public for very many weeks. We had the phrases used here that it was socialism and it was welcomed as socialism. We had this peculiar phrase about egalitarianism, that at last it had been achieved, and although the toe was only in the door we still would get freedom to kick the door down and make our proper advance to socialist medicine.
Defiantly it was said in this House that the Hierarchy of this country knew how to defend themselves; that this legislation had been before this country and before the Dáil for many months, and yet there had not been one word, one line or cheep of protest against it. There was not. As far as that member, Deputy Dr. Browne, or as far as any of us knew, that was the case. The Minister knew how false that was, because he had been approached and he had these criticisms. Yet he shambled along, apparently impenetrable to argument and insensitive to any matter of principle, apparently unaffected by any reason until we again got this collision that had occurred in 1947, 1950 and 1951. Again we had the huddled business, smuggling behind closed doors, and the suppression of what the public are entitled to know, in an effort to get the Minister breathing space so that he need not appear shamefaced, having to confess what went wrong. He would not be in such a lamentable position if he had accepted, when proffered, the advice which he is now rather reluctantly going to take. However, those aspects will come out later.
In this House there has been a great deal of adverse comment of the medical profession. The medical profession, in all this matter, are supposed to be acting very selfishly. Despicable phrases were used about them by the Minister for Health that he presumed arose out of something said over in England. The situation would soondevelop like that in England, and the doctors would find they are financially better off under the health services plans, but in England, while they are better off, they objected, because they had to pay income-tax. That, coming from a member of the profession, was cast at the I.M.A. as being presumably the reason why they objected to this scheme. They might make a bit more money, but they would be compulsorily honest. They would have to put in the correct income-tax returns and to that degree might lose. There, in any event, this legislation turned aside from the profession. The profession were to be at the best ignored; the county manager, a lay person, was to take on a variety of important responsibilities under these proposals.
I say the profession were at the best to be ignored. Deputy McGrath had a different view. Deputy McGrath wants them prosecuted or possibly manda-mused into doing their duty. Deputy McGrath thought that after this legislation passed those who held themselves out as unwilling to co-operate or work the scheme should have the Attorney-General put on to them. That is the free society into which Ireland is drifting. Under Section 4 everything was to be free but when it came to the practical application if people did not co-operate the Attorney-General would get after them. They would be either prosecuted in the Criminal Court or efforts would be made, I suppose by some application of mandamus, to get unwilling doctors to give the services under the health proposals that they are expected to give.
I know that in 1950 there were different proposals. The view of the Minister for Health in those days was that the Department had power to insist on the dispensary doctors coming in under the scheme. The attitude was put up in a minute which still remains on a file in the Minister's Department and which he can see, that the Department believed they could operate these powers and when they did the others would have to come in or that the others would cave in.
We have the situation in which the profession are opposed to this legislation.They have expressed their view that the scheme is unworkable, it will not be a good one and they will not co-operate. Reading the debates and listening to what has been said on this question, I have waited to have somebody put up a reason why the doctors should behave in this way. Their conduct at least merits a question mark. Why are they behaving in this way? I understand that it is accepted by those who speak for the Government that these health proposals will mean expenditure of more money on health services. If that is the case I should imagine—and I think the Minister for Health accepts this himself—that the members of the medical profession would benefit financially. Why, against their financial interests, do they take this line? The cheapjack way of speaking of it is to say it is only Merrion Square and the crescents who object and they apparently have power to overawe all their colleagues, even those who come from the rural areas or those who come from the provincial towns. Strangely enough these specialists from Merrion Square and from the crescents find it possible to overawe the National Health Council.
The National Health Council is a body of some 30 people elected on a peculiar basis. There are representatives of the General Council of County Councils on it; there are representatives of the municipal authorities on it; there are certain doctors appointed by the medical association and certain others who come from elsewhere. In the last ten days I glanced down through the list of names. From my own knowledge of the political views of those whose names I saw on that sheet, I would say not less than 50 per cent. are in their politics affiliated to the present Government. Yet, I understand, after a nine hours' interview (two periods) with the Minister for Health, the Minister did not find it possible to get a single person of the 30 to approve of a single part of the proposals of the health legislation we are discussing. If the influence of the specialists in Merrion Square and from the crescents is so powerful that they can coerce their colleagues who are not of the specialist type, overpower thepeople coming up from the country, and even get their influence worked with representatives of the General Council of County Councils, the municipal authorities and a whole heap of other people, it is a striking fact that there is no person to be found in the room with the Minister for Health who can say a good word about a single one of the Minister's proposals. How is it ever hoped to have this scheme worked, even if the scheme could get over the difficulties with regard to Catholic social teaching? What belief is there, what real expectation is there, that a scheme dealing with the health of the people could be made to work if the doctors and the community are against it?
Deputy Larkin, generally very accurate on matters about which he speaks in this House, did make a statement here which was inaccurate. I listened to hear how his statement would be put across in the Radio Éireann version of the proceedings of Dáil Éireann, and there was a cute distortion of Deputy Larkin's phrase, to get over the mistake he made. Deputy Larkin said—I am not quoting his exact words; I am just giving the gist of his remarks: "What is the good of the I.M.A. holding out against the scheme? When a more powerful body than they are"—I presume he was referring to the B.M.A.—"took up the same attitude of non-co-operation, they had to give in because of disunity in their ranks." That, of course, is not the case. It was not the doctors who gave in. It was the Minister of Health who gave in.
I have here a book on national health service in Great Britain written by one, James Stirling Ross. This book does not run to more than six or seven pages with regard to what he calls "The Settlement." Deputy Larkin spoke of disunity amongst the doctors. There were three plebiscites amongst the doctors in England. The first was a mere preparatory one. The second was the effective one for the time being, and the voting was 40,000 odd against the Act and 4,000 odd for it.There was not much disunity there. Having got that vote, the B.M.A. were put in a position of great strength but the B.M.A. did, nevertheless, make a further approach to the Minister and, according to this book, the Minister, Mr. Bevan, spoke in the House on the 7th April and said he had been trying to find out for himself—I wonder did the Minister here ever put this question to himself—"What it is that is really and sincerely worrying the doctors." The book goes on to state that it was the fear of a full-time salaried State medical service. Mr. Bevan thereupon gave the guarantee that a whole-time service would not be introduced by regulation under the Act. A number of points which were published in a medical journal known as The Lancetwere then put to the Minister and eventually, after the Minister of Health had promised enough to enable the medical people to give their co-operation, they took a new plebiscite and they said that they would not advise non-co-operation unless at least 13,000 of the general medical practitioners voted for non-co-operation. The result, as far as the general practitioners were concerned, showed that 8,600 odd voted for accepting the scheme and 9,500 odd against.
So far from there being disunity, there was even this vote against accepting it but, as the majority did not number 13,000, which was the necessary requirement for deciding on non-co-operation, they said they would co-operate. Once they got together, even though there was quite a number of general practitioners still against it, things went smoothly.
The chairman of the B.M.A. wrote a letter, and this I want to quote because it shows how these men took their stand on principle and how, when they were met on grounds of principle, they could wholeheartedly work a scheme although the doctors did not believe it would be for the betterment of the people in England. In that letter he stated:—
"There will be no shortage of good-will. The profession will seek to make the new public service the best that is humanly possible underpresent circumstances. The individual citizen will be free to decide whether he will take advantage of the public service in whole or in part. But this will not mean that there will be two qualities of medical service rendered to the public. Only the best is good enough for the public service and we shall do our utmost to provide it."
That drew a corresponding message of good-will from Mr. Bevan, the Minister of Health on the other side. The fight was for a principle, the fight is here for a principle. The doctors here too object to being made salaried members of a State medical service. Apart from that, the doctors have indicated in a series of articles in both the Independentand theStandardwhy they are opposing the scheme of the Department of Health and why they should not be asked to give it their co-operation because of deficiencies in institutions and deficiencies in personnel, medical and nursing. Do not forget the phrase I have quoted: “Only the best is good enough for the public service and we shall do our utmost to provide it.”
What has happened here? We are told that the services are to be given on the public ward level. We have a division of the people into two classes or groups—one group of which, I suppose, is regarded as being envied by the lower income group. Let us take the top level, the person whose family means do not go beyond £600 a year. From figures given in this House it has been established that the 1939 £ is now worth 8/-. Six hundred pounds a year now represents a £240 income of the 1939 character. Anyone beyond that income is outside this scheme, be he married or otherwise. Anybody else not on the public assistance level cannot avail of the proposals in this legislation, and the Minister's consideration for those who come within the scheme is that of the public ward—a place that some of them are not accustomed to go—and in the public ward, if they are above the lower income group, they will pay £2 2s. a week. If they go into some private or some semi-private home, whether they have to look for specialists' services and pay this £2 2s. or not, theyare outside this scheme. If that is the corresponding Irish effort to the British health services let it be exposed for how contemptibly low it is. "Only the best is good enough for the public service in England and we shall do our utmost to provide it."
Here the most that can be provided is the public ward. Deputy Larkin said he did not see why members of the profession here would seem to regard the public ward as something horrible or something pretty horrible. It may not be, but the best that this country can afford should certainly be away and above that until the country gets richer and there is more production. At any rate that is the level on which we are starting. If there are people in this community who think when they get ill that they would like something in the way of privacy, people who do not like the promiscuous conditions of the public ward, who would like a little better, possibly, in the way of food, something better in the way of service of food, some place where people who visit them can be received in privacy by them and where they can enjoy their talk without a whole group of people listening in, we are denying these to anybody who comes in under this scheme, even though they pay for them. The public ward level is going to be good enough here under our improved health services, not the best that the public service demands and should get, as it is going to get apparently in England.
Most people in this debate have sheered off from the cost. The Minister set off on a tour of the public authorities to popularise this Bill. His reception by the first one or two was sufficiently bad to put him off the tour and a member of the Department took up the running. From both—I take it the Minister accepts responsibility for what the head of his Department said—we get this estimate of cost: it was not going to be less than 2/- in the £ on the rates, which would pay half the cost of the service. The other half is to be found some way. If it is going to be found by the people who were in the mood they were in at this time last year it will be found in another cut of the subsidies, so thatwe will have 2/- in the £ on the rates and the rest provided in some other way, but possibly by a saving on the breadstuff of the community.
A sum of 2/- in the £ may seem a small amount. Deputy McGrath, as Lord Mayor of Cork, has recently succeeded in putting 5/- on the rates, plus an extra 6d., and I suppose that the addition of 2/- will not loom very large in the eyes of the Cork ratepayers, if they can tolerate the 5/6 which is going on this year. We are to have 2/- on the rates, and the service then is to depend to a great extent upon the health authority, the county manager, or, in places like Dublin, the city manager. Under certain parts of this legislation, the county manager is to decide who will pay the two guineas and to whom may the two guineas be remitted; he is going to decide on the type of medical service that may be given to certain people, and when the patient goes freely to the doctor of that patient's choice, and that freely-chosen doctor thinks of sending his patient to a hospital where he thinks that person will get the medical attention that person requires, the county manager can say: "No; you are going to another hospital. I will not let you go where your medical attendant desires you should go." Again, in the background of it all, wherever the county manager directs any patient, that patient, arriving anywhere is shown up to the public ward. For 2/- on the rates, we are to get a free public ward treatment—2/- on the rates as to half the cost, and possibly a cut in subsidies to provide the rest.
I think there are certain people in this House who have a great right to complain at this moment. I have no doubt that, when certain people, in complete defiance of their election promises, last year walked into the Division Lobby to support a Budget which cut subsidies, after these people had made promises to maintain and increase subsidies, the way they were brought to vote for that cut in subsidies was the consideration offered of a good health service later in the year.Let them now go to their constituents and tell them that their bread, their butter, their tea and their sugar are all increased in price, and that now the consideration has got to come, if the Minister can get over the objections of the Hierarchy. The consideration is going to be a service at the disposal of the county or city manager; under his control, under that layman's control, controlling sometimes the doctor and certainly always the hospital, with, at the very best, the offer of a public ward when the patient eventually arrives at the hospital.
In any taxation, one has to relate the incidence of the taxation to the service given. The community under this legislation is divided into three groups: the low income group, the middle income group, and the rest. The middle income group, I see, is at the very amazingly low level of a maximum at the old-time rate of £240 a year salary. These people are going to pay and it has been pointed out that they will likely pay three times—once, to provide the service for those who are destitute; secondly, on the basis that they are providing a service for themselves; and thirdly, for the service they actually will provide for themselves.
Free choice has been commented on by so many people that I do not want to stress it or criticise to any great extent. May I say simply this, that the free choice is not a characteristic of this measure? There is, in fact, no free choice. There is a free choice under very limited circumstances amongst a certain number of what are called participating doctors, but to describe that as freedom of choice to the patient is taking the words completely out of their context and distorting the plain meaning of plain words.
So far as the lower income group under this legislation are concerned, they will get no improvement. It has been put here, and there is force in the argument, that they will have their conditions disimproved, because they will find the hospitals, the institutions, the public wards in which they used to get their treatment crowded out by new applicants who will reluctantlyhave to avail themselves of services they do not want because they have been made pay for them. The middle income group are not getting any treatment—the treatment they expected or were accustomed to get. They are not getting the treatment given in England where the health service is open to those who go to a private or semi-private home. How it is to be paid for, I do not know. Deputy McQuillan has made the suggestion that farmers ought to be made pay according to their valuations, and the Minister may take note of that.
