Dáil Éireann díospóireacht -
Wednesday, 5 Jun 1957

Vol. 162 No. 3

Committee on Finance. - Health and Mental Treatment Bill, 1957—Committee Stage.

SECTION 1.

General Mulcahy

I move amendment No. 1 standing in the name of Deputy T.F. O'Higgins:—

1. In sub-section (1) to delete paragraph (a) and substitute the following:—

(a) by the deletion in sub-section (4) of the words "not exceeding six" in the third and fourth lines thereof, and the substitution therefor of "not exceeding, in the case of the dependents of persons specified in sub-section (2) (a) of this section and in the case of such of the persons specified in sub-section (2) (c) of this section and their dependents, whose farm or farms exceed £25 in valuation, the sum of ten shillings, and in all other cases the sum of six".

This matter was discussed already. It was pointed out that this is a rather serious departure in principle from the provisions of the original Act and from the general type of intention, as expressed by the Minister already, enshrined in the general principles of the Health Act.

Minister for Health (Mr. MacEntee)

We are not accepting this amendment.

General Mulcahy

Can the Minister say on what grounds he is not accepting the amendment?

Mr. MacEntee

On the grounds which I have already set out at length in my Second Reading speech.

Mr. T.F. O'Higgins

The purpose of the amendment is to try to segregate in some way the charges imposed under the Bill on those entitled to services under Section 15 of the Act. As Deputies will appreciate, under Section 15 of the Health Act, 1953, there are certain categories of eligible persons, first of all, those entitled to free medical services whose right is evidenced by their being on the general medical service register; secondly, insured persons, which, of course, means all persons insured under the Social Welfare Act; thirdly, all persons whose yearly means do not exceed £600 and fourthly, farmers whose valuation does not exceed £50. There are other people also entitled to services under the Health Act but the Minister's proposal in this Bill is to impose on all those categories, except those entitled to free medical services, a charge of 10/- per day in respect of their treatment in hospital.

I said on Second Reading, and I felt very strongly, that this is going too far, too quickly. I could always understand that a case might be made in respect of some of these classes that a charge greater than 6/- a day might be imposed, but I feel that the Minister's proposal may inflict a very serious hardship on these categories of entitled people mentioned in the Health Act.

I shall just take the two classes mentioned in the amendment as an example. In the first place, let us take insured persons, and in this connection may I say that on Second Reading when I was speaking I inadvertently mentioned that roughly 800,000 insured persons were entitled to services prior to the Health Act? The Minister corrected me; I think from the record, I appear to dispute the Minister's correction but I would like to say that in that respect he was perfectly correct. Whatever the exact figure may be, my recollection is that prior to the Health Act, approximately 400,000 insured persons were entitled to specialist and hospital services without any charge.

These people had that right. Under the Health Act a change was provided. Under the Health Act an insured person whether in benefit or not—in other words, whether he had three years' stamps or not—was entitled to services, to specialist and in-treatment service in hospitals only at a charge of 6/- per day. Ostensibly, the specialist services were provided free but he was charged 6/- per day as an in-patient in hospital. There was considerable opposition to that charge and it became my responsibility, although I was not party to the legislation, to defend throughout the country the charge that was imposed. I defended it in precisely the same way as the Minister referred to it on the Second Reading of this Bill, to the effect that while the insured person under the Health Act was being charged 6/- per day for his hospital treatment he now had the advantage of having his wife and children also provided with in-patient treatment in hospital at a charge of 6/- a day——

Mr. MacEntee

I think the Deputy should emphasise that the 6/- to which he is referring is a maximum charge.

Mr. T.F. O'Higgins

I can assure the Minister, as I think the Minister will find very quickly, that the maximum charge of 6/- per day is the usual charge. I have not come across any case—there may be cases; I do not dispute it—in which anything less than the maximum was charged by any health authority. In any event, the defence which I made to every health authority in the country was that for the charge of 6/- now being imposed under the Health Act the insured persons received similar rights for their dependents.

I do not think that defence satisfied insured persons and those who spoke on their behalf throughout the country that this charge of 6/- per day was a reasonable one, but I would like to remind Deputies that this 6/- charge under the Health Act came into operation only in April of last year and accordingly it is a charge that is little more than 12 months in operation. If there are any Deputies here who are aware of the criticism that has arisen in the last 12 months about this 6/- per day charge, they can certainly recognise the justice of the suggestion I made on Second Reading that the 6/- per day charge was so recently in operation that it seems unjust now to increase it by more than 50 per cent.

If I still had the responsibility in the matter, I might have introduced legislation, once health insurance was available to our people, to increase some of these charges under the Health Act. I think I would have excluded from the effect of such increases all insured persons themselves and certainly the small farmer. I would have excluded insured persons for this reason. As Deputies will realise, when an insured person falls ill and has to go into hospital, his wage ceases in many cases and generally he is then drawing not a wage but a benefit under the Social Welfare Act. That benefit is then the only source from which his hospital maintenance has to be provided and his family have to be kept in food, the rent paid and so on. The purpose of this amendment, or one of its objects, is to ask the Dáil to say that an insured person, when he becomes ill and has to go to hospital, should not be charged any more than it was proposed to charge him in 1953 when the Health Act was passed.

That proposal is based on experience; it is based on a knowledge of the fact that when an insured person becomes ill in many cases he is not earning the fixed, or any, wage. He is depending on a social welfare benefit and, accordingly, my submission to the Dáil is that he should not be charged anything approaching the proposed charge of 10/- per day. I concede in the amendment, since apparently it is part of the principle of the Bill, that a charge of 10/- per day may be imposed on the dependents of insured persons if they get sick. Though generally I would be against it, I can see some case for it because if a child gets ill, presumably the father is still earning wages and possibly from those wages a sum of 10/- per day might be forthcoming. But I can see no case to be made for imposing this charge on a sick worker whose sickness may entail loss of income—a person who may become completely dependent on whatever social welfare payments he is entitled to.

The first object of this amendment, therefore, is to ensure that, under the Minister's proposals, the charge of 10/- per day will not fall upon insured workers in this State who themselves have to go to hospital, who themselves have to get hospital treatment and who, because of their illness or injury, lose their source of income. The second purpose of the amendment is to try to separate in some way that category of entitled persons who may be classed as farmers.

I propose in this amendment to ask the Dáil to say that in respect of each farmer and his dependents, whose valuation does not exceed £25, the old charge of 6/- per day should remain and that the new charge of 10/- per day should apply only where the valuation exceeds £25. Again, if there is to be an increase in the charge some effort should be made, even though it may be difficult, even though it may involve the Minister and his Department in some research, to ensure that the charge does not press unduly on different sections throughout the country.

All of us know that in so far as valuation of land is a yardstick of wealth and living standards it is a very faulty one indeed. There are landholders in different parts of the country who, holding land with a valuation of £50, may be regarded as being in a very good way of living while only 70 or 80 miles from him land of the same valuation may not be regarded as anything very extravagant.

I have endeavoured in this amendment to take a valuation of £25. I feel from my experience—and I have discussed this matter with, I think, every health authority in the country—that, taking a valuation of £25, it is safe to say that below that figure it would be a hardship to impose a charge of £3 10s. per week in respect of hospital treatment for the farmer, his wife or other dependents. Above that valuation figure a case might be made for the increased charge in respect of certain individuals. I bear in mind in the amendment that under the section proposed to be amended there is a general hardship clause under which the health authorities are entitled to remit charges if they feel a case of personal hardship has been established.

I seriously recommend this amendment to the Dáil. It is aimed at ensuring that a charge which may be unjust should not fall on all insured persons. The Minister has pointed out this is a maximum charge. I wonder will Deputies agreed with me when I say that while it may be a maximum charge, in relation to the 6/- per day charge it has worked out as the charge that will be imposed. Dublin Deputies know that under the Health Act in respect of a person who in any way exercised any sort of choice of Dublin hospitals the Dublin Corporation paid in respect of their treatment only a sum of £4 4s. per week which is, in fact, imposing on an insured person the 6/- per day charge.

Generally speaking, throughout the country all persons who may be charged in fact are charged the full rate under the Health Act. I do not think it would be quite fair of the Minister to ask those who genuinely have doubts about the wisdom of this charge to reject this amendment on the basis that the 10/- per day charge will not be imposed. Of course it will; it is intended that it will be imposed because the expectation is that £90,000 will be saved to the Exchequer. That sum cannot be saved unless health authorities throughout the country impose this 10/- per day. Certainly, that has been their practice up to this.

If it is done it means that certain workers in this city and elsewhere, who are troubled enough because of their illness, who worry enough because their wages have suddenly ceased, will have to face this charge of £3 10s. per week for their hospital treatment. Workers will find themselves with their wives and families having to exist on their social welfare benefit payment. I think that is wrong. I think that if the Minister is free to review his opinion he will agree that it is unjust. He will agree in respect of such persons that the other provisions of Section 15 are going to be invoked to suggest that no charge at all will be imposed. The purpose of this amendment is to suggest that no charge may be imposed in respect of such cases.

In relation to farmers, if the Minister proposes to charge all farmers in this country with a valuation of £50, 10/- per day, the purpose of my amendment is to suggest some half-way house, to suggest that the charge be imposed only on those with a valuation of over £25.

Mr. MacEntee

Let me first of all reciprocate the service which the Deputy has rendered to the accuracy of the knowledge which every Deputy should have of the conditions under which medical hospital treatment was given prior to the enactment of the 1953 Act. When we were debating that Bill on its Second Reading the Deputy made certain statements in relation to the position of insured persons. He omitted, as he has acknowledged to-day, to point out that treatment was given under very severe restrictions. First of all a worker had to have 156 stamps on his card. Secondly, it was given only for six weeks and thirdly, of course, it was not given to his dependents at all.

I should like to apologise to the Deputy because I said in the course of my reply to him on Second Reading that I had not heard him mention the term for which treatment is given. I now wish to say that the Deputy did point out that hospital treatment was for a limited term.

Mr. Dillon

If this civility goes on the Minister will qualify for hospital treatment.

Mr. MacEntee

And others will qualify also. Is it not rather extraordinary at the same time that the Deputy who was so conscious of the disability under which insured persons laboured in respect of hospital treatment prior to the enactment of the 1953 Act, should have been one of the foremost opponents of the Act? I know it did fall to his lot, under pressure from some of his colleagues and allies in the Coalition, to bring into operation certain provisions of the Act. In the course of the speech to which we have just listened he has been at pains to misrepresent the provisions of Section 15 of the Act. If you read his speech——

Mr. T.F. O'Higgins

Obviously the Minister will not qualify for hospital treatment.

Mr. MacEntee

If you read his speech it contains the statement that the maximum charge of 10/- per day would be the universal and general charge. Every second sentence contained that statement. It was an act of deliberate propaganda to misrepresent even yet the provisions of the 1953 Act and of Section 15 which conferred such great benefits not only on insured persons and their dependents but on other sections of the public as well. The Deputy learned this propaganda technique in a school where it has been brought to perfection; in a school which inspired the old Blueshirt movement.

An Leas-Cheann Comhairle

That does not arise on this Bill.

Mr. O'Sullivan

I wonder is there a doctor in the House?

Mr. T.F. O'Higgins

It is a psychiatrist he needs.

Mr. MacEntee

The Deputy learned under the able guidance of a person who said that if a he is repeated often enough people will begin to believe it.

Mr. T.F. O'Higgins

The Minister realises this is the Committee Stage. I can speak as many times as I like.

Mr. MacEntee

I heard the Deputy with patience, with a degree of patience that I found it hard to exercise. Let any Deputy get the report of Deputy O'Higgins's speech and he will see, as I have said, that Deputy O'Higgins repeated and reiterated time and time again——

Mr. T.F. O'Higgins

And I say it again.

Mr. MacEntee

——that the maximum charge would be the usual and the universal charge and then he went on to give his authority for that statement. He went on to say: "As far as I know that will be the situation." What inquiries did Deputy O'Higgins make in relation to the matter even when he was Minister for Health? I cannot find any record that this question was examined in my Department before I set certain inquiries on foot. I do know this. I have received deputations from health authorities in the course of which they said that the charge of 6/- per day was not the general and universal charge. I have made other inquiries since; more definite inquiries, and I find that, according to the estimates which are made and the information supplied to me, the maximum charge is not general and universal, that it is in fact an exceptional charge.

I have had a test check made in certain institutions here in Dublin and I find, first of all, that only one person out of four who comes under the provisions of Section 15 is charged at all. Does Deputy O'Higgins know that?

Mr. T.F. O'Higgins

Nonsense.

Mr. MacEntee

The Deputy says it is nonsense. I want to know what investigations did the Deputy make?

Mr. T.F. O'Higgins

Will the Minister answer a question?

Mr. MacEntee

I am going to finish my speech.

Mr. T.F. O'Higgins

The Minister is talking nonsense.

Mr. MacEntee

I have said now that a test check has indicated that only one person out of four was charged at all.

Mr. T.F. O'Higgins

Was paying?

Mr. MacEntee

Was charged under Section 15.

Mr. T.F. O'Higgins

The Minister will learn.

Mr. MacEntee

And of those fewer than 55 per cent. were paying the maximum charge. That is the position.

Mr. T.F. O'Higgins

You propose now to increase that charge to 10/-.

Mr. MacEntee

Deputy O'Higgins had the audacity to get up here and, as I have said, in every second sentence of his speech he tried to mislead the Dáil and the country by suggesting that this maximum charge, the maximum charge permitted, was the general, universal, and inevitable charge. That is not discussing the problem in a responsible way.

The Deputy also said that there had been considerable criticism of the provisions of Section 15 which permits the health authority to ask for a contribution from certain classes of patients towards the cost of their treatment in hospital. The Deputy said there was considerable opposition to the 6/-. No doubt, there was some opposition, but it was opposition which was fostered and inspired by the Fine Gael spokesmen at every crossroads in the country.

Mr. T.F. O'Higgins

Was it against me? I happened to be Minister.

Mr. MacEntee

Oh, no. That was the Deputy's get-out. It was not against Deputy O'Higgins. Not at all!

Mr. T.F. O'Higgins

I happened to be Minister.

Mr. MacEntee

It was against the Fianna Fáil Health Act——

Mr. T.F. O'Higgins

That I implemented.

Mr. MacEntee

——and the Deputy was held out as the poor innocent victim of the Labour element in the Coalition.

Mr. T.F. O'Higgins

The 6/- charge started under Fianna Fáil.

Mr. MacEntee

The Deputy was being held out as the poor young man who had to do what his Labour colleagues told him and operate the provisions of the iniquitous Health Act of 1953. Now his performance here to-day was not at all consistent with the attitude he and his colleagues—certainly his colleagues at any rate—took outside this House.

Following upon this misstatement that every insured person in hospital will be compelled to pay £3 10s. per week, the Deputy referred to a hypothetical case of an insured person who, by reason of the fact that he becomes ill, loses his job and he then went on to say that that poor man would be compelled to pay £3 10s. per week. I think the Deputy ought to take another look at the Health Act. If a person is out of employment, he has no income and one cannot take breaks off a Highlander—not even the Fine Gael Party could do that—and, therefore, if he has no income I do not think any health authority would have the audacity to try to collect from him £3 10s. a week, as Deputy O'Higgins has suggested they would.

Mr. Coogan

He is a patient, even if he is idle, is he not?

Mr. MacEntee

Let me try to make it quite clear now so that we shall not have any further misrepresentation in relation to this matter. These charges will not be imposed and will not apply to the institutional services provided for maternity cases, nor to patients receiving institutional treatment for infectious diseases, nor to pupils of national schools receiving institutional treatment in respect of defects discovered at school health examinations. I hope we are quite clear about that for we do not want to hear Deputy O'Higgins when he goes outside this House again making the same sort of misstatement as he made on Second Reading, when he implied that maternity cases would be affected by this.

Mr. T.F. O'Higgins

I did not say that. The Minister should contain himself. I never said that.

An Leas-Cheann Comhairle

Order!

Mr. T.F. O'Higgins

I never said that.

Mr. MacEntee

Wait till we see what the Deputy said.

Mr. T.F. O'Higgins

I never said that. The Minister should contain himself.

Mr. MacEntee

I am quoting now——

Mr. T.F. O'Higgins

If the Minister quotes me as having said that, then he is misquoting me. I never said that. I brought the maternity services into operation, and I know all about them.

Mr. MacEntee

I just want to make certain that these misstatements will not be repeated.

Mr. T.F. O'Higgins

Do not talk nonsense.

Mr. MacEntee

The misstatements which the Deputy will not believe now were made by himself—by him and his colleagues. I am quoting from Volume 162, column 38 of the Official Report. The Deputy was referring to the maternity service:—

"I am glad that service is now in operation and working successfully, but it is a general practitioner service, service based on the family doctor. If specialist assistance is needed, then, under this Act, a charge must be imposed, and I want to remind Deputies that whatever discretion is given to health authorities in respect of a charge for persons going into hospital, under this Bill, if it is not amended, it is mandatory on them to charge for specialist services."

That is what the Deputy said.

Mr. T.F. O'Higgins

Read it again.

Mr. MacEntee

Clearly relating the payment for specialist services——

Mr. T.F. O'Higgins

I said a general practitioner service.

Mr. Davern

The Deputy should take his medicine now.

Mr. T.F. O'Higgins

I do not mind taking my own medicine, but I object to that.

Mr. MacEntee

——and the charges which he alleged would be made for them to the maternity service.

Mr. T.F. O'Higgins

I never said that.

Mr. MacEntee

"I am glad that service is now in operation", and then he went on to say:—

"If specialist assistance is needed, then, under this Act, a charge must be imposed..."

Mr. T.F. O'Higgins

Oh, there is no hope for the Minister.

Mr. MacEntee

The Deputy may, perhaps, want to correct that statement.

Mr. T.F. O'Higgins

No, the statement can stand.

Mr. MacEntee

I only want to say that that is the Deputy as reported in the Official Report. I do not know whether or not the Deputy revised the typescript of the report—perhaps he did not. It is very difficult sometimes for Deputies or Ministers, speaking here, to be reported correctly, particularly when there is a crossfire of interruption coming from the Opposition Benches and, as I say, it may be an error in paragraphing; it may be that the whole of what the Deputy said was not caught by the reporter.

Mr. T.F. O'Higgins

Will the Minister let me ask one question?

Mr. MacEntee

But I am not pinning him down to that statement because, to me, it is inconceivable that any person who had been a Minister for Health could possibly have made it. I mention it now so that we will be quite clear that the Deputy did not intend to say what he is reported to have said, and I am quite prepared to accept that position. But I want to make it quite clear now that the charges for specialist services which are being provided for by the Bill are charges for specialist services under Section 15 only and these services, whether general practitioner, specialist or hospital maternity services will continue to be provided free of charge to the recipient. I hope we are all satisfied about that now and that we shall not hear this suggestion repeated.

Mr. T.F. O'Higgins

The suggestion the Minister made.

Mr. MacEntee

No, the suggestion the Deputy made. I have to take, subject to corrections which may be made in it later, the Official Report as being a correct report of what the Deputy said and I just want to nail that statement now and say that it is not true and I am glad to know, from the attempts which the Deputy has made to interrupt me, that he does not believe he made that statement.

Mr. T.F. O'Higgins

The Official Report does not show that I made it either. I went out of my way to say "the general practitioner service".

Mr. Corish

On a point of order. I wonder could this crossfire cease so that the official reporter will at least have a chance of getting the Minister's speech?

An Leas-Cheann Comhairle

That is scarcely a point of order.

Mr. MacEntee

I shall read what I have in front of me:—

"The Minister goes on to say that also excluded from these increases is the maternity service, that is, the general practitioner service. That is a service in respect of which I had considerable difficulty in providing something that would work——"

General Mulcahy

What is the Minister quoting?

Mr. MacEntee

I am quoting from column 38 of the Official Report of the 29th May.

General Mulcahy

And the Minister is quoting from Deputy O'Higgins?

Mr. MacEntee

I am quoting what is reported here. I am quoting the full text. Deputy O'Higgins is reported to have said:—

"That is a service in respect of which I had considerable difficulty in providing something that would work and be accepted by all. I am glad that service is now in operation and working successfully, but it is a general practitioner service, service based on the family doctor."

What does that really imply? When he said it was a general practitioner service based on the family doctor, he excluded by implication any specialist services that might be needed apart from those which the family doctor could provide. That is the implication. It may be the Deputy was speaking impromptu and I do not want to hold him to this, but I want to clear myself of the charge which the Deputy has made that I quoted something which he did not say. Then he went on to say this:—

"If specialist assistance is needed, then, under this Act"—

and here he draws a clear distinction between the family doctor service and the specialist service:—

"a charge must be imposed and I want to remind Deputies that whatever discretion is given to health authorities in respect of a charge for persons going into hospital, under this Bill, if it is not amended, it is mandatory on them to charge for specialist services."

That is what the Deputy is reported to have said.

Mr. T.F. O'Higgins

Will the Minister permit me to explain that reference?

Mr. MacEntee

I think I can take it that the Deputy did not mean it to be construed as I have construed it.

Mr. T.F. O'Higgins

The Minister, in opening, said that he was excluding the charges for specialist services in this Bill, under the maternity service, and I was pointing out this was a general practitioner service which could not be charged any way.

Mr. MacEntee

I was pointing that out already. I did point it out and I emphasised it. The reason I am dealing with this point now is that the Deputy stood up and referred to my statement in such a way as would lead people to believe that even in respect of the maternity service we were making it mandatory on the health authority to charge for specialist services. That was the implication of that statement. However, the Deputy says he did not mean that, that he does not intend it to be read in that way, so that matter has been cleared up. I am satisfied. I hope that we shall not hear that statement repeated outside this House——

Mr. T.F. O'Higgins

I will repeat it because it is not capable of the meaning the Minister has given it.

Mr. MacEntee

——or used for propaganda purposes against this Bill. Having dealt with the arguments which have been used in support of the amendment, let me come to consider the amendment itself. Under Section 15 there are four categories of patients who are entitled to benefit under the section. The Deputy's amendment proposes to subdivide those categories further. He tries to draw a distinction between an insured person, on the one hand, and the dependent of an insured person on the other. He tries to draw a distinction between a farmer who owns land the valuation of which exceeds £25 and does not exceed £50, and the farmer who owns land the valuation of which does not exceed £25. That introduces quite an unnecessary complication and a complication which would make the administration of the Act most difficult and expensive. I think that one of the reasons why this has been done is to increase still further its unpopularity with the health authorities which the Deputy alleges exists.

I do not think the Act is at all as unpopular as Deputy O'Higgins would like it to be, but I know it would certainly be more unpopular with the ratepayers and the local authorities if, instead of having to deal with four categories of patients under Section 15, they had to deal with at least six categories. We would have more red tape, more application forms, more disputes with the manager in relation to each one of these categories. Is that the purpose for which this amendment was put down? I suggest that this was at the back of the Deputy's mind, that by making the position more complicated it would intensify such opposition as there might be among health authorities to the operation of the 1953 Act. As I have said, I do not for a moment believe that the Act is as unpopular as Deputy O'Higgins suggests, but quite obviously the purpose of creating these additional categories is to make administration more difficult, more expensive and more vexatious.

Apart from this aspect of the matter, let us consider what the Deputy proposes to do by his amendment. The Deputy who is so concerned about the position of the insured person comes in here and proposes to put the insured person in a less advantageous position than some of the other categories which he is content to allow to stand as they appear in Section 15. Under the Deputy's amendment there might be an insured person earning, say, £300 a year, £6 a week in round figures. He might—I say "might"— have to pay 10/- a day if he were in hospital but that would be because he would have other resources. Deputy O'Higgins, however, takes the view that he would have to pay 10/- a day. The whole burden of his speech was that this insured person would have to pay 10/- a day so long as he himself or any dependent of his was in hospital. That is the general purport of Deputy O'Higgins's amendment. On the other hand, there might be a small shopkeeper earning, say, £599 a year and a dependent of his, under Deputy O'Higgins's amendment, could not be charged more than 6/- a day. So, here we have a Deputy, those heart is brimming over with consideration and sympathy for the unfortunate insured person, putting him in this situation that he would have to pay 10/- a day —the Deputy said he would have to pay 10/- a day; £3 10s. a week—for a dependent of his so long as that dependent was in hospital, even if the insured person's income did not not exceed £300. On the other hand, a shopkeeper with the resources of property and other things behind him and the certainty of an income derived from trading, if he had an income of £599 and had a dependent in hospital, would have to pay only 6/-. I suggest that all this is contrary to natural justice and that there is no purpose in this amendment.

The real purpose of the amendment was just to muddy the waters and to make propaganda against the Bill because, if there really had been serious consideration given to the effects of the amendment, I doubt if Deputy O'Higgins would put it down. Therefore, on those grounds, I ask the House to reject it.

General Mulcahy

The Minister has tried to clear a lot of things but in the general confusion that he has introduced here. I should like to get clear on one point. In the early part of the Minister's statement he attempted to rebut the suggestion that this additional 4/- would really be charged. I should like to get clear on that.

The Minister indicated when he was introducing this measure that £90,000 a year would be saved to the State and that £90,000 a year would be saved to the local authorities. That implies to me that somebody will pay the additional 4/- in respect of 900,000 patient days. The implication is that the additional 4/- will be charged for about 2,460 patients spending the whole of the 12 months in hospital. Can we be clear on that, that is, that the extent to which the additional 4/- a day will be charged will be the charging over the full year of 4/- a day for 2,460-odd patients?

Dr. Browne

There are a few small points arising out of the debate. In regard to the remark of the Minister on the question of the shopkeeper with all the resources of his shop—I know I am not quoting the Minister verbatim—that it would not be right that he should not be charged, that it would be contrary to natural justice if he were not, I wonder would the Minister expand that thesis a little for us and tell us, if that is so, why is it that the magnificent provisions of the 1947 Health Act which the Minister helped to frame, I have no doubt, and which his colleagues helped to introduce, contained a number of clauses, all of which, according to him now, must have contravened the law of natural justice in so far as in relation to the fever hospital treatment regulations, the infectious diseases treatment regulations, the tuberculosis treatment section of that Act and, of course, the famous mother and child provisions, the Act contained a free no means test provision which lays down that a person gets treatment in hospital irrespective of income, family income or personal income? The result is that there are throughout the country at the moment in all our tuberculosis hospitals and sanatoria and fever hospitals and to a certain extent in our maternity hospitals, shopkeepers, wealthy persons, who are being treated under the provisions of the 1947 Health Act of the Fianna Fáil Party, a magnificent Act which, as I have said before, any Government would be proud to have introduced.

Are these people who are in hospital in any way contravening the law of natural justice, whatever that may be? I am very vague about it. The Minister may know about it. He may know more about it now than he did in 1947 when he allowed these things to go through. Does he intend now, in order to remedy the offence to the law of natural justice, to remedy it in respect of these other services and introduce charges of some kind or other in relation to tuberculosis services and fever hospital services generally?

Does the Minister now want to backtrack on the magnificent provisions of the 1947 Act as he is backtracking on the relatively conservative provisions of the 1953 Health Act and does he want now to introduce charges in order to catch the wealthy shopkeeper or other wealthy person who is at present benefiting from the provision of these services?

It would appear to me to be a logical conclusion to the argument he used a moment ago that he should now try to seek out all those people and try to remedy the position in relation to the law of natural justice which he says is offended if a person who can pay does not pay. If a person who falls ill, goes to hospital and gets treated and does not pay if he has money, then this in some way contravenes this curious law of natural justice which applies in health services and which does not seem to me to apply in so many other of our services, whether the service is free fertilisers, lime and so on for farmers or the hundred and one amenities that people get to help them— children's allowances, Small Dwellings Acquisition Act loans and all these other amenities which people get without means test. Are all these people contravening the law of natural justice if they get these amenities from the State without being subjected to a means test and if they have money and, superficially, do not appear to need the grants or concessions from the State?

This, of course, is a very important point because it was one of the main arguments used by the present Opposition against Fianna Fáil when they were trying to introduce the 1953 Act and when at one time I was trying to introduce the mother and child provisions of the Fianna Fáil 1947 Health Act. Has the Minister gone over to the Opposition? Does the Minister now share in this point of view that free health services are contrary to the law of natural justice or that the principle is in any way vitiated or offended by giving a person a health service which he can pay for himself? Does he now in any way wish to repudiate on behalf of Fianna Fáil or do Fianna Fáil wish to repudiate, the free, no means test principle of their 1947 Act? Is that the point he is trying to make now in his suggestion that the wealthy person who can pay for health services should pay for them in order that we may keep intact this curious, amorphous, confused thing, the law of natural justice?

The Minister has made a point in reply to Deputy O'Higgins that there is only a negligible number of people paying the full 6/- at present. I will accept his very small number. A small series of cases were investigated to find out whether they were paying the full 6/- at present and whether the local authorities were using their discretionary powers to reduce that charge in certain cases.

In the first place, I do not know whether this argument merits the vehemence with which the Minister used it to refute Deputy O'Higgins's suggestion that the charges are nearly invariably 6/-. I have no figures at all to go on, but from what one hears, while the 6/- may be a discretionary charge it appears to me to be the standard in use at the moment. The Minister has produced this series of cases to show that only in a negligible number of cases is the full 6/- charged. I am giving only my impression and I do not wish to appear to be in any way dogmatic about it, but I get the general impression that Deputy O'Higgins is nearer the truth when he says that, on the whole, 6/- is the usual charge made by local authorities.

I think that whatever was the case in Deputy O'Higgins's time it is more likely in the present Minister's time that the full charge will be made, particularly when one recalls the answers to questions one hears in the House in which, by implication, the Minister appears to criticise or chide the benevolent-minded managers, the managers who know conditions particularly well and who tend to err on what I call the human justice side that seems to come into these things so very little, through consideration and ordinary human understanding of the personal problems, the financial problems, of the average unfortunate person faced with sickness or ill-health and the insecurity that follows.

I recall one remark of the Minister's in which he appeared to give the general impression that he did not want this soft-heartedness of the managers and it appeared that he wanted them to deal with such cases in a very rigid way so that if a particular charge was recommended, that was the charge he would prefer to have charged. If however, he wishes to undo the impression that I have in my mind, at any rate, through listening to him here, and to undo the impression he made in this House, I hope he will do it, and tell the managers that he would prefer them to err on the side of being thoughtful for the problems of the family in sickness, that he would treat with sympathy and consideration any decision of a county manager which appeared to err on the side of being generous rather than on the side of being stringent and harsh and that he would, as Minister, prefer that all these claims for health services were considered in a generally sympathetic way and that that would be his attitude to it.

That is of great importance to managers and health authorities generally. They are bound by the headline set by the Minister to a considerable extent and where they have a generously-minded Minister who is sympathetic to their anxiety to provide good health services it makes a great deal of difference to them. It gives them some support in coming to a decision which might not be in accordance with the absolute letter of the law but which would be in keeping with the spirit of the law as we send it out from here to give as good health services as can be provided under the circumstances.

I wonder when the Minister was thinking about this matter of increasing the charge and looking for a tax— because I insist that it is a tax, or at least one form of it; essentially, it is another form of taxation on the less wealthy and the poor who are already hit by the Budget—when he was thinking of the £90,000 he intended to get, an infinitesimal sum compared with the vast £100,000,000 Budget and because of that it seems all the more inexplicable why he should go for it at the expense of the sick—when he was considering this question, did he have in mind, or was he going on the assumption which he has used here to refute the argument of Deputy O'Higgins, that only a very tiny number of people pay the relatively small amount charged now? I think 25 per cent. was the figure he gave. When he was assessing the amount that would come from the increase from 6/- to 10/-, when he tried to assess the amount available from this increase, did he assess it on the assumption that only about 25 per cent. or so of the people trying to avail of the Health Act would be charged? Or did he assess it on the assumption that a higher number of people would be charged for health services under the present Act?

If he is basing his assumption on a contention that the apparent position is that only 25 per cent. of the persons are charged, then that seems to me to be a very dangerous, or courageous assumption, if you like, to base it on the very small series of cases from which he has derived this information, a relatively small series of cases from which he has derived his information? Is he, in assessing the amount he is getting, deciding that only a relatively small number of people are charged under the Health Act or is he basing it on Deputy O'Higgins's assumption that a very large number are charged the full sum under the Act? Will the figure be in the region of 25 per cent. as suggested by the Minister? Will the number of persons charged 10/- be in the region of 25 per cent. or so, as suggested by him, or will it be in the region of 100 per cent., as suggested by Deputy O'Higgins? To those of us who talk very much to, or have any contact with, the average person it seems the impression we have is that the permitted charge is the standard charge. Is the Minister going on the assumption that the permitted charge will be the standard charge or not?

I wonder did it mean anything to him, did it make any impression on him, the fact that such a tiny percentage of people were charged the full 6/- by health authorities? Did it not enter his mind, and did he not accept, or could he not accept, the reason why there is this small figure, or this apparent small percentage of people who paid the full 6/-? Is it not merely an indication of the fact that only a relatively small number of people can, without great hardship to themselves, pay any charge——

Mr. T.F. O'Higgins

Hear, hear!

Dr. Browne

——in relation to health services, any charge of this nature? And because of that, because of the information he has received that a relatively small number of people are chargeable under the Health Act in the opinion of the health authorities, surely that is one very good reason, a most compelling reason and indication against increasing the charge? If anything, it is surely a case for eliminating the charge and not increasing it. How can he justify increasing this charge when he already knows the health authorities find that only very few people can pay even 6/-?

Instead of that, it has been increased by over 50 per cent. That seems to me to be the act of a completely unreasonable person. However, the Minister may have an explanation for doing what he has done here. The main case made by Deputy T.F. O'Higgins was, to my mind, when he talked about the worry of sickness, the uncertainty of employment which sickness brings about, the difficulty of knowing how long a person will be sick, whether his job will be waiting for him when he gets better. These questions seemed to me to constitute a familiar argument, the sort of arguments with which we became familiar from Fianna Fáil in the past. They were the arguments I made when I was pleading for the complete elimination of any charges for good efficient health services for the people. They were arguments which must have been used before my time in the House in order to put through the tuberculosis provisions of the 1947 Act.

They are all compelling arguments; all are arguments that have been borne out by the magnificent results of the 1947 Health Act under which we have a fine, efficient, well-working and just health service. The arguments of Deputy T.F. O'Higgins to-day could well be applied not only to a proposal to reduce the charge from 10/- to 6/- per day but to eliminating the charge altogether. As I have said, these are arguments which anybody who knows very much about health services generally will understand as being most real, telling and compelling.

That the charges should be increased to 10/- per day is indefensible. I maintain there should be no charges at all. I believe that was the system Deputy Dr. Ryan had in mind as Minister for Health when accusations were made against him that the Health Act was not going far enough. Certainly the amendment is an improvement. I believe the arguments made for it by Deputy T.F. O'Higgins are cogent ones. However, I believe this amendment does not go half far enough. The only way that this Act could give us a proper health service would be through the complete elimination of these charges—the extension of Fianna Fáil's plan under the 1947 Health Act in relation to fevers, infectious diseases and, to a limited extent, to child, maternity and infant schemes. I do not think there is any question of such a scheme interfering with what the Minister has called "natural justice".

Mr. MacEntee

I think I should follow Deputy Dr. Browne immediately because I think he misunderstood something I said in regard to the statement of Deputy T.F. O'Higgins in relation to this amendment. I did say that the proposals in the amendment were contrary to natural justice and I proceeded to point out why. On the hypothesis put forward by Deputy Dr. Browne's interpretation of the amendment, an insured person whose income was, say, £300 a year, would have to pay 10/- a day for every day that a dependent of his was in hospital and, on the other hand, a shopkeeper with an income of £599 19s. 11d. derived from his business would be called upon to pay at most 6/- a day for a dependent of his.

I said that an amendment which sought to do that was contrary to natural justice. It was only in that context that I used the phrase "natural justice". I do not want to get into a general debate here on the merits or demerits of the means test. That issue was decided by the House when it adopted the 1953 Act. This Bill proposes only to amend the 1953 Act on what is a comparatively minor issue. Therefore, I do not propose to try to refute the arguments which Deputy Dr. Browne used when he touched on that particular aspect.

I think there are a couple of other things I ought to say in order to make my own position clear. I do not regard taxation as an advantage. In general, like most people, I feel it is an evil which we should try to minimise and eliminate as much as possible. And when one asks a person who is in a position to do so to contribute towards the cost of a service which is provided for him, that is not taxation. Its nature is fundamentally different. Taxation is a tribute exacted from the general mass of the people in order to provide general services. This is a charge made for treatment received, for the upkeep and maintenance of persons in institutions.

How can that be called taxation? If a person who could afford to contribute were free to go into any institution— we will not talk about hospitals—and if he were to receive free all the benefits and advantages which that institution could confer upon him and if, at the same time, the general mass of people were to be taxed in order to maintain that institution, that is likely to cause hardship to many of those who are taxed. If a person who can afford to contribute towards his maintenance in such institutions is asked to contribute, I think it is better and more equitable, fairer and more just that he should be asked to make that contribution rather than that the entire cost of the services provided by that institution should be put on the backs of the mass of the people, those who are in the lower income groups.

That is my position anyhow. There is no question of taxing the sick or anything else. It is merely a question of asking a person who can pay for a service, or who can contribute some part of the cost of the service, to make the contribution in fairness to the general community and in fairness, particularly, to those who compose the greater part of the community, those who are in the lower income group.

Deputy Dr. Browne, I think like myself, tends to exaggerate his point of view. I did not suggest that it was only wealthy shopkeepers were concerned when I was discussing the merits of Deputy O'Higgins's amendment. I did not use the term wealthy shopkeepers in the way he has suggested. He has used it on a number of occasions to reinforce his argument. I said they were in the upper limit of the middle income group. I referred to a shopkeeper who had an income of £599 per annum derived from trading in his shop. I do not regard that person as a wealthy person and I am sure Deputy Dr. Browne does not regard him as such either. I do not know, but I suppose he may have in reasonable comfort if he manages his affairs prudently, but I do not regard him as a wealthy person. I do not see any point in obscuring the issue in this debate by using that adjective "wealthy" and by applying it to people in that class.

I did not say that it was a very tiny number of persons who will be affected by this Bill. I was addressing myself solely to the argument used by Deputy T.F. O'Higgins that this maximum charge was the general and universal charge. I did not suggest that there would not be an appreciable number of persons affected by it. I did not say there would be a tiny number of people affected by it, but I did say these would be a very definite minority of Section 15 cases. I said that on the basis of such information as I have been able to procure since I had the matter investigated. I did find that in the City of Dublin the number of Section 15 cases who have to pay is very much fewer than 25 per cent. of the total number covered by the provisions of Section 15.

Let me say this, and it indicates what the general public attitude is towards this issue. Over 40 per cent. of the patients under Section 15 make payment voluntarily, willingly and readily without pressure being brought to bear upon them at all. That is the general attitude of the self-respecting citizen towards this question. I think it is an attitude which is to be commended because it shows that we have still self-reliance in our people and that it is not being sapped by the frequent suggestion that everybody is entitled to get everything for nothing.

Another issue raised by Deputy Mulcahy and Deputy Dr. Browne was in regard to this question of £90,000. There is more than one section in this Bill. I did not at any time suggest, that by the operation of Section 1 only, I hoped to get something between £70,000 and £90,000, that I hoped to save the community something between £70,000 and £90,000, the community as taxpayers, and a similar sum to the community as ratepayers. I did not say I was going to get that out of Section 1 of the Bill.

Mr. McQuillan

Is that £90,000 for the remainder of this year?

Mr. MacEntee

For a full year. I mentioned £90,000 but what is involved is £180,000 which will be shared between the ratepayers on the one hand, and the taxpayers on the other. If you can differentiate between them you are welcome to do so. I do not think any great hardship will be imposed on any person. It will depend on whether the persons affected by the Act can afford to pay these sums or not. If it is found, on investigation by the health authorities, that they cannot afford to pay them then we shall not get the £70,000 or £90,000 which we think the provisions will allow. We shall not get it if they cannot afford to pay it and there will be no undue pressure brought to bear on the managers or anybody else.

They will be expected to operate this Act with full consideration of the circumstances as they discover them. I am perfectly certain that no responsible person will act harshly or with undue severity in a matter of this sort. My general experience of all administrative people is that they give the benefit of the doubt wherever they can. They give the advantage, wherever they can, to the citizen. There is no use in anybody getting up here and trying to pretend that county managers, city managers or other officers are out to penalise or grind down in any way those who have to take advantage of Section 15 of the Act.

The figures I have given here after actual inquiry, a limited investigation if you like, indicate that in this large City of Dublin the Act is administered fairly, justly, and equitably, as between the individual who can afford to pay something and the general community that has to meet the deficiency if he is not able to pay the full cost of his treatment.

It is not unusual for us who are in public life to receive many representations about alleged hardship, and alleged influence in the administration of statutory provisions. There may be a genuine hardship case where some aspect has been overlooked when it was being dealt with; but you will always have a very great number of people who believe that members of public authorities, members of the Dáil and Ministers are able to influence decisions in their favour, even when the merits do not warrant any intervention on the part of the public representative or the Minister. That is well known. We shall always get the man who believes that if he can get his case put by a Deputy or a county councillor he will be able to have the balance tilted in his favour.

That does not mean that because people come along and say this is what is being taken as the general universal practice we must not be careful in these matters. We must draw a very clear distinction in our own mind between what is told to us by an interested party and what we can ascertain by actual investigation. Therefore, I am quite satisfied in relation to Dublin, and I am reasonably satisfied in relation to the rest of the country, that the maximum charge is seldom imposed upon any person who has to have institutional treatment.

Mr. T.F. O'Higgins

I want to remind the Minister who has just concluded on a note of sweet reasonableness that he is not the man who spoke a short while ago against the amendment which I put forward. I tabled the amendment in accordance with my rights as a Deputy of this House. It was intended to be helpful to the Minister and the House. It was intended to prevent what I regard as an injustice being imposed upon the workers throughout the country and upon small farmers.

The Minister was pleased in his reply to impugn my motives in putting down that amendment and suggested that my purpose was to make the administration of the health services under the Health Act more unpopular. He was pleased to suggest that I was in some way opposed to the administrational services under the Health Act of 1953. I will not yield to anyone in this House in relation to the actual work I did as Minister to provide that these services would operate.

As Minister, I accepted in full the need for the services under the Health Act and I made it my concern to see that they were not merely promised but were provided. It is because I am firmly convinced that the Minister is acting impetuously and hastily in this Bill that I have endeavoured in some way to prevent some of the injustice that his Bill proposes falling upon sections who are least able to meet it. The Minister in a very airy way talks about different examples. I would not blame Deputy Dr. Browne thinking the Minister meant in his reply that a shopkeeper who earned £599 a year was a person of affluence and standing.

I am quite certain that an insured worker who falls sick cannot afford to pay £3 10s. per week. I do not care what inquiries the Minister may make, or what information the Minister may have at his disposal, the fact is that such a bill cannot be met and the proof comes from the Minister's own mouth. With regard to the 6/- per day charge on workers in this city and throughout the country in the past 12 months under the Health Act of 1953, the Minister says that fewer than 25 per cent. pay. Of course fewer than 25 per cent. pay because fewer than 25 per cent., according to the Minister, are proved to be able to pay. This is 25 per cent. of the eligible persons under Section 15.

In the name of Heavens what is the sense of this Bill? Is it to charge that 25 per cent. more? Surely we should recognise that the 6/- a day has been proved difficult to meet, particularly I suggest where a worker becomes ill. I did not suggest that he would lose his employment but his wages may cease and that worker, on the Minister's figure, is unable to meet the charge of two guineas per week. I think it is asking this House to be more than patient to suggest that when the record of 12 months had shown that only one person out of four is able to pay 6/- that, therefore, the solution is to charge everybody 10/-. That is certainly arguing ad absurdum but those are the Minister's own figures.

Without having the information ready to me that the Minister has, I know from my experience in different parts of the country that, in fact, this discretionary charge of 6/- per day is sought in every case unless the person is a holder of a medical card and, therefore, demonstrably entitled to free medical services or unless the person concerned is otherwise entitled to free medical services under the Health Act. In the first instance, the full hospital charge of 6/- per day is demanded. It then becomes a case of who can convince the strongest in order to see what the bill may be settled for.

Certainly the people who complain to me are not persons interested in it but rather persons who are interested in the general administrational services. They tell me, in fact, that in most cases the money sought is secured. I think it is a pity that we are not enabled to discuss this amendment. I do not say the amendment is perfect but it is an effort genuinely conceived to ensure that a hardship would not be imposed. I think it is a pity it cannot be so received by the Minister.

I think it is absurd that we should have the Minister bringing blue shirts and all the rest into this debate. What are we here for? Are we going to get any sanity in our discussions here? My motives were genuine motives, designed to ensure that the administration of the health services in this country would proceed normally and rationally and that a Minister merely for the sake of some budgetary consideration would not proceed to impose that potential charge or tax which in many cases might mean considerable hardship.

When the Minister proceeds to reply to my proposals and say that what I say is nonsense, because practically no one is paying this charge, anyway, the Minister is answering himself in the most effective way. In fact, it is proposed to raise £180,000 by this Bill. That is not chicken feed—£180,000 as applied to all the eligible classes under Section 15, holders of medical cards who remained and who represent 30 per cent. of the population. It is proposed to raise £180,000 from those people and from the small charges imposed for specialist services. In fact it is expected—I believe the Minister knows it—that the majority of entitled persons under Section 15 will now pay 10/- instead of 6/-.

I have no ready figures available to me but I know that to raise some £180,000, or something less than that, on hospital services alone, will certainly mean that over 2,000 hospital beds in this country will be occupied for the year by patients who will have to pay 4/- extra. I do not believe it is taking this House properly into his confidence for the Minister to advance a whole number of different grounds in defence of this proposal. Either this is a measure designed to save the taxpayer and the ratepayer a total sum of £180,000 or it is not. If it is aimed at saving £180,000 then it is certainly designed to ensure that the majority of persons entitled to hospital services under Section 15 will pay henceforth 10/- per day instead of 6/-. That seems reasonably clear. But the Minister is not prepared to say that. He is quite content to bat on different kinds of wickets. If he is faced with that charge, he says: "Very few people paid this charge up to this. Therefore, there is no injustice." If that is so, this Bill is completely unnecessary.

If so few people up to this are paying 6/- per day, why is it necessary to consume the time of this House with this unnecessary legislation? Why all this trouble and why add further to the difficulties I hoped might be over by bringing in legislation which is going to be effective only for a very small percentage of those against whom it is aimed? I think that would be a reductio ad absurdum. Therefore, I do not believe it and I am quite convinced that this is intended to be a genuine charge.

The Minister knows it is expected that this charge will yield £90,000 to the Exchequer by way of a saving and the same amount to ratepayers. If I am incorrect in that, I shall be interested to see the manner in which the Minister's Estimates are framed for next year. I shall be interested to see whether a saving will be taken to this extent in the administration of health services next year. I am certain such a saving will be taken because the Budget statement of the Minister for Finance takes that saving already. There is no question of any conjecture about it. The framework of the Budget is based on the fact that this money will be saved and, whether the Minister for Health likes it or not, he is told by the Minister for Finance that £90,000 must be provided by way of saving under this heading. Therefore, what is the sense in coming in to meet this amendment and suggesting it is not necessary, that these charges will not be imposed, that they are not imposed and that, in fact, only a small section of the community is affected?

I put down these amendments. I believe in them. I made it clear both in Government and since, in opposition, that I am firmly convinced that some increase in charges might be necessary under the Health Act for those who might be regarded as able to pay. I would only have done so if an alternative means of providing for their own health services were available. The Minister does it now.

The Health Insurance provision may be available in the near future but it is not available at the moment. The Minister does it without attempting to segregate who can and who cannot afford it. This amendment is designed to ensure that the charge will not be a general one and that those whom a Deputy of this House can in the short time available try to distinguish in some way may not have to pay.

Deputy Dr. Browne supported some of my arguments in proposing this amendment. I was somewhat horrified to find him saying that my arguments were pointing in a direction in which certainly they were not intended to point. I should hate to think that anything I have said in this debate or on the Second Reading, or anything I am likely to say on health services, could ever be regarded as a support for the theory that any person in this country, irrespective of his means and standing, is entitled to free health services. I do not subscribe to that view. It is a degenerate view and one which is contrary to our character and outlook in this country. It has always been part of our tradition here—whatever may be said of other people—that we like to pay our way and stand on our own feet. I have no sympathy whatsoever with those who think that health services in this country and our health problem can be solved by establishing some paternal State that will look after all of us from the cradle to the grave. Once we embark upon that, we shall end in doing nothing.

Free health services are never free. They all have to be paid for eventually. I should far prefer to see encouraged amongst our people a spirit of self-reliance and a belief that each one of us, to the extent we can, would attempt to solve our own problems. It is because I believe that this kind of proposal in this Bill may eventually lead to more supporters for Deputy Dr. Browne's views that I am so concerned about it. The administration of the Health Act has been difficult. It was a new Act and a difficult Act dealing with many complexities. To my bitter cost, I know how easy it has been to magnify difficulties to quite an unwarranted degree.

An Ceann Comhairle

I think the Deputy would agree that we should not open the question of the administration of the Health Act.

Mr. T.F. O'Higgins

Perhaps, in passing from it, I might be allowed to say it is a pity that, under the Minister's proposal, a great number of people who were entitled to benefit under Section 15 of the Act will now believe they are being unfairly treated —that they have to meet a fresh charge when they have only begun to be accustomed to the idea of a charge at all. That may have the inevitable result of a feeling of irresponsibility and a feeling that the proper solution is no charge for anyone, irrespective of what his standing, position or income may be.

I think that would be a considerable disservice to our people. I would say very sincerely to the Minister that he should reconsider the stand he has taken on this amendment, that he should regard it, if he feels free to do it, as an amendment designed to help him and help the administration of services here and designed to prevent an injustice which I believe is taking place. He should accept the amendment and accept the principle behind it.

Dr. Hillery

Some speakers have given the impression, whether they intended to do so or not, that the Bill proposed by the Minister would extend to other people the charges now being made under the Health Acts. They gave the impression that a bigger number of people will now be subject to these charges. I do not think that is intended in the Bill at all. What is to be considered is that the people who are now deemed to be able to pay up to 6/- a day may be deemed, after the passage of this Bill, to be able to pay up to a maximum of 10/- per day. Deputy O'Higgins said that where before only one in four was considered to be able to pay, now everybody would be made pay 10/-. I do not think that is intended in the Bill at all.

It is a spurious argument to say, as Deputy Dr. Browne said, that because a small group only were liable to pay, therefore, they are not well able to pay. It is no indication at all of the capacity of a person to pay his debts to say he belongs to a small group. It must be clear that if a man heretofore was deemed by his local authority not to be able to pay up to a maximum of 6/-, he will be deemed now not to be able to pay, even though the maximum is 10/-. Therefore, these people will not be asked at all. I do not know whether that argument was put forward on purpose; I hope it was not.

I think it unfair to suggest that, because these charges were accepted in principle in former Health Acts and are now being increased, the time may come when charges in the fever hospitals and tuberculosis hospitals will also be made. It must be clear that there is a public responsibility in relation to infectious diseases. It serves the public well to pay for the individual's care and isolation in the case of infectious diseases. Therefore, it is and must be regarded as a public responsibility. As the present Acts, which are being amended, relate to the individual responsibility, the public responsibility does not enter to the same extent. It is most unfair to suggest that the Minister's action now is paying the way for making charges in relation to infectious diseases and maintenance in hospitals.

Anybody who has argued against the Bill has made sure that he did not refer to the charges which could be made as being maximum charges, and he certainly did not give any credit to the local authorities for their administration of the Acts. The only change is in the maximum amount payable. There is no change in the number of people to be affected. Certainly the poor are not to be affected by this. This House seems always to land on top of the poor when arguing against anything. The people to be affected by this Bill are those who are able to pay. They will not be a further burden on taxation, to which the poor subscribe. Therefore, it is exactly the opposite of attacking the poor.

Mr. McQuillan

I want to put myself on record here as being opposed, first of all, to the Bill and also as not supporting this amendment by Deputy O'Higgins. Personally, I am against the idea of these charges. I shall not speak at any length on many of the points raised here by Deputies on both sides. The only important point that emerges is the absolute agreement between the Minister and the ex-Minister on this question of policy. As far as this is concerned, they are absolutely at one. It does not make the slightest difference who sits on the ministerial bench at the present time. I have often used the expression, "Tweedledum and tweedledee" but on this occasion I think I will say that the Irish people are caught between the devil and the deep sea. It makes no difference whether it is Fine Gael or Fianna Fáil, when it comes to health services or any other services.

This amendment is to ensure, according to Deputy Dr. Hillery, that those who can now pay 6/- per day for hospital services will pay instead 10/- a day. Mark the philosophy of people who bring in that type of legislation. Those who are ill are to pay more for their treatment while those who go to the races and gamble will have to pay less in taxation. Is that not an extraordinary outlook in this civilised, Christian community?

The Minister has stated that a sum of £180,000 will be saved, on a 50-50 basis, perhaps, to the ratepayers and to the Exchequer. The purpose of this measure—let us be quite blunt about it—was to save that. It is a form of taxation, if you like. It is saving the Exchequer handing out a further £90,000. We have that type of weak legislation in the same Budget in which the colleague of the Minister for Health, the Minister for Finance, says to the Turf Club and the Racing Board, "Here you are, gentlemen. I will not charge you £140,000 this year for stamp duty. That is the figure I took off you last year. I am handing it back to you this year." When it comes to gambling and driving around the country in big motor cars for the luxury of race meetings, we find that the imposition on those gentlemen last year, in the form of special stamp duty, had to be removed in the Budget. It was removed silently. There was not a "peep" out of any Deputy on the Fianna Fáil Benches when it came up. While that is being passed, we have at the same time the case put forward that those who are ill must pay more for treatment.

Deputy O'Higgins expressed himself as horrified that some of the arguments put forward by him would add to the case made by Dr. Browne for the complete removal of these charges. If Deputy O'Higgins takes time off next week to read the debate and read his own contribution, he will see quite clearly that, if there is any logic in his approach to it, that is where his argument would lead. There is only one way out of the difficulty these people have been led into over health services and that is to get rid of all these charges. In the long run, it would be a lot less expensive than setting up a horde of officials, inspectors and investigators to examine into the very private concerns of every family in the State. This type of legislation demeans and attempts to demoralise the community.

The amendment put forward here by the former Minister is a further attempt to demean and demoralise the rural community, with a further limit in connection with the 25 valuation. The extraordinary situation was that the Minister himself put forward the best argument against Deputy O'Higgins's case, that if we accept his suggestion about the £25 limit for the farmer, it will mean further investigation, more inspection and possibly an increase in the number employed on these inspections. That is the argument put forward by the Minister.

The fact is that home assistance officers and investigation officers are going full tilt all over the country, examining the credentials and accounts in connection with people under care in hospitals. There is an army of those officials at present and I do not want to see that army added to.

Deputy O'Higgins is very fond of telling the House that the Irish people are self-reliant. The Deputy is able to stand on the backs of the 750,000 who have left the country and who are glad to get the socialised health services available outside this country. I suppose he is critical of the large sections of the Irish population which he and others helped to drive out, owing to his lack of responsibility and that of others, in regard to their duties, whether in office or not.

Mr. T.F. O'Higgins

Including the Deputy.

Mr. McQuillan

I do not know, but I will do my best, at any rate, to expose the hypocrisy and sham which goes on here in regard to health services.

Mr. T.F. O'Higgins

The hurler on the fence is the best hurler.

Mr. McQuillan

It is hard to know which side of the fence to get down on here.

Mr. O'Sullivan

It is easier to come down on both.

Mr. McQuillan

I would rather stay on the fence.

Dr. Browne

Deputy McQuillan came down on the right side.

Mr. O'Sullivan

Deputy Browne came down on both sides.

Mr. McQuillan

A point was raised by the Minister that there is no proof that the local authority will extract the full pound of flesh in connection with these increased charges. The simplest way to deal with this, to assure the House that such will not be the case in future, is for the Minister, if he has not the figures available, to get the figures from all the local authorities and tell us the total percentage in the country who paid this 6/-. Perhaps that is not a fair question to ask and maybe the Minister has not the figures at the moment. They could be made available and he could give an indication as to where county managers said: "I find this applicant not able to pay 6/-; I will charge him 4/-." Has the Minister got evidence that county managers have varied that charge in the country? I should like to know that, as it is very important, since the decision, the implementation of any legislation like this, is to be left to the individual county managers —they are the health authorities.

There is no use in pretending here that it is the members of the local authority who will decide the charges, whether 10/- or 6/-, when this becomes legislation. The final decision in all these matters lies with the county manager. He is the health authority, the sole health authority. A county manager is only a human being and I do not think there are two human beings so alike that the manager in Kerry would adopt exactly the same ideas and methods as the manager in Kildare or Laois, for example. It is quite possible that in certain areas the county managers will administer the health services in a more reasonable fashion than in other areas. I think that is unfair on the community as a whole, as it does not give equal opportunities and fair treatment to all the citizens of the State. The treatment is being meted out on a basis which depends on whether the manager is stupid, generous or a crank. It is left to him to decide. The local authority, in the sense of the members of the county council, have no discretion in the matter.

Apart from all that, the former Minister was a member of a local authority—I do not know if he is now— and will realise that, as a result both of the Bill and of his amendment, if accepted, more work will be imposed on the ordinary members, that is, the county councillors. They will receive further representations from their constituents requesting that such and such a hospital bill be reduced or cancelled. Many people now have reached the stage where they cannot believe that the local authority will deal fairly with their problems, unless they get representations made on their behalf by members of the local authority itself. This type of legislation will create further havoc in that respect. More and more people will go to their representatives looking for the exercise of "pull" in order to get a bill reduced.

Mr. O'Sullivan

To get the valuation reduced?

Mr. McQuillan

To get the hospital bill reduced.

Mr. T.F. O'Higgins

It will depend on the valuation.

Mr. O'Sullivan

Will it not depend on the valuation?

Mr. McQuillan

I think the Deputies who talk now have not the foggiest idea at all of what local authorities do. It is beginning to dawn on them now.

Mr. O'Sullivan

All the intelligence is embodied in one man.

Mr. McQuillan

I do not accept that, but I would like Deputy O'Sullivan to realise that in his own constituency members of the county council every day get representations from persons who were in hospital to have the bill reduced—whether they are farmers, shopkeepers or anything else.

Mr. T.F. O'Higgins

The amendment says that if the valuation is more than £25, you may be charged 10/- if it is less, you cannot.

Mr. McQuillan

Does that clear the whole situation in the Deputy's mind?

Mr. T.F. O'Higgins

The amendment is aimed only at dealing with what may be charged. You cannot be charged if your valuation is under £25.

Mr. McQuillan

I am quite aware of what is in the amendment and I know, as far as it is concerned, there is no such statement in the Bill or the amendment, to suggest that "must" is the operative word. That is not suggested. The word "may" can be as emphatic as "must" with many county managers. That is what I want cleared up, in order to get it into the county managers' heads that "may" does not mean "must". Representations have to be made to him very, very strongly at times on that particular line; and I am not anxious that further representations should have to be made to any county manager to have that clarified for him.

I would not like to be taken as pointing a finger at the county manager in my own constituency in this regard. I have discussed this matter with members of the local authority in various parts of the county and I have found a great deal of satisfaction amongst those members with the manner in which the county manager has interpreted various sections of the Health Act. The amendment is certainly not going to make the position any easier. I want to have it on record that, apart from some of the considerations in the Bill itself, I am on principle against the amendment as being impracticable and unworkable.

Mr. O'Sullivan

Deputy McQuillan has tried to put it across that the acceptance of this amendment will mean additional administrative expenses. I think the Minister could inform Deputy McQuillan that a person must provide a certificate as to the extent of his valuation. I support the proposal of Deputy O'Higgins and support it following consultations with some of my constituents over the week-end. They agree that this would be an equitable thing to do. They cannot see, if the Minister must in his budgetary considerations this year save £90,000 on the health services, why any farmer of £5, £6 or £7 valuation should be required to pay the same increase as a farmer of £45, £46 or £47 valuation. Surely that is clear to those who claim——

Mr. McQuillan

The Deputy must not have been listening to Deputy O'Higgins, who argued that many of the farmers with a £50 valuation are as badly in need of service as those in the group referred to by the Deputy.

Mr. O'Sullivan

I doubt if Deputy O'Higgins used those words. I am speaking generally; I am not talking about specific instances. Even if one went above that figure, one could find people above that valuation in rather unusual circumstances, but speaking of the class in the £25 to £50 category, if there is to be a saving, would it not be better that it should not extend to those under the £25 valuation? When the Minister is tightening up, it is certainly unfair to require those on the lower valuations to meet the same additional charge as those in the higher valuations. For that reason, many of us support the amendment.

Major de Valera

Listening to this discussion, it seemed to me at first as if some of the people who were talking wanted to have it both ways. At the time of the Budget, the criticism was that the Government was not taking action uniformly over the community and the implication was that the better off people should have been made to pay and should not have shared in any advantage. That was the whole case against the Budget. When I came in here, it seemed to me that this case was made in certain quarters where it is now considered that what the Minister is doing is designed to balance in favour of those who cannot pay and to call upon those who can pay. The opposite argument is being invoked; in other words, certain people are trying to have it both ways.

When it comes to general discussions on the Budget they talk about favouring the rich. When a provision is brought in which enables an equitable scale to be provided then, because there is uniformity for everyone, the opposite cry is raised and frankly I came in to deal with that particular problem. But now it seems to me that on this particular amendment the issue appears to be one which is in some respects a matter of mechanics. It is apparently agreed, as between the principal Opposition speakers and this side of the House, that it is equitable to bring about a situation that people who can afford to pay, that is genuinely afford to pay, should contribute in order that the facilities and the funds will be there to provide the necessary contributions and, if necessary, free service for those who cannot afford to pay. That is the simple principle that is involved in this amendment and this discussion, as I see it.

We have a situation where the Minister envisaged, and apparently the movers of the amendment envisaged, contributions by those who can afford to pay and, of course, those who cannot afford to pay, or who are found not to be in a position to pay, will be catered for as heretofore. Therefore, it seems to me that the net issue in this amendment is the one as to how to do it. It seems to me that the proposal of the Minister is the simpler one as the machinery is set up.

I do not wish to weary the House with a re-examination of the mechanism of the health schemes. I think the mechanism is probably open to criticism in many regards but for the moment, in order not to widen the discussion, I accept the mechanism as we have it. Is it not the more direct simpler thing to do what the Minister has done? That is to raise the level to embrace a greater number with a capacity to pay than previously. I could understand many of the arguments that have been put forward on the basis that it was a mandatory question, if it was a question of making everyone pay 10/-, but let us not get away from the Minister's proposal that the charge may go as far as 10/-. It simply means that a person who was well able to pay 10/-, and probably more, has hitherto been only called upon to pay up to 6/-. After that the person who can and could afford to pay more than 6/- can be called upon to pay up to 10/-. That is all that is in issue in this amendment. Anyone who cannot pay 10/- or 6/- will not be in any worse position than he was. I think it is important to grasp that point.

Therefore, the situation is simply this. On the Minister's proposal, anyone who can afford to pay will pay in accordance with his ability to pay, up to the limit the Minister is fixing. The only effect of this legislation is to cover more of the well-off class who were supposed to be getting so many benefits under the Budget, than were covered previously. In other words, the people in the well-off classes, the rich people and the better-off people, about whom we heard so much in the Budget, who were heretofore exempt from paying anything over 6/- per day will now be called upon to contribute according to their means and, logically, if one applies the same arguments as were applied to the Budget in this particular instance, then the case is made.

As against that, Deputy O'Higgins's proposal becomes one of mechanics. I am not very experienced or competent to judge in detail the question of mechanics and I shall not, therefore, go into detail. From experience on this side of the House and some experience on the other side of the House, it is the generally accepted practice here for Oppositions to bring in counter-proposals to those put forward by the Government. These proposals are considered but invariably the Government refuses to amend its proposals because, with the knowledge and advice available to it in the various Departments of State, it has come to the conclusion that a certain process is the most efficient, most economical and just way of operating.

Mr. T.F. O'Higgins

Who is to be satisfied? The Department or the Dáil?

Major de Valera

I am putting this as an argument. I do not give it as an overriding reason. Let the Deputy be reasonable. Very often if an impartial observer—and, like the reasonable man, it is impossible to get an impartial observer—were to watch the deliberations here he would probably discover that, when it is a question of mechanism as against a question of principle, the Minister is more likely, because of the advice available to him, to have the more workable solution. In the course of his argument Deputy O'Higgins made constant reference to lack of figures and lack of information and qualified his statements because of the non-availability of figures and information as far as he was concerned. That is understandable. We have all been in that position. In modern times, with complex administration, one has that difficulty. I advance that as one argument in favour of supporting the Minister's view since we are now clear on principle.

I shall hark back now to what was said by Deputy Hillery, who has considerable knowledge of these matters. He said that there is misapprehension. That is quite true. This is not a question of raising the charges. It is simply a matter of raising the ceiling and it will only be the better-off classes that will be affected, thereby enabling us to make more provision for those who cannot afford to pay.

Deputy McQuillan made several points about the mechanics of the health scheme. I do not propose to go into that at the moment. Rather wide issues are involved, though I believe there is a good deal to be examined into so far as the mechanism and so forth of the scheme are concerned. Deputies in Dublin City in recent years have had private representations and complaints about the administration of health services. Questions have been raised which make any thinking Deputy wonder whether all the legislation in relation to health has been as beneficial as it was hoped it would be in certain directions. Undoubtedly in other directions, and here again Deputy Hillery's remarks deserve to be emphasised, there are certain aspects in which there is a real public interest in health.

I do not suggest that in all health matters there is not an interest, but there are certain aspects in which there is a more immediate public interest, such as in infectious diseases and tuberculosis. So far as they are concerned, a considerable amount of good work has been done, particularly in relation to tuberculosis. The scheme has worked satisfactorily.

Dr. Browne

To which aspects is the Deputy referring? Would he develop that point?

Major de Valera

I am talking now more of what one might describe as ordinary sickness. I am not talking about tuberculosis or fevers. For the moment I prefer to leave it at that. I prefer not to be specific. Where the general hospitals are concerned there is concomitant with their overall problem a financial problem. Generally, the situation is not as happy as one would wish.

An Ceann Comhairle

The Deputy is going rather wide.

Major de Valera

Perhaps I am wandering but the point I am trying to make is that, accepting the principle, it is equitable to seek contributions from those who can afford to pay and by raising the level, as the Minister is raising the level here, we are merely bringing in those who at the moment are not paying what they can afford to pay. That is only fair.

Mr. McQuillan

I do not like to interrupt but, on the point made in relation to those who, the Deputy says, can afford to pay, why not then be logical and make them pay the full cost of treatment instead of just 10/-? Why stop at 10/-?

Major de Valera

Logic is difficult to define and the words "logic" and "logically" are sometimes used to prove something which is not logical. The Deputy's point is another day's argument. I accept the system as it is. Deputy O'Higgins and the Minister accept the system. The Deputy would open a much wider question which it may be no harm to examine at another time and in another place.

For the moment I simply say that it is equitable to make those who can afford to pay, contribute. Since the machinery is already in existence and since that principle is already in operation, the Minister's proposal is a reasonable one. Probably it is the best proposal in the circumstances notwithstanding Deputy O'Higgins's proposition. I think the preference lies with the Minister's proposal because it is more adaptable to the system as it is. It is equitable in principle and it will involve less adjustments in machinery and probably cause less complication in its implementation than the relatively novel suggestion that has come from the other side.

Mr. Kyne

The Labour Party will not support this amendment since we consider that the only way in which we can express our views is by opposing the section as a whole. Notwithstanding what the Minister has indicated as the results of his investigations in Dublin, in the country generally the maximum charge of 6/- per day has been implemented in practically every case where the middle income group is concerned. It may be true that the man or woman earning £599 10s. can pay something more than the person who is just barely over the medical card group or the home assistance group. It is quite possible that certain sections can pay and that the line must be drawn somewhere but this proposal will mean that, no matter how small may be the amount over and above the sum the county manager fixes as entitling one to a medical card, the county manager will in future charge such people this additional 4/- per day.

We believe the 6/- per day has been charged, but the Health Act has not been long enough in force to get a fair trial. We feel this is just an economy measure, a method of balancing the Budget. We have pointed out—I think I actually said it on this section in the original Bill—that the Labour Party recognised the danger of the Health Bill not being a contributory scheme where the member had statutory rights, that it was subject to the whim of any Minister who any time he ran into difficult times, could immediately increase the charges. Our words are coming true. The difficult times are there and the charges are being increased. It is not a question of natural rights or a question of ethics of any sort. It is just a question of economy and needs be.

We feel, as the Labour group, that our section of people, no matter what the Minister says, will have to pay this increase of 4/-. No matter what goodwill the Minister has and no matter what good intentions he has, there is no right of appeal against the county manager's decision. If a county manager decides that a person not holding a medical card must pay that amount irrespective of his means, he will have to pay. Consequently, we cannot support the amendment, but we must oppose the section when it comes up.

Mr. Corry

I do not think that either the Minister or the Department knows what is happening down the country. If an unfortunate person who had to go into hospital was told he would have to pay 10/- a day, he would be the happiest person in the world. I have before me a certain case which I will instance for the benefit of the House. A widow with 28 acres of land of a poor law valuation of £25, living in a part of the country known as Ballymacoda, went into hospital. This is the bill she received: treatment from 4th April to 16th May, £31 10s., use of operating theatre, £2 2s.; surgical expenses, £33 14s.; X-rays, etc., £7 odd. The total was £77 5s. 8d., less Health Act contribution, £25 4s., leaving a balance of £52 1s. 8d. for 42 days in hospital.

This woman's relatives came to me. I told them to pay 6/- a day and no more. They had great difficulty in getting the woman out of hospital on the payment of £20, that is, £7 8s. more than they should have paid under the Health Act. They were informed that, unless the other £32 1s. 8d. was paid within seven days, the matter would be placed in the hands of the hospital's solicitor. I intend to hand this bill over to the Minister when I have concluded so that he may deal with it.

Mr. O'Sullivan

Would the Deputy say was it a local authority hospital, or what kind of hospital it was?

Mr. Corry

A Cork hospital. Apparently the local authority and the State had to pay that hospital £25 4s., but the unfortunate woman with the 28 acres had to pay them £52 more. We members of local authorities are well aware that the charges have been trebled since those people found they could knock anything out under the Health Act. Unless patients go into hospital with the toes coming out of their boots, they will have the doctor saying to them: "What about my feel?" and I know of at least nine or ten cases where the doctor was paid fees in addition to having his whack out of the Health Act.

An Ceann Comhairle

The Deputy should come to the amendment instead of traversing the administration of the Health Act.

Mr. Corry

I want to know whether under this Bill that woman with the £25 valuation is entitled to free treatment in hospital on payment of 10/- a day. That is a fair question and the unfortunate people down the country want to know the answer. I do not intend to go into the manner in which the Health Act has been administered. I can tell the Minister that there are thousands of people working on medical cards at the present time——

An Ceann Comhairle

The Deputy says he does not intend going into it and then proceeds to go into it.

Mr. Corry

I shall have another opportunity of going into it and I shall present cases such as I have dealt with now. I want the Minister to say whether or not a farmer on a £25 valuation holding is entitled to free medical treatment and hospital treatment at 10/- a day.

Mr. Kyne

If you support the amendment, you will get it free.

Mr. Corry

They are glad to get out at the 10/- a day, without having to pay the £50.

Dr. Browne

The general trend of the speeches on both sides of the House seems to be that people who can afford it should pay and that any other view is a degenerate one and contrary to the character of our people. I do not think any case has been put forward to substantiate that point of view, and it is such a serious thing for a responsible former Minister and an existing Minister to say that I find it difficult to let it pass without some comment. It is such a fallacious point of view that one finds difficulty in believing that anyone could conscientiously or honestly hold it.

However, assuming the view is conscientiously and honestly held on both sides of the House that everybody must pay and that any other view in respect of health services is contrary to the character of our people, then the correct thing for these people to do—Deputy O'Higgins and, I think, Deputy Hillery and the Minister—is to pursue that to its logical conclusion, and alter the existing free services of one kind or another which are made available by the State to the community. Indeed, I would challenge the Party in opposition or the Government to find out whether this attitude to free services is contrary to the character of our people. The fact is that 1,000,000 of our fellow-Irishmen in the Six Counties are at the moment using a completely free health service and, as far as I can see, in no way resent the fact that there are these services there. I do not think that they are acting in any way that could be said to be contrary to the character of our people.

Will the people who hold these views, conscientiously believe them, put forward the idea, in order to find out whether our people are in favour or against free services of one kind or another, that all the existing free services be ended?

An Ceann Comhairle

The Deputy is widening the scope of the debate.

Dr. Browne

Unfortunately, in order to try to deal with the point which has been put forward by both sides of the House.

An Ceann Comhairle

The House is not arguing free services versus paid services.

Dr. Browne

Neither was I, but, unfortunately, it was put forward. However, I shall not deal with it to any extent except to suggest that the logical conclusion of their argument is to amend the existing free services, tuberculosis services, the various infectious diseases services, primary school free services that people are getting who, presumably, can pay for them, children's allowances, farm allowances of one kind or another. Does the Minister propose to change all these in order to bring them into conformity with the character of the Irish people? I bow to your ruling, a Cheann Comhairle. We shall probably have another opportunity of dealing with it, but it is, quite clearly, an interesting point of view.

An Ceann Comhairle

It is clearly wide of the mark, of course.

Dr. Browne

The suggestion was made, mostly by Deputy Major de Valera, that this was merely an attempt to do good by stealth, a sort of Robin Hood act, to rob the rich in order to pay for the poor people who could not afford these services. On the contrary, I think the general principle involved is robbing the poor in order to pay for the commitments that the Minister for Finance has made to various other wealthy sections and in that way I do not think that the argument is a valid one at all. It seems to me that, if there is any need to raise charges at all, these charges can be raised, but raised in relation either to rates or taxes. In that way you can get an increase in the money required from the people who are best able to bear that burden.

The suggestion that free health services are never free, of course, is true in so far as the services have to be paid for in taxation of one kind or another but taxation is so designed to bear as equitably as possible on the people who are paying that taxation. I believe that there is the nub of the whole antagonism in this House to the extension of free health services of one kind or another, particularly in this context.

These are all hypocritical arguments about the poor who cannot pay. I think they are concerned about the wealthier sections who do not want to pay more increased taxation. Let them confess to that and admit that. Indeed, I must concede that to the Minister. He did concede that he was worried about the increased taxation but that is a more honest argument than the argument of Deputy Major de Valera that the Minister is trying to take the money from those sick persons who are able to pay in order to pay for the health services of those who could not afford to pay.

Indeed, all Deputy Major de Valera's arguments about the equity of taking from people who can afford to pay, the people paying 6/- now who could afford to pay 10/-, and in that way save the poor person who could not pay, have been put forward before, I think largely by the Opposition, when Fianna Fáil were trying to bring in free health services, as arguments against the extension of free health services. It usually in the past came from the Opposition side of the House. Fianna Fáil, up to very recently, of course, opposed that and brought in the legislation which they did bring in.

For the life of me, I cannot see why any issue should be involved here in relation to whether a person pays for a service directly or in taxation. If the contention is true that no free services are really free, then, of course, if anybody is worried about somebody getting something for nothing, his argument is met because presumably everybody who can pay pays taxation so that everybody who gets these services is paying to the limit of his ability to pay.

I do not think that that is the most important argument. The main argument that I have on this whole question is a medical argument, that these free services are better services; they give better health services. That is the most important argument, not socialism or anything else. They give better health services. These arguments in relation to taxation are old arguments that have been put forward since the beginning of time in relation to the extension of any social service of any kind to the mass of the people, to the underprivileged generally, and up to very recently they have been answered, by the Fianna Fáil Party at any rate, in ignoring them. Consequently, it is all the more regrettable to hear Deputy de Valera putting them forward now.

In the midst of Deputy Dr. Ryan's most vehement fight to put the 1953 Health Act through the Dáil I remember in a moment of great frustration he accused the Opposition of being bloody frauds and bloody hypocrites.

An Leas-Cheann Comhairle

The Deputy is getting away from the amendment.

Dr. Browne

When Deputy de Valera was speaking, it struck me that the bloody frauds and bloody hypocrites were not on one side of the House any longer.

An Leas-Cheann Comhairle

The Deputy should pay some attention to the Chair.

Mr. MacEntee

Before you put the question, I just want to refer——

Mr. O'Sullivan

The Minister is not concluding?

Mr. MacEntee

Oh yes I am. Otherwise I do not speak.

Mr. T.F. O'Higgins

May I say just one thing before the Minister concludes? I know we are all free to think, but I do not know whether any of those in the House who are free to act could have been in any sense convinced by the arguments advanced here by the Minister. Deputy Major de Valera said—I do not know whether he had studied this matter before he spoke—that the Minister's proposal was a simple and easy way of making the better-off sections pay for benefits under the Health Act. He seemed to suggest this was merely a matter of mechanism. I wonder was he serious in saying that? Of course the Minister's proposal is simpler and easier to administer because it hits all sections under Section 15. I am certain it might commend itself on the ground of its simplicity.

My proposal, I know, errs on the side of being more cumbersome, perhaps, more difficult to administer— although I do not believe that—but its object is to prevent an imposition falling uniformly on all sections under the Act irrespective of whether they are able to meet it or not. It is an effort to do a bit of sifting to ensure that under Section 15 only those better able to afford it will have to meet the increased charge which the Minister thinks is necessary.

Had I my way, were it open to me, in proposing the amendment to this Bill I would oppose the charge imposed by the Minister in its entirety. That course was not open because the principle of the Bill was accepted by the Dáil on the Second Reading and therefore we must start from the fact that it is the view of the Dáil that increased charges for these services must be provided. Starting from that, I have endeavoured in this amendment to ensure that these charges will be as limited in their application as possible having due regard to the view of the Dáil that some increases are necessary.

I think it was Deputy McQuillan who said that this amendment would result in further investigations as to means and so on. I do not think he could have been serious in that. At the moment, in order to qualify under the Health Act farmers must demonstrate that their valuation does not exceed £50. If they have to produce their poor law valuation certificates that in itself demonstrates whether or not their valuation is above or below £25. There is no added difficulty in regard to that. If they are farmers in the sense contemplated under the Health Act, if they depend on farming, the production of their poor law valuation certificate entitles them, if it is less than £25, not to be charged the increase proposed by the Minister.

Again in relation to insured persons, no investigation as to means is involved. Once a person is insured even for a day under the provisions of the Social Welfare Act, under this amendment he is entitled to be shielded from the increase proposed by the Minister and no investigation as to means is involved. So far as administration is concerned it is simple. A farmer whose valuation does not exceed £25 or any insured person is entitled under this amendment to get the same treatment under the Health Act of 1953 as he was entitled to get before the Minister introduced this Bill. Therefore, I would suggest that the amendment—it may not be perfect —should be accepted. I think the principle of imposing this taxation in present circumstances for budgetary purposes is wrong but as we have to accept that principle, at least it should be our concern here to seek to ensure that a bit of legislation, conceived, I believe, impetuously, should not be allowed to have a very harmful effect on many sections that should not have an increased burden imposed on them.

May I add that it has been suggested here, and the point has been made by the Minister, that these are discretionary charges? Of course they are, but Deputies will realise that under Section 15 there are certain categories of persons who are given a statutory right or entitlement to services. There is also a general category of people who are entitled to services if they demonstrate that they are in hardship. I must say, again from my experience, I find that since these services came into operation scarcely 12 months ago, generally speaking, in the first instance an effort is made to get from those who may be charged, the full hospital charge of 6/-.

I fear that now the effect will be the same, that the full charge of 10/- per day will be sought in every case. I do not say it will always be paid because I know well, since I believe in this amendment, that in a great many cases it cannot be paid because the money is not there and, in fact, if the section remains unamended in the Bill, the health authorities throughout the country will be involved in more administrative trouble because they will be inundated with representations through public representatives asking that bills of, say, £3 10s. or so be reduced because, for example, the worker involved by reason of his illness lost his wages and is unable to pay.

I am certain that when reasonable cases of that kind are made to health authorities deductions will in fact be given and that the bill will be written down. I am certain that in many cases it will be written down to nothing, but it seems to me quite wrong that we should, by our legislation here, impose a burden which may not be charged merely for the sake of uniformity. In my opinion it would be far wiser for the Minister to recognise the facts now and realise that when a worker becomes ill his source of income ceases; he is unable to pay a hospital bill and he should not be asked to do it.

Again, it is only reasonable the Minister should realise that farmers with a valuation of less than £25, whatever case may be made for their being asked to pay something, are not in a position to pay 10/- per day for themselves or for their dependents.

Mr. M.J. O'Higgins

I do not want to delay the House very long, but I think that in the interest of the discussion which has been taking place as to whether or not the Minister's proposals in this Bill, which the amendment is designed to ameliorate, will affect many or few people, it is worth while placing on record the reply which the Minister gave to a question on this subject last month. On 14th May last, Deputy Declan Costello asked the Minister if he would state the number of persons who, it is estimated, will be affected each year by the proposed increases in charges and the imposition of new charges in the health services outlined in the Budget speech.

The Minister replied that an estimated 17,000 persons would be affected in a single year by the proposed increase in charges for institutional services. The remainder of the Minister's reply dealt with the new charges for specialist services. I merely want to point out that, in my view, 17,000 persons cannot be dismissed as just a few people. According to the Minister's estimate, 17,000 people will be affected by the increased charges imposed by this Bill. On that occasion, Deputy Dr. Browne asked, by way of supplementary question, if the Minister could give any indication of the total amount involved. The Minister's reply was: "At a rough guess, between £70,000 and £90,000."

I assume that the Minister, in giving that reply, was thinking in terms of the saving to the Exchequer only and not of the saving to local authorities. The figure mentioned here earlier this evening was that the total, as between the ratepayers, on the one hand, and the taxpayers, on the other, would be about £180,000. I should like to continue with what the Minister had to say on that occasion—May 14th last— because it is interesting to know that a Deputy from the Minister's Party thought fit to ask a supplementary question. Deputy J. Brennan asked: "Is the Minister aware that there is a tendency on the part of the county managers to charge the maximum fee in each case, irrespective of means, in the middle income groups?" I have no doubt Deputy Dr. Browne would be interested in the Minister's reply to that. The Minister said: "I regret to say that my information is to the contrary—that in many instances county managers are reluctant to demand all they might legitimately require."

It seems to me to be quite clear from the Minister's reply to Deputy Brennan's supplementary question that as far as the Minister's attitude on this question of charges is concerned, he has left his views on record. His views are that he regrets that the information he has is that county managers are reluctant to demand all they might legitimately require. As far as the Minister is concerned, I take that to mean that, if he has any say in it, he will see that county managers will demand everything to which they are legitimately entitled under the provisions of the Health Act and of this Bill, which will go through when the Minister mobilises his forces behind him.

An Leas-Cheann Comhairle

I cannot call on the Minister at this stage— the Committee Stage.

Mr. MacEntee

Because of the continuous obstruction of certain people, I cannot reply to Deputy Corry. I can only say I will have the matter he raised investigated.

Amendment put.

The Committee divided: Tá, 73; Níl, 34.

Tá

• Aiken, Frank.
• Allen, Denis.
• Bartley, Gerald.
• Beegan, Patrick.
• Boland, Gerald.
• Boland, Kevin.
• Booth, Lionel.
• Brady, Philip A.
• Brady, Seán.
• Breen, Dan.
• Brennan, Joseph.
• Brennan, Paudge.
• Breslin, Cormac.
• Briscoe, Robert.
• Burke, Patrick.
• Calleary, Phelim A.
• Carty, Michael.
• Childers, Erskine.
• Clohessy, Patrick.
• Collins, James J.
• Corry, Martin J.
• Cotter, Edward.
• Crowley, Honor M.
• Cunningham, Liam.
• Davern, Mick.
• de Valera, Eamon.
• de Valera, Vivion.
• Doherty, Seán.
• Donegan, Batt.
• Dooley, Patrick.
• Egan, Kieran P.
• Egan, Nicholas.
• Fanning, John.
• Faulkner, Padraig.
• Flynn, Stephen.
• Gallagher, Colm.
• Galvin, John.
• Geoghegan, John.
• Gibbons, James.
• Gilbride, Eugene.
• Gogan, Richard P.
• Griffin, James.
• Haughey, Charles.
• Hillery, Patrick J.
• Hilliard, Michael.
• Humphreys, Francis.
• Kenneally, William.
• Kennedy, Michael J.
• Killilea, Mark.
• Kitt, Michael F.
• Lemass, Noel T.
• Lemass, Seán.
• Loughman, Frank.
• Lynch, Celia.
• Lynch, Jack.
• MacCarthy, Seán.
• McEllistrim, Thomas.
• MacEntee, Seán.
• Maher, Peadar.
• Medlar, Martin.
• Moher, John W.
• Moloney, Daniel J.
• Mooney, Patrick.
• O'Briain, Donnchadh.
• O'Malley, Donogh.
• Ormonde, John.
• O'Toole, James.
• Ryan, James.
• Ryan, Mary B.
• Sheldon, William A.W.
• Sheridan, Michael.
• Smith, Patrick.
• Traynor, Oscar.

Níl

• Barrett, Stephen D.
• Beirne, John.
• Belton, Jack.
• Byrne, Patrick.
• Byrne, Tom.
• Costello, Declan D.
• Costello, John A.
• Crotty, Patrick J.
• Dockrell, Maurice E.
• Esmonde, Anthony C.
• Fagan, Charles.
• Flanagan, Oliver J.
• Giles, Patrick.
• Hogan, Bridget.
• Hughes, Joseph.
• Jones, Denis F.
• Kenny, Henry.
• Carew, John.
• Carroll, James.
• Coburn, George.
• Coogan, Fintan.
• Cosgrave, Liam.
• Lynch, Thaddeus.
• McGilligan, Patrick.
• McMenamin, Daniel.
• Manley, Timothy.
• Mulcahy, Richard.
• Murphy, Richard.
• O'Higgins, Michael J.
• O'Higgins, Thomas F.
• O'Reilly, Patrick.
• O'Sullivan, Denis J.
• Reynolds, Mary.
• Rooney, Eamonn.

Tellers:—Tá: Deputies Ó Briain and Hilliard; Níl: Deputies O'Sullivan and Crotty.

Question—"That the word proposed to be deleted stand"—put.

Amendment negatived.

Mr. T.F. O'Higgins

I move amendment No. 2:—

In sub-section (1) (b), line 24, to delete "shall" and substitute "may".

The purpose of this amendment, which deals with the charge sought to be imposed for specialist services under Section 1 of the Bill, is in some way to prevent this charge falling where perhaps the person seeking the service is unable to pay for it.

I draw the attention of Deputies to the wording of the proposed new sub-section (5) in the Bill. It provides as follows:—

"Where specialist services are made available under sub-section (1) of this section for a person who is not a person specified in sub-section (2) of Section 14 of this Act and who is not an in-patient in an institution, there shall be charged, on each occasion on which the services are provided, such charge as may be specified by Order made from time to time by the Minister...."

In other words, the effect of the Minister's proposal is to remove any discretion from health authorities and to provide that each health authority must impose a charge in respect of specialist services for each eligible person who is not an in-patient in a hospital and who is not a holder of a medical card.

I would remind Deputies that this proposed amendment is quite contrary to the principle of the Health Act, 1953. Whatever different arguments may have been put forward on behalf of the Health Act, 1953, or against it, the one thing that was clear and recognised was that specialist services were being provided free for all eligible persons, whether or not they held medical cards or whether or not they were entitled to free general practitioner medical services. They were all, under the Health Act, entitled to free specialist services.

The Minister's proposal now is aimed against that principle. It is aimed at imposing a charge and I would remind Deputies that this charge is not a discretionary charge. It is not a charge that may be imposed. It is a charge that shall be imposed on every person who seeks henceforth to avail of the specialist services as an out-patient in any of the local authority or other hospitals with whom health authorities have arrangements. I want Deputies to have regard to this. I understand it to have been accepted policy that no person should be denied needed medical care and attention because of lack of means. At least to that extent, we were all taken to have agreed and at least in that regard I would have found myself in agreement with Deputy Dr. Browne and others.

Here now is a proposal, however. The charges may not appear to be significant, but it, nevertheless, is a proposal which says that the health authority shall not henceforth be under any obligation—in fact, may not—to provide specialist services for eligible persons, unless the sum designated by the Minister is paid. That appears to me to be a most remarkable departure from what we were told represented the policy and the aims of the Health Act, 1953.

The Minister told us in his Second Reading speech that the charges he proposes to make will be 7/6d. in respect of an X-ray and 3/6d., I think he said, in respect of the first visit to a specialist and 2/- in respect of each repeat visit. Those charges, depending on the way one looks at it, may not appear dramatic or significant, but they will appear quite a heavy burden to a worker who becomes ill. He may not have to go to hospital, but he is unable to work. He sees his doctor and his doctor tells him that he had better go to hospital to have an X-ray. He then cannot get his X-ray, unless he provides a sum of 7/6d., and if it is in Dublin or elsewhere, neither can the health authority, under the administrative proposal, provide him with the facilities because it is obligatory, under the Minister's proposal, to impose this fee or payment.

Again, the amendment I have suggested is not designed to attack the principle of this Bill since that was accepted on the Second Reading. It is designed to prevent a hardship being imposed, perhaps not intended, but a hardship on persons who are sick and are poor and who require specialist services. The amendment is a simple one. It is designed to give to health authorities a discretion to enable them to impose a charge, if they so wish, since that is the principle of the Bill and also enable them to refrain from imposing a charge, if they so wish. I think it is reasonable and proper and in accordance with the view we all have of the need in the case of the individual of specialist services. No one should be deprived of those services merely because he has not got in his pocket a few coins to jingle.

Under the Minister's proposal, if a person requires an X-ray and has not got three half-crowns in his pocket, that is the end of it. He cannot get it and the health authority cannot give it because there stand between him and the X-ray three half-crowns. I am certain that, upon reflection, the Minister will agree that that is not a desirable state of affairs and that he will agree with me that in relation to these ser vices a discretion should be given the same as is elsewhere provided under the Health Act.

Mr. Kyne

The Labour Party will have to continue to adopt on this the attitude they took on the previous amendment of not agreeing to vote for it. Our attitude is that no charge should be made. It is true that this amendment seeks to give a discretionary power, but our attitude and belief is that where you give a discretionary power, the maximum has always become the minimum and "may" becomes "shall". There is no difference whether the word is "may" or "shall" inasmuch as, in the administration of the Act, the 7/6 will be charged. We do not want to be misunderstood and we do not want it implied that because we did not vote for an amendment which said "may" or "shall", we admitted there was some case for increasing the charges.

Our attitude is that the Health Act should be left as it was. We feel that an alteration that will worsen the position of the middle income group— which, in general, is made up of the ordinary working people of this country—is a deliberate attempt to save the Government, and possibly taxpayers, money. It will be done at the expense of the working people—those who can least afford it. Consequently, while not voting for the amendment, we shall oppose the section as a whole.

Mr. O. Flanagan

Deputy O'Higgins has put the case very fairly and forcibly. The Minister for Health must be well aware that in recent years, particularly in very recent years, we have had the pleasing state of affairs whereby T.B. is completely and entirely on the way out. I feel that that is due to the fact that people have had recourse to the X-ray so freely. Appeals were made by the Minister for Health and his predecessors to people to avail of the X-ray. Practically every doctor throughout the country will very freely advise a patient, after a severe chill or a heavy cold, to have an X-ray. It is the surest and safest manner of discovering any ill-effects after a severe chill or cold.

Can any person say it is reasonable to expect an old age pensioner or a recipient of home assistance to pay 7/6 for an X-ray? Consider the case of a person in receipt of unemployment benefit who requires an X-ray but who must pay 7/6 for it. Such a person will give first consideration to the household requirements even though the natural reaction would be to look after one's health. Therefore, I feel the collection of 7/6 for an X-ray should be left to the discretion of the local authority.

It may be argued that there is great danger in leaving such a decision in the hands of the health authority who, naturally, is the county manager. All county managers are not hard-hearted. I know of no case in which the county manager, as the health authority, deliberately turned down an application that had merit. Again, the chairman of the local authority always has recourse to the county manager, as have the members of the local authority, to put forward the merits of any case. If Deputy O'Higgins's amendment is not accepted, the local authority or even the county manager, no matter how willing he may be to give special consideration to the needs of the poorer sections of the community, will be placed in a very difficult position.

It has been pointed out that there are many people who will not have 7/6 at their disposal for an X-ray. It is unnatural and inhuman that we should embody a clause in our legislation whereby no person may have an X-ray except by paying 7/6. What will happen to the unfortunate person who has not 7/6 and who is in need of an X-ray? Perhaps the Minister for Health will answer that question.

There was a time when the present Minister for Health and the members of his Party loudly said that no citizen would be refused proper medical attention, specialist treatment or X-ray, for want of money. They have changed entirely from that viewpoint.

Mr. Loughman

Did the Deputy say that the old age pensioners will have to pay 7/6?

Mr. O. Flanagan

They may have to do so if they have not a medical card.

Mr. Galvin

Any needy person would have a medical card.

Mr. Loughman

Does the Deputy think that all old age pensioners have not a card?

Mr. O. Flanagan

Surely Deputies know that not every old age pensioner has a medical card. I could supply a long list of old age pensioners in my constituency who have not medical cards. I am sorry that Deputy Loughman is not the county manager in my constituency because then perhaps quite a number of difficulties might be solved in so far as that matter is concerned. If an old age pensioner has a son or two sons who are road workers or agricultural workers in full employment he will not get a medical card. Now, even though he has no medical card, if he has not the 7/6 to pay for an X-ray he will have to do without it.

Mr. Allen

What about the unemployed man?

An Leas-Cheann Comhairle

Deputy Flanagan must be allowed to speak without interruption.

Mr. O. Flanagan

The old age pensioner who has not a medical card is a fairly good example to cite. Is he now expected to pay 7/6 for an X-ray out of his old age pension, not to talk of a second or a third X-ray? The relevant section of this Bill provides that he must pay. If the Minister for Health and his Party are as sympathetic as they pretend to be at election times towards the poorer sections I feel that, in fairness, this matter should be reconsidered.

The substitution of the word "may" for "shall" gives the local authority an option. When a strong case is put forward I find that most county managers, having investigated the financial circumstances of the aggrieved party and found that there is merit in their case, are reasonable. However, if the county manager, as the health authority, has not the law on his side to enable him to decide in favour of the aggrieved person I believe that the brunt of the difficulties will now fall on the person seeking the X-ray.

Apart entirely from old age pensioners, there are the people on home assistance. Then again, you also have people who receive home assistance to supplement very small incomes. When this Bill becomes law, such persons will be obliged to pay for an X-ray. I do not consider that that is right. I appeal to the Minister to accept this amendment which is reasonable. If there is merit in any particular case, the county manager may then make the decision about the payment.

If this section is enacted, many people will not avail of the X-ray service. The Minister for Health should be deeply concerned, as I have no doubt he is, with the health of the community. He should not, however, place obstacles in the way of citizens seeking to comply with the advice given them by their doctors in regard to X-rays. I can see a good deal of difficulty. If this becomes law, I can see that a section of the community, and no small section, will be denied the right of an X-ray. Most of us here can remember a time when all working class people could have free X-rays. It is not very many years ago at all.

If the amendment is not accepted, it can lead to a severe hardship on a section of the community. Are deserving people, who feel they are entitled to an X-ray, to be refused it because they have not 7/6 to place before the radiographer, the almoner or the matron of the hospital? Will the Minister explain what is the position of a person who has not got 7/6 for an X-ray? Is he to have a collection? Is he to ask his friends to contribute the three half-crowns? Does he expect such a person to go without an X-ray? Not everybody has 7/6 to spend freely, particularly in these times. I would like to know where the Minister expects such a person to get 7/6. Will the Minister give it to him? It is all very well to say that the poorer sections of the community, who have not got medical cards, are obliged to pay 7/6. If they have not got the 7/6, who is to give it to them? An X-ray may be prescribed, and their health may break down completely because they do not have an X-ray. I think there is at least a responsibility on the Minister to leave this matter to the discretion of the health authority. I hope he will.

Dr. Esmonde

I should like to support this amendment for two reasons. First of all, I am very largely in agreement with what Deputy Flanagan said. It is a question of collecting the sum. I am very dubious as to whether a sum that will accrue to the State for the purpose of balancing off the Health Act, which is already imposing a burden on the people without sufficient return for it, will be fully recouped. If it is not, and if the larger portion of the money is to be expended on administrative expenses, this does not seem to me to be a practical section.

As I said on the Second Reading, if anyone is sent to a hospital for the purpose of an examination, he goes in and maybe is examined by a consulting physician, if you like, or a consulting surgeon. He is sent by the local district officer, as he is now known— the district medical officer. There may be no thought in the mind of the patient, in the mind of the doctor who sent him or even in the mind of the surgeon who examines him that he has to have an X-ray. Deputy Flanagan has raised the point of who will pay the 7/6. Where will the 7/6 come from? Obviously, you cannot go out in the street and have a collection of 7/6 for Mr. X to have an X-ray. If not, is it then to be booked? If it is to be booked, it will mean further administrative expenses.

My objection to the 1952 Act and any subsequent legislation that may flow from that, is the fact that it was impracticable from beginning to end. It is a snowball in the collection of administrative expenses. I think this section in itself, and in fact every section in this Bill, proves that. I further object to it on the grounds that it further violates the relations that exist between doctor and patient. I know, of course, that some Deputies will object to that, but there has always been a relationship between doctor and patient, a confidential relationship, that seems to be entirely abolished in this case. An X-ray may not lead to very intimate details, but it ploughs through the whole function of a State Health Act in any shape or form that every import you have to put on, every charge you have to make, will lead subsequently to an investigation.

Those are my objections to this. They are a few of many. In every section of the Act, in every part of health legislation you deal with, you come up against the same thing. If Deputies go to a doctor they do not want everybody to know what is wrong with them. They do not want their private affairs made public. That is what happens with State legislation and for that reason I am opposed to it. Therefore, I will have the pleasure of voting for this amendment.

Mr. T.F. O'Higgins

Are we to hear from the Minister?

Mr. MacEntee

I am not accepting the amendment.

Mr. O. Flanagan

The Minister should explain to us what is the position of a person who has not 7/6.

Mr. M.J. O'Higgins

This amendment is designed to alter the definite character of the section proposed by the Minister. A certain amount of play was made, in arguing in favour of this Bill previously, on the grounds that it was permissive legislation, that it simply permitted the local authority to charge up to a maximum of 10/- and so on. With regard to the matter we are dealing with now, there is no question of permissive legislation. By the Bill which the Minister is proposing the imposition of these new charges is being made mandatory. The amendment is designed to alter the mandatory character of the Minister's proposal, or at least mitigate it to the extent of making it permissive.

I think, in ordinary courtesy to Deputies, the Minister should give us an explanation if he will not accept the amendment, particularly having regard to the arguments which have been advanced from his own side of the House that one of the merits of this Bill is that it is simply permissive legislation. There is nothing permissive about this. If the Minister feels, in regard to the increase in the charge from 6/- to 10/-, that there was some merit in leaving it permissive, as something that the health authority might or might not do, surely the same argument can be made in favour of the amendment which has been proposed to make the imposition of these new charges permissive also?

I did not hear the proposer of the amendment, but certainly the arguments which have been advanced by Deputy Flanagan are arguments which the Minister should, in my view, endeavour to answer, if he can. Quite apart from anything else, as a matter of courtesy to the House we should hear from the Minister, if he will not accept this amendment, why he will not accept it.

Mr. McQuillan

The arguments put forward by both Deputy Flanagan and Deputy O'Higgins would lead any neutral observer to think that it is wrong and inadvisable to have any charge whatever in connection with X-ray services. It would be simpler, from the point of view of administration and easier and less costly, if such a suggestion as that indicated by Deputy Flanagan were adopted. He mentioned the case of an old age pensioner who did not happen to have a medical card and pointed out that quite possibly under this measure the old age pensioner would be required now to pay for an X-ray if an X-ray is recommended for him. That is correct. What has rather surprised me, and what is disturbing to the public, is that there are so many Deputies who are not aware that under the provisions of the Health Act such is the case and that Deputies in the Fianna Fáil benches who interrupted Deputy Flanagan have shown a complete lack of knowledge of the administration of the Health Act.

Mr. Galvin

A home assistance recipient not getting a health card Perfectly ridiculous.

Mr. McQuillan

I am referring specifically to the old age pensioner who does not happen to have a medical card and who must be charged 7/6 under this measure. For the information of the Deputies on my right, there is a large number of old age pensioners in this country who do not hold medical cards.

Mr. Galvin

They should not get an old age pension.

Mr. McQuillan

Deputy Galvin and Deputy Loughman from Tipperary were very vocal in their interruptions on this matter. They should be aware that income has a bearing on the issue of medical cards. It is clear that those who have interrupted have no knowledge whatever of how the decision is arrived at when a medical card is being issued. That is a very serious situation, because it shows that a Minister can, with sufficient backing of Deputies like those, bring any type of legislation through the House successfully, with that sufficiency of members who do not make themselves familiar with the proposed legislation. If the Minister is logical in his approach, he should accept this amendment by Deputy O'Higgins.

In case any one misunderstands my position, I want to make it quite clear that I am against any charge whatever, having taken that line all through the health discussions here for many years. My action in connection with this is to say: "A plague on both your Houses." I do not intend to support this amendment myself personally. I intend to vote against the actual section when the section comes before us for adoption or otherwise.

I want to show the fallacy of the arguments which are being put here at the moment. On the previous amendment the Minister argued that county managers or local authorities were not unreasonable and he felt the managers would be reasonable in the interpretation of legislation passed here. In taking up that line, he said that it was "permissive"—I think that is the word he used—and that there was enough scope in the legislation to allow discretion to the managers where hardship might be involved. Why did he find it necessary to leave discretionary power to the manager in certain aspects and why now in this particular portion make it mandatory? It is no longer permissive and the permission is not allowed there to managers to vary it. "You must", and that is all there is to it.

The charge is to be 7/6 for an X-ray and at this stage it is ridiculous for the Minister to bring in legislation to try to enforce that. The man who has not the 7/6 must get the X-ray. I agree with Deputy Esmonde that you cannot go outside and have a collection for an individual.

I would prefer to see agreement here on health services, on the basis that the best possible services be made available for all our people, rather than take the line of thought of some Deputies, that nobody should be deprived of treatment because of lack of means to pay for it. That may sound a plausible approach, but one interpretation of it could be that we can degrade certain sections or lower them to such an extent that they will be getting certain services only at the whim of others. Such legislation is undesirable. It has been in effect for many years and we do not see the end of it in the present measure.

I am perturbed about the case of an individual who has not a medical card and is not entitled to it and who may need an X-ray. In the words of Deputy Flanagan, he may have had a heavy cold and then be advised to have an X-ray. Is it suggested that that individual or a member of his family will have to pay for it? If so, the position is even more serious than people outside would believe it to be. One of the greatest advances made here in recent years was the triumph over tuberculosis. That was achieved by cutting all the red tape; whether you were the richest or the poorest in the State did not matter. The poorest person got exactly the same service as the rich and there was no question of means test or degrading inquiry as to how many eggs the hens laid in the year.

If we are to revert to the old system in operation prior to the 1947 Act, the position is more serious than even the most reactionary Deputies believe. I should like to have that position cleared up. If we are to interpret from what we read, the implication is that the result will be an increase in those likely to suffer from tubercuculosis. If a man is told to get an X-ray within a certain period and fails to get it, the result may be tragic for him and his family. In three or six months he may have to undergo prolonged treatment at heavy cost to the State and the community. If the necessary X-ray was taken in time the cost of treatment might be negligible. Very often any tendency such as this may mean that the individual may postpone taking the X-ray and the result will be serious for himself and the community as a whole. I should like to have that position clarified to make sure that that cannot happen if, and when, this measure becomes law.

Mr. O. Flanagan

May I put this aspect of the case to the Minister? Apart entirely from the old age pensioner who has not received his medical card, there are school medical examinations which take place frequently. If there are four or five children attending school, and their father is unemployed, and if they are supposed to have X-ray as a result of the examination, does the Minister not consider it too much to expect the unemployed father to be obliged to pay 7/6 in respect of each of those four or five X-rays? I feel that this is too important a point for the Minister to remain silent. The old age pensioner without his medical card is a case which is one of many throughout the country and, as has been asked earlier to-night, is a person who has not got 7/6 to do without the X-ray?

I think the Minister is treating the House with a considerable amount of contempt on a very important issue because as Deputy McQuillan has said, the X-ray may be the means of saving the life of the person concerned. Again an X-ray in time may be the means of saving a whole family from an infectious disease. I think the Minister, in accordance with the reasonable manner in which Deputy O'Higgins has put forward his amendment, supported by Deputy Dr. Esmonde who speaks from his own knowledge as a doctor, cannot get away with remaining silent when a case of so great importance and calling for the most sympathetic consideration is put before him. I should be glad if he would make a statement on the matter to clear it up.

Mr. MacEntee

I am accused of treating the House with contempt. I do not treat the House with contempt but I do treat with contempt the arguments I have just heard from Deputy Flanagan and the proposer of this amendment. I do not know whether Deputy Flanagan is aware of what is contained in the Health Act, or in this Bill, but I can assure him that there will not be any interference with the present position for those who are covered by sub-section (7) or Section 15 of the principal Act. Nobody is going to interfere with the present system whereby any person who wants to avail of tuberculosis services can get an X-ray free of charge, nor will the Bill change the position in respect of any child who is receiving treatment arising out of a medical national school inspection. Those matters are not affected by this Bill but they are being trotted out by the Opposition in order to becloud the issue.

Another person referred to was the old age pensioner who had not got a medical card. Let us see what sort of old age pensioner has not got a medical card. It is quite true that there are some old age pensioners who have not got medical cards but they are old age pensioners who are in rather peculiar circumstances. If the Deputy had looked it up he would have seen who they are. They are persons who are not entitled to a medical card because of the provisions of sub-section (6) of Section 15 of the 1953 Act which says that when the yearly means are being calculated they must include the yearly means of any unmarried son or daughter of such person concerned, where the son or daughter is normally resident with such person.

Deputy Flanagan knows the type of old age pensioner excluded by that. He knows that it is an old age pensioner who has assigned a farm and made a covenant whereby he would be entitled to accommodation, maintenance and upkeep. The valuation of the farm may be £100, £120 or £150. That is the type of person that Deputy Flanagan wants this House to believe could not raise 7/6 for an X-ray.

Mr. O. Flanagan

Not at all.

Mr. MacEntee

He can come, as is often the case, driving in his motor car to draw his old age allowance. He can pay 5/- a gallon for petrol but not 7/6 for an X-ray, according to Deputy Flanagan. Is there any use using schoolboy, debating society arguments in a serious issue of this sort? Deputy Dr. Esmonde referred to the person who goes to see a doctor and the doctor says that he requires an X-ray. Then this poor patient trots down to the out-patients' clinic and presents himself there. He has to trot down to it because, according to Deputy Dr. Esmonde, he has not got the wherewithal to pay his bus fare.

Mr. O. Flanagan

He did not go that far.

Mr. MacEntee

If he did not, it is only because he was more moderate than the Deputy.

Mr. T. Lynch

According to the Minister he would be going down in a Cadillac.

Mr. MacEntee

These are fanciful objections. The cost of an X-ray to the health authority is very much more than 7/6 and the cost of specialist's advice is very much more than 3/- or 2/-. They are not recurring charges; they are not going to recur in the sense that they will be daily charges in the same way as the charges made for institutional charges. They are exceptional charges which will arise in exceptional and rare instances, in the great majority of cases. I do not think it a great hardship to ask those who want to see what they look like inside, or who want to avail of the best advice available, to pay this moderate fee. After all, so far as specialist advice is concerned, they would pay more for a packet of cigarettes.

Mr. O. Flanagan

What kind of a packet of cigarettes would cost more than 7/6? Talk sense. They may be 7/6 before the Minister leaves office. That is not a dirty gibe; that is a statement of fact.

An Leas-Cheann Comhairle

Order!

Mr. MacEntee

Deputy Flanagan should simmer down. He should relapse into the silence which he used to maintain on these benches.

Mr. O. Flanagan

I am here now.

A Deputy

You can stay there.

Mr. O. Flanagan

I can assure the Minister I am very comfortable here. I am more comfortable here than the Minister is where he is.

Mr. MacEntee

Let the Deputy become the sort of dumb quadruped to which Deputy Dillon once likened certain people in this House: just be silent and listen. I do not say the cost of the X-ray would be little more than the price of a packet of cigarettes. I said that taking the specialist's advice would be less than the cost of a packet of cigarettes. Perhaps the X-ray might cost as much as two packets of cigarettes; but, damn it all, if the X-ray is going to help him to preserve his life, surely the community is entitled to say: "Well, give up a couple of packets of cigarettes for one week at least." All this talk about a man not having three half-crowns to jingle in his pocket is so much claptrap. Seven and sixpence is 7/6. Of course it is; it always was. The fact of the matter is it is equivalent now, as I have said, to about 50 cigarettes. I do not smoke, but I think that is about the price.

Mr. O. Flanagan

I do not smoke either, but I disagree with the Minister entirely.

Mr. MacEntee

All a man has to do, if he wants to have an X-ray and if he does not come under Section 14, is to deprive himself for a short period of 50 cigarettes.

Mr. Corish

Good man!

Mr. Coogan

Another smokescreen.

Mr. MacEntee

That puts all the pathetic case made on the other side for this amendment in its right perspective and that is what has to be done, if we are to get this country out of the mess in which the Coalition has landed us.

Mr. T.F. O'Higgins

I am not surprised the Minister took so long to get on his feet if that represents the manner in which he refutes the arguments advanced on behalf of this amendment. The amendment is a simple one. It should certainly call for a simple reply, if there is a reply at all.

I do not suggest that a charge of 7/6, or any other charge, may always be impossible to bear. I can assure the Minister that there have been, there are and there may be in the future some people so reckless as to spend their three half-crowns on 50 cigarettes —if 50 cigarettes cost that much. There are some people so unfortunate as to have no means of income. There are some people who may have to spend the three half-crowns on buying 2 lbs. of butter—less than 2 lbs. of butter under the Minister's Government's proposals in the Budget. Whatever the reason may be, all I have asked the Minister to do is to bear in mind that there may be people who have not got the necessary money. To such people, the Minister says: "Because you have not, you will not get any of these specialist services."

That is unreasonable; that is contrary to the policy of the Health Act. It is contrary to the underlying principle of the health services we have developed here. It is contrary to the slogan of the Minister's Party, the Party which asked the people to accept that health should not depend on wealth. It is contrary to common sense that we should, by legislation, say to certain people: "Because you have not got this money and cannot pay, you will not get any specialist services. You cannot be X-rayed."

All I have asked the Minister and the House to do is to say that the charge may be discretionary. These cases may not be many in number. The Minister may be right in saying that such cases may arise only rarely. All I have asked the House to do is to make this charge a discretionary charge and not a mandatory charge in all cases. Why should the Minister come in here blowing hot and cold? Why should he defend the increase proposed in the previous sub-section and say that there it is discretionary; it may be imposed or it may not be imposed? Why should he, then, in relation to this charge insist that in all respects it must be mandatory and no exception may be made?

I think that is an unreasonable attitude and I am astonished at the Minister. He should at least have undertaken to consider this amendment further. He must recognise that quite a number of people do not qualify for free medical treatment, who are not nevertheless in a position to pay even a charge as small as this. The administration of Section 14, as the Minister is aware, differs in different counties. Reference was made to persons in receipt of the full old age pension. When I had the responsibility that the Minister has now, I was informed that there were persons in receipt of the full old age pension who were refused medical registration. I thought that was wrong. I thought it was quite wrong that this State, under part of its social legislation, should regard persons as entitled to a full old age pension but not entitled to free medical services.

As the Minister is aware, I issued a circular to all health authorities advising them to register automatically persons in receipt of the full old age pension and certain other categories. The fact is that circular was not implemented by all county managers and there are counties in which persons in receipt of old age pensions, and not necessarily the kind of case the Minister has mentioned, have been refused medical registration. There are cases in which persons, who never owned a rood of land in their lives and who are in receipt of old age pensions, have been refused medical registration by certain county managers.

It all comes down to this: under the Minister's proposal, no matter what the means may or may not be, no matter what hard luck or ill-fortune may befall, a person who requires an X-ray, for example, cannot have it unless he pays 7/6. Neither can the health authority make it available to him, even though that authority may be convinced that he lacks the three half-crowns, through no fault of his own, because the Minister's proposal says that this charge shall be imposed. All my amendment suggests is that instead of the word "shall" we should insert the word "may", and it will then be a matter within the administration and policy of health authorities to impose a charge where they think it should be imposed, but they will have the discretion not to impose a charge where they are satisfied that such a charge would deprive a person of a service he requires.

Mr. O. Flanagan

I am surprised that the Minister has treated this very important matter with so much comedy. One would expect the Minister to treat this urgent problem with some seriousness. The Minister has pointed out that there is no person in need of an X-ray who would not be only too pleased to sacrifice two packets of cigarettes to see his inside. Those are the Minister's own words. There is no person who ever wanted an X-ray who wanted to see his inside, because if he did itself he would not understand it. It is the doctor who sends the patient for the X-ray who wants to study the X-ray. I feel that for a responsible Minister to have such a statement on record in the House shows complete disregard for the merits of this urgent and sympathetic case. He goes on to say that he will have no trouble finding the 7/6 if he stops smoking two packets of cigarettes. Assuming the person is like the Minister and myself and does not smoke——

Mr. MacEntee

Then he will have the 7/6.

Mr. O. Flanagan

If the person is like the Minister and myself, a nonsmoker, he then has to find 7/6, which means that he must do without a pound and a half of butter. Who has the easier task, the man who has to do without two packets of cigarettes in order to find the 7/6 or the unfortunate man who must do without the pound and a half of butter, or perhaps sacrifice a loaf of bread a day?

An Ceann Comhairle

The Deputy may not discuss matters of taxation on this amendment.

Mr. Corish

It is all done in the name of balancing the Budget.

An Ceann Comhairle

These matters may not be discussed on this amendment.

Mr. O. Flanagan

The Minister gave an example of how the person who required an X-ray could secure the 7/6 for it.

An Ceann Comhairle

Even the Minister may be disorderly.

Mr. M.J. O'Higgins

He could do without a gallon and a half of petrol.

Mr. O. Flanagan

Yes. The Minister is very shrewd. It must be admitted that no man can paint a case to suit his own ends better than the Minister for Health. He gave an example of an old age pensioner who had not his medical card but who signed his place over to his married son or daughter with the reservation that he was to be given free keep, free lodging, and all the rest. Surely the Minister deliberately picked out this type of old age pensioner to suit himself? There may not be so many of those old age pensioners in the State. There is quite a number of old age pensioners who have no medical cards and who never owned a perch of land in their lives, who never had any assignments to make or anything to leave in a will.

As Deputy O'Higgins has pointed out, it is of the greatest importance that the House should now give special consideration to the fact that a person will be refused an X-ray unless he can place three half-crowns on the counter of the clinic. I asked earlier in the night where the person is to get this 7/6. The county council or the county health authority cannot give him the X-ray free. The local authority is prevented from so doing. Assuming the local home assistance officer, the local dispensary doctor, the local county councillor or the local warden, as the case may be, can certify that this is a person who has not got 7/6 for an X-ray, I submit that when this section is passed even though these various people, who are equipped with a first-class knowledge as to the applicant's circumstances, certify that this is a person who has not got 7/6 to spend on an X-ray and who needs the 7/6 to purchase the necessaries of life, not cigarettes or petrol as described by the Minister a few moments ago, that citizen is to be denied the X-ray which, as Deputy McQuillan earlier in the night pointed out, might be the means of saving his life.

One would have expected the Minister for Health to put up serious objections in this matter. Deputy O'Higgins's arguments are not unreasonable. All he is arguing is that it be left to the decision of the local health authority as to whether the X-ray is to be given or not. I believe that the Minister should accept the amendment because he knows from his own experience that the local authorities are extremely strict as to who receives home assistance or who is given any type of public assistance. He can trust the local authority. He can particularly trust the county manager and those given that responsibility to see that no person will be given an X-ray who is not entitled to it.

We are putting up the case of the unfortunate person who is prescribed an X-ray by his doctor and cannot pay for it. That is the type of people in whom we on this side of the House are interested. Will the Minister tell us, without bringing in any red herrings, if the person has not got 7/6 who will give it to him? He cannot have the X-ray unless he has the 7/6. Is that person to carry on without the X-ray and is that person to ignore the advice of his doctor? Surely the Minister will see that the section of the community that is best entitled to obtain an X-ray free will get those facilities.

If a patient who is sent to the clinic for an X-ray and is refused the X-ray, returns to the doctor, naturally enough, there is nothing further the doctor can do for the patient. The doctor has pointed out the importance of the X-ray and the patient not having had the X-ray there is no point in his reporting back to his doctor when his complaint cannot be diagnosed properly.

I am sure the Minister for Health can read an X-ray. Most of us with average intelligence, particularly if we ever had any dealings with or recourse to X-rays, can read one, but for the Minister to tell this House that a citizen is anxious to run off with 7/6 in his hand to get an X-ray for the purpose of seeing his inside is an unworthy statement to come from the lips of any responsible person charged with the administration of the Department of Health.

I would ask the Minister to reconsider this matter because there are many hard-working, honest citizens who will now be denied the right of an X-ray because of the provisions he is introducing and which he is asking this House to pass. While the Fianna Fáil Deputies may say what little inconvenience this will cause to the poorer section of the community, they do not tell us where the unfortunate person is to get the 7/6.

An Ceann Comhairle

The Deputy is repeating himself.

Mr. O. Flanagan

That is the question I have been asking the Minister since 7 o'clock and it is now 9 o'clock. Where is the 7/6 to come from? That is the kernel of the whole situation. If that question could be answered I am sure it would satisfy Deputy O'Higgins and other Deputies in the House and give a great deal of satisfaction throughout the country as well.

Mr. Loughman

I think we have established that a person who has a medical card is entitled to a free X-ray.

Mr. MacEntee

Of course.

Mr. Loughman

I think that is established. The person around whom Deputy Flanagan built his case is an old age pensioner who, the home assistance officer, the dispensary doctor, the warden and the county council are satisfied has no money. Surely a person of that description is entitled to a medical card under any circumstances.

Mr. O. Flanagan

Not always.

Mr. Loughman

Yes.

Mr. O. Flanagan

I have numerous cases in my area.

Mr. Loughman

I am satisfied that such a person is entitled to a medical card and to argue that he is not is simply arguing for the sake of talk. All the reasoning that we have had this evening against this charge of 7/6 is based on very foolish grounds. There is no person who is as poor as Deputy Flanagan suggested who is not entitled to a medical card. I believe that, having a medical card, he is entitled to the X-ray.

Mr. Corish

I am very reluctant to intervene because I am not a member of a local authority. I welcome the intervention of Deputy Loughman. I do not know whether or not he is a member of a local authority.

Mr. Loughman

I am not.

Mr. Corish

At least he has experience of the administration of the health services in his own county. He has given a certain example which he says shows that there is no hardship. May I give another example?

Mr. Loughman

Certainly.

Mr. Corish

This whole Bill is quite a serious matter for the people who are supposed to benefit under it. Let me give the example of the road worker who, say, gets £5 a week. He becomes ill and is ordered to have an X-ray. He is expected to pay 7/6. That may be all right for the first week, but, by reason of the fact that he has £5 a week—at least in my county—he is not entitled to a medical service card.

Mr. Galvin

In sickness, yes.

Mr. Corish

What is the purpose of not giving it to him when he is well?

Mr. Galvin

In sickness, he will get it.

Mr. Corish

It may happen in Cork. That is my complaint about the Health Act, that the administration of it all over the country varies. This road worker with £5 per week becomes ill and, after perhaps two weeks of waiting, he gets his disability benefit, which amounts to 30/- per week. After he has attended a doctor two or three times, perhaps over a period of three or four weeks, the doctor decides that he should have an X-ray. The doctor does not decide that on the first visit. The man has lived on 30/- a week and if then he is ordered to have an X-ray, he is expected to pay 7/6 for it.

Mr. Galvin

No. He is entitled to a medical card then.

Mr. Corish

I will deal with that.

Mr. Galvin

He is unemployed then.

Mr. Corish

That is an argument that we put up when the then Minister, Dr. Ryan, was putting the Bill through the House. We were not listened to. He is expected to pay 7/6 for the X-ray.

Mr. Galvin

He is not.

An Ceann Comhairle

Deputy Galvin will have an opportunity of making his case, if he wants to. Deputy Corish is entitled to speak.

Mr. Corish

I have given the experience in County Wexford and I can speak only for my own constituency. He is expected to pay 7/6, and, under this Bill, if he is ordered into hospital, he will be expected to pay 10/- per day.

I made certain inquiries about this and discovered that in my constituency the maximum charge is the usual charge. I asked a member of Wexford County Council staff, who assured me that the 6/- a day was the ordinary charge. The manager, or whoever administers the Health Act, never once used the discretion which the 1953 Act was supposed to have given to the manager. Members of local authorities are not absolutely blameless in that respect, in not insisting that he should use his discretion. Such a person is not deemed to be in the lower income group until he has been ill for six weeks or two months. That is my experience and I do not pretend to know either Cork City or County. I can speak about the County of Wexford and I know I speak for constituencies represented by some of my colleagues in the Labour Party.

The objectionable thing about this is not the 7/6 or the 3/- for the specialist service; it is the mean way in which the Government tax people who will be ill in order to get £90,000, the same Government as gave a total of £370,000 to the Racing Board and to the master bakers.

Dr. Browne

I should like to put another point of view altogether to the Minister, in the hope that he might reconsider the decision to alter the permissive to the compulsory charge and would consider Deputy O'Higgins's amendment. It strikes me that this proposition by the Minister is on a par with the mediaeval obscurantist window tax under which the more windows, the more ventilation and airiness you tried to get into your house, the more it cost you.

The very serious consequences of this proposition will be felt in the first instance by the doctor, the conscientious practitioner. I do not know if the Minister fully appreciates the position of radiology generally in health services. In making it difficult for a doctor to prescribe an X-ray picture for the patient, he will make a very big contribution towards restricting the use of the advances in radiological technique which can be of great help to the doctor and, of course, in that way, a great help to a patient. It occurs in other branches of medicine where a general practitioner is treating a poor person and he has a choice of two drugs, a very expensive drug which the patient cannot afford and a cheaper drug which he gives the patient. The cheaper drug takes longer, is not so certain, but, at least, it is in most cases effective. The patient is denied the advantage of the speedier and easier drug because of his poverty, but the patient survives in the majority of cases. These are things told to me by general practitioners. I have little or no experience of general practice myself. There are conscientious general practitioners who find that they cannot give a patient a particular medicine because of the cost, and so they give a substitute. In that way, they discharge their responsibility to their patient to the best of their ability in the circumstances.

The trouble about an X-ray picture is that there is no substitute for it at all and the doctor is in the position of either ordering an X-ray picture or not ordering an X-ray picture. I believe that one of the consequences of this provision here is that doctors will tend to become more chary, more nervous of ordering an X-ray picture for patients, the reason being that the vast majority of X-ray pictures are normal and it is only a minority which are abnormal. The general practitioner's trouble is that, if he orders a series of X-rays which he thinks are necessary and which are unnecessary, he has to tell the patient that the series of pictures, costing 7/6 each, are all quite normal and the time will come when the patient will begin to wonder whether the doctor is a fool in putting him to this unnecessary expense. Eventually, the doctor will have to be a very strong-minded man to resist the temptation to say: "Unless there is absolute certainty, I will not prescribe an X-ray picture."

I remember, in the days before chest radiology was free, that many times a general practitioner was very loath to put a patient to the expense of an X-ray picture for fear the general idea would get around that he lost his head immediately a person got a cough and sent the person for X-ray and the person had to pay. The result was that the doctor was eventually in that way—it was a subtle enough influence —frightened into waiting until the symptoms were so clearly defined that he hardly needed an X-ray at all in order to decide whether the condition was active or not.

I think there will be a tendency on the part of the doctor who does not want to cause his patients unnecessary expense to wait, but the trouble about it is that, as I say, it is an impossible situation. If you can tell that there is nothing wrong with the patient, there is no need for an X-ray; it is in the uncertain case that it is required. As I say, the majority of X-ray pictures are normal. Then the doctor will be faced with the prospect of ordering a lot of normal and costly X-ray pictures, or of withholding X-ray until it is probably too late to do any good. I think that is a probable serious consequence of this proposition.

There are other considerations. There are the cases of difficult diagnosis, the difficult early disease type of case, and medical-legal questions may be involved in cases where a person has been subjected to some sort of accident and will not be able to recover damages from an insurance company, a person who falls, for instance, in the ordinary way and probably hurts himself. If the doctor is in doubt as to whether there is a fracture or something like that which can be diagnosed by an X-ray picture, if he hesitates and does not get an X-ray in such a case—he may be concerned about the cost to the patient and he may hesitate to have the X-ray picture taken—then he is faced with the possibility of some medical or legal action for malpractice or something of that nature, because he has not taken the precautions the average medical practitioner would consider to be the normal precautions in such a case.

I think that from the point of view of the patient and the doctor, this is a very considerable deterioration in the existing situation. I think it must inevitably cause a deterioration in the standard of medicine, creating a situation where a doctor, with the best will in the world, may not be able to give his patient the best available treatment. It must also bring about the position in which the wonderful advances made in recent years in the medical field, particularly in radiology, will be denied to people merely because of the fear which the general practitioner will have in his mind on the subject of committing the patient to a whole lot of X-rays in the hope that out of the many X-rays which are normal, he may find one which is abnormal.

I do not think that is a dilemma which should be created. I think no regulation should be passed in this House which will restrict the right of the medical practitioner to use all the modern means at his disposal, including the many new therapeutic substances, in dealing with his patients. I think this proposition of the Minister does that, and I think the amendment mitigates it to some extent. As for myself, I believe there should be no charge at all for these things and for that reason I propose to abstain on this amendment and vote against the section.

Mr. Kyne

I should like to ask the Minister very honestly if he would answer a question when he is replying, if he replies at all. I shall read the particular section on which I am not quite clear. It says:—

"Where specialist services are made available ... there shall be charged, on each occasion on which the services are provided ..."

Does it mean that the fee is to be paid before the services are provided or are the services given first and charged for afterwards? If the latter is the case, I am not particularly worried, because if a person has not got the money, so long as the service is carried out, all they can do is try to get the money afterwards. Should it be the case, however, that the people will not get the service at all until they produce the money, that would be a desperate situation. I should like the Minister to give his views on which comes first, the money or the service?

Mr. O. Flanagan

The Minister may go ahead and answer that question of Deputy Kyne's.

Mr. MacEntee

No; I would rather answer Deputy Flanagan's as well.

Mr. O. Flanagan

My reading of it is that the money must be produced first before the service is rendered. I feel that Deputy Dr. Browne has made a very strong case and has put the merits of the case from an entirely different angle.

Deputy Corish has spoken of the road worker and has put forward a concrete case. I should like to refer to another section of the community, the forestry workers who are in receipt of £5 a week. When such a worker becomes ill and obliged to have an X-ray in the course of his illness, he will be receiving social welfare benefit. He is expected to pay 7/6 for his X-ray. The forestry worker will not have a medical card as a person in receipt of £5 a week has no medical card and is looked upon as a wage earner, not in the medical card category.

In the constituencies which Deputy O'Higgins and I have the honour to represent, there is a large number of forestry workers. We do not want to be faced with difficulties afterwards; we want to put forward our views to the Minister before the difficulties arise. Take the forestry worker who comes in without a medical card. He will be obliged to deprive his family of 7/6 every time he has an X-ray.

Another point that we want to have cleared up is this: assuming a doctor sends a patient for X-ray and that when the patient arrives to have the X-ray, it is found that the pictures have to be taken at different angles, may I take it that the one 7/6 will cover the visit, or does he have to pay 7/6 for each separate picture taken? I do not claim to be—and I am sure everyone in the House will agree that I am far from being—a doctor, but I can understand that an ankle, for instance, has to be X-rayed from various angles. If a patient is sent along with an ankle injury or with an injury to his knee-cap the ankle or knee-cap has to be X-rayed from various angles. Does this provision mean that 7/6 must be paid for each film used or that the one 7/6 will cover a number of films on the occasion of the patient's visit to the clinic?

I view this with the greatest possible seriousness. There may be people—I am not suggesting for a moment that there are—who would be anxious to help the Government to rake in this £90,000 and the moment a patient would appear for X-ray would say: "You will have to have four pictures or five pictures taken" or, depending on the awkwardness of the injury, a larger number of pictures. I want to know does the one fee of 7/6 cover the visit to the clinic or must the 7/6 be paid for each film taken?

Will the road worker, the forester or the old age pensioner who has not got a health card and who receives an injury have to pay 7/6 for each X-ray film taken? For instance, the collar-bone must be filmed from three different angles. Will the worker have to pay 7/6 for each of these three films? If four different films have to be taken of an injured joint will the worker have to pay 7/6 for each of these? I can see very clearly a difficulty arising in this.

An Ceann Comhairle

I think the Deputy has made that sufficiently clear.

Mr. O. Flanagan

I hope I have made it sufficiently clear to get an answer from the Minister.

Mr. J.J. Collins

Deputy Flanagan's speech seems to indicate that there is a peculiar situation in Leix-Offaly where the married forester does not get a health card. I am surprised to hear that a married forestry worker is not in receipt of a health card. There must be some peculiar law operating in Leix-Offaly. In my constituency of West Limerick we have married foresters and road workers all of whom are in receipt of health cards. I do not think Deputy Flanagan should shed too many tears or have any doubt whatsoever as to whether the people mentioned are entitled to free X-ray examinations. The section only asks the people in the middle income group to pay. A large number of people come for X-rays to the county infirmary in Limerick. If they are in the lower income group the X-ray examination is free. It is also free to those with chest complaints.

Mr. T.F. O'Higgins

It is free in all cases now.

Mr. J.J. Collins

We know exactly what it costs us. In the Limerick County Infirmary, a voluntary hospital, we know that X-rays are costing an average of 30/- each to the institution. I do not think that we are putting an inordinately high burden on the middle income group by asking them to pay 7/6 for an X-ray examination. Deputy Flanagan talks about paying 7/6 each for films taken from different angles. That is a childish way of approaching this problem. Perhaps Deputy Flanagan wanted to have his banter with the Minister. The sum of 7/6 is not an extraordinary charge.

Mr. O. Flanagan

It is not to you people, although I do not see you throwing away money.

Mr. J.J. Collins

Take a farmer in the middle income group with a valuation of something like £50. He may be in receipt of a fat creamery cheque every month. Does Deputy Flanagan say that a charge of 7/6 to such a man is an outrage? Deputy Kyne asked a simple question as to whether the charge was made before or after the X-ray examination. It has always been the practice that the charge is made after the examination. In my county if it is found that the person cannot pay, even though he is in the middle income group, it is brought to the notice of the county manager who is the health authority and if there is a case of hardship the manager will remit the charge. Asking members of the middle income group who can afford it to pay 7/6 for an X-ray examination will not do any serious harm.

Mr. Kyne

Is it not desirable that the Minister should say whether payment of the charge will be demanded before or after the examination?

Mr. J.J. Collins

I cannot anticipate what the Minister will say. That has been the practice.

Mr. Kyne

I should like that made clear by the Minister.

Mr. Loughman

It might be safer to leave the matter open.

Mr. T.F. O'Higgins

It might be safer to accept the amendment.

Mr. Russell

I gather from the Minister's remarks that the purpose behind the introduction of this Bill is to relieve the Exchequer of a certain amount of expenditure. I agree with the sentiment behind his objective when he says the country is going through an exceedingly difficult time and that it will take general sacrifices on the part of the people before we can hope to regard ourselves as being in a strong economic position again. I am wondering if the Minister, in bringing in this Bill, is asking a certain section of the community to pay more than might be regarded as an equitable share of the burden.

This Bill does depart from the 1953 Health Act introduced by the Minister's own Party. The reason for that departure is that the Minister desires to save the Exchequer something like £90,000 a year. I agree with the principle that if a person can afford to pay for a medical or any other service he should pay; principally because by doing so he would give an opportunity to those who cannot pay to enjoy the same service. This country cannot afford to carry generally the standard of living which it has been enjoying in recent years. While some sections have been enjoying that standard of living, quite a substantial number of them have not been doing so because there has been an inequitable sharing of the burden, and I am afraid the recent Budget, to a very large extent, will result in that burden being still more inequitably distributed. I have already made that point in my contribution to the Budget debate and I shall not repeat myself now.

I agree with this amendment and I shall support it. I think this charge should be permissive on the part of the local health authorities. It might be true that a person in the category visualised by the Minister might be able to pay this small charge but what this Bill does say, in effect, is a very different thing. One cannot always say that on all occasions persons in the middle income group can afford to pay 7/6. I think a mistake has been made in arguing too strongly about the widow with one independent son. That family might have a good income. The son might be in a position to pay.

On the other hand, there are a number of people who are not entitled to medical cards, who are members of the middle income group and who are finding things very difficult. I do not think it would require a very active imagination to suggest that there are occasions when, to those people, a charge of 7/6 might be very difficult to meet. A person in the middle income group with four or five children might find it difficult at a certain time to produce 7/6. That person might be a non-smoker, already making heavy sacrifices for his family. I would suggest, therefore, that the amendment, which is a reasonable one, would get over that occasion. My experience is that the local health authority, in my case the city manager, gives a reasonable interpretation of these cases.

I would like to support the amendment proposed by Deputy O'Higgins. I do not think the Deputy has in mind savings to the Exchequer but it does do something towards making the burden a little more equitable and I think it is a reasonable amendment.

Mr. MacEntee

It is a great pity that some of the speeches that have recently been delivered here were not delivered at the outset of the debate on this amendment so that a person would have serious arguments to deal with. Let me take the arguments put forward by Deputy Russell. Before I come to deal with that, let me make it quite clear that no person who is in receipt of a medical card, no person who is entitled to the benefit of Section 14, is going to be affected by the proposals in this Bill in any way whatsoever. I want that to go home and to sink into the mind of Deputy O. Flanagan.

Mr. O. Flanagan

We know that.

Mr. MacEntee

Yes, the Deputy has made a confession that he knew it. So did Deputy O'Higgins know it; but that was not the tenor of their speeches. They were talking about the poor man who could not pay 7/6, the poor man who did not smoke or do anything like that, who could not find 7/6; the poor man who is an unemployed person.

Mr. T.F. O'Higgins

What about him?

Mr. MacEntee

They kept on like that and the whole purpose was to mislead the House and mislead the country.

Mr. O'Malley

Hear, hear!

Mr. MacEntee

Let us stop talking about the people in the lower income group, though that has been made the basis of the speeches on the amendment. We are not talking about people in the lower income group but, as Deputy Russell has pointed out, we are dealing with those who are in the middle income group.

Mr. T.F. O'Higgins

We are talking about the person who has to pay 7/6.

Mr. MacEntee

I have listened to the Deputy with a great deal of patience. Take your medicine.

Mr. T.F. O'Higgins

At 7/6 a bottle.

Mr. MacEntee

The Deputy knows this is a foolish amendment.

Mr. T.F. O'Higgins

7/6 a bottle.

Mr. MacEntee

The Deputy wanted me to talk and I am going to talk now if he will permit me to without interruption. I was coming to the moderate, sensible, reasonable speech made by Deputy Russell. He asks why cannot we accept the amendment and leave this to the discretion of the local authorities. Let us see what is involved. It involves 7/6 for an X-ray examination, plus the first visit to the specialist and if there happens to be a return visit, as probably there would be, another 2/-. That is 12/6. That is the total sum involved and for the sake of determining whether a person can or cannot pay 12/6, we are going to have, as Deputy Dr. Browne called it, an inquisition into a man's family circumstances— what Deputy O'Higgins said was prying into his household affairs—instead of saying plainly and simply it is better to find this 7/6 and any other consequent specialist charges than to have this investigation into family circumstances.

We know that every self-respecting man would prefer to pay the 7/6, and whatever else would be involved, rather than have this examination of his means by a county manager or some person deputed by the county manager to undertake that investigation. Deputy O'Higgins and Deputy Dr. Browne want that sort of means test. I think that if a man is in the broad category of the middle income group and has not got a medical card he can without any undue hardship find 7/6. At least the vast majority of the people in that group can. There is no use in our legislating to meet the hard case. It makes administration impossible. It makes the cost of the service entirely expensive. There is no use in arguing from a case of the old age pensioner to the general case of the middle income group who are going to be affected by the Order when the Order is made. Therefore, I suggest to Deputy Russell that having looked at it in a practical way there is not any merit in this amendment.

I think that amendment was put down without any great deal of thought. It seems to have been put down on the basis: "Well, you have given the local authorities permission under sub-section (4) of Section 15 of the Act, then why not give them permission under sub-section (5)?" It is one of these things that are done without due thought, without trying to find out what the implications of it are. These are the implications of the amendment. If a man wants to have an X-ray you say: "Let him go and prove to the county manager that his family circumstances are such that they will not permit him to raise 7/6, and that his working sons and working daughters will not give him the 7/6, if he does not have it in his own pocket." Does that dispose of the whole talk about the three half-crowns and where they are to come from?

Mr. McQuillan

Is the payment made before or after the X-ray?

Mr. O. Flanagan

He will not answer that.

Mr. T.F. O'Higgins

He does not know that.

Mr. MacEntee

I will give the answers in the order of importance.

Mr. McQuillan

That is most important.

Mr. MacEntee

It is not really of practical importance. There is no use in having a means test after the X-ray.

Mr. T.F. O'Higgins

The money must be put down.

An Leas-Cheann Comhairle

Order, order! The Minister must be allowed to speak without interruption.

Mr. MacEntee

It is a great pity I cannot get any good manners from there. I had to listen with a great deal of restraint to some of the foolish speeches that were made by Deputy O. Flanagan. Deputy Flanagan did not even read the section in the Bill and, not having read it, he ventured to inform Deputy Kyne what he thought the section meant. I say he did not read the section. If he did read the section, we would not have had the fascinating citations of broken ankles, broken necks, and the rest.

Mr. O. Flanagan

Hard necks.

Mr. Kyne

We can see them without an X-ray.

Mr. MacEntee

We would not have had that talk because the section says 7/6 in case of an X-ray examination and, when the radiologist is examining the patient, surely he will take as many films as he thinks are necessary. I say there is the answer to all of Deputy Flanagan's futile case which he has spent hours from 7 o'clock building up here to deceive and mislead the people. Have we settled that?

With reference to whether the payment will be made before or after, I have pointed out the futility of having an investigation of means in relation to this matter. Therefore, as far as I am concerned, I think it would be more convenient and, indeed, it would make very little difference to suggest that the fee should be paid in advance. It is not uncommon for many people to consult their own family doctor and pay in advance. Many people do that and a lot of doctors will allow the bills to run, but in any event what will happen is this: a scheme of payment has to be devised and this section permits the Minister to do that. It permits him to make an Order. He is not bound by the Health Act to table the Order, but the Order will be tabled in the House. All the details of that Order can then be subject to an examination, and any Deputy who wishes may put down a question in relation to it or raise the proposals in it on the Adjournment. At the moment, my feeling is it can be done without undue hardship. If we can devise a practical way of doing it, the fees would be paid in advance. There is no use having a charge for an X-ray and then, maybe, have to chase a man all around the country in order to collect the 7/6 from him. It would be much more convenient and much more economic to do it in the way I have suggested.

Let us get back to the other alleged hard case—the hypothetical case of the uninsured person out of work who may not have a medical card. This is one of the examples cited by the mover of the amendment. Of course, a person in the circumstances described could get a medical card immediately ad hoc. He would, of course, then be entitled to all the benefits of the services. The further we go into this matter, the more absurd appears to be the contention that an unemployed, uninsured person can be affected by this proposal. I have disposed of the lower income group. I have disposed of all the women availing of the maternity services and all the persons requiring X-ray examinations under the tuberculosis schemes. Accordingly, we are confined solely to those people who, being in the middle income group, have recourse to the family doctor, in the first instance, and are prepared to pay him his fee, in the first instance, before they are advised to have an X-ray examination.

This brings me to the case made against the section by Deputy Dr. Browne. I think the arguments which he adduced were no stronger than any of the arguments adduced by the other speakers to whom I referred. Deputy Dr. Browne, in my opinion, built up a highly fanciful case on the basis of the supposed reluctance of a general practitioner, himself treating his patient for a fee, to advise him to pay another 7/6 in order to have an X-ray. On what basis?—on the basis that most of the X-ray examinations did not disclose any abnormality or any condition which required treatment. Surely to goodness, most patients whose doctor felt it would be advisable for them to have an X-ray examination would be glad to have the reassurance which he feels when told that his X-rays were entirely normal, even at the cost of 7/6 for the X-ray.

I cannot see that the mere fact that a man will have to pay 7/6 before he has an X-ray examination which will enable his family doctor to diagnose his case more accurately will deter either the patient or the practitioner from advising him to avail of the service. It is just incomprehensible to me that that argument could be seriously put forward in this House. It would indicate that those who use it believe that the members of our medical profession are lacking in moral courage and in rectitude, since because they fear the X-ray will show that the patient was not suffering from any abnormality, they will hesitate to send the patient forward for such examination. I think I have shown there is no merit in this amendment and I hope that we will be able to dispose of it now, having discussed it for four hours.

Mr. O. Flanagan

The more the Minister speaks on this section, the meaner and the lower this Bill becomes. I feel that the payment of the 7/6 in advance is the meanest and the lowest piece of legislation passed in this House for quite a long time. It was even so mean that I am sure it shocked Deputy Collins who thought the 7/6 was to be paid after the X-ray examination. The Minister points out that it is easier to make them pay before than to have to chase people around the country to collect it. That gives one to understand that this will affect the person who has not the 7/6, since the Minister makes provision to have the 7/6 paid before the X-ray is taken. This is the lowest piece of legislation passed through this House, since the Budget, anyway.

Mr. Kyne

When I expressed my surprise at the fact that the Minister answered my question in the way he did, I think Deputy Collins must be equally surprised. I knew, even when I asked the question, that Deputy Flanagan and the Fine Gael Deputies were under a misapprehension. To my amazement, the Minister indicated that so far as he was concerned at present, before a person who is not the holder of a medical card is advised by a doctor to have an X-ray examination, he must pay 7/6. I think the Labour Party took a right line in refusing to vote to amend the Act. We intend to vote against the section as a whole.

Mr. O. Flanagan

Would the person who could only scrape up 7/- and could not find the other 6d. still be refused?

Mr. T.F. O'Higgins

It is no laughing matter.

Mr. Russell

The Minister mentioned that his Bill was intended to save the person the embarrassment of a means test. I suggest that anybody who felt embarrassed and could pay the money could still pay the 7/6, if he thought it was permissive. Secondly, the Minister did not advert to my point that in regard to the Bill, as it stands, a person must, whatever his circumstances, if he is in that class, pay 7/6. There is no way out for him. Perhaps the Minister might find some way of covering the few occasions on which a person in that group would not have the 7/6. I cannot believe that such a situation would not arise. I am sure it can arise.

The Committee divided: Tá, 71; Níl, 33.

Tá

• Aiken, Frank.
• Allen, Denis.
• Bartley, Gerald.
• Beegan, Patrick.
• Boland, Gerald.
• Boland, Kevin.
• Booth, Lionel.
• Brady, Philip A.
• Brady, Seán.
• Breen, Dan.
• Brennan, Joseph.
• Brennan, Paudge.
• Breslin, Cormac.
• Burke, Patrick.
• Calleary, Phelim A.
• Carty, Michael.
• Childers, Erskine.
• Clohessy, Patrick.
• Collins, James J.
• Corry, Martin J.
• Cotter, Edward.
• Crowley, Honor M.
• Cunningham, Liam.
• Davern, Mick.
• de Valera, Eamon.
• de Valera, Vivion.
• Doherty, Seán.
• Donegan, Batt.
• Dooley, Patrick.
• Egan, Kieran P.
• Egan, Nicholas.
• Fanning, John.
• Faulkiner, Pádraig.
• Flynn, Stephen.
• Gallagher, Colm.
• Galvin, John.
• Geoghegan, John.
• Gibbons, James.
• Gilbride, Eugene.
• Gogan, Richard P.
• Griffin, James.
• Haughey, Charles.
• Hillery, Patrick J.
• Hilliard, Michael.
• Humphreys, Francis.
• Kenneally, William.
• Kennedy, Michael J.
• Killilea, Mark.
• Kitt, Michael F.
• Lemass, Noel T.
• Lemass, Seán.
• Loughman, Frank.
• Lynch, Celia.
• Lynch, Jack.
• MacCarthy, Seán.
• McEllistrim, Thomas.
• MacEntee, Seán.
• Maher, Peadar.
• Medlar, Martin.
• Moher, John W.
• Moloney, Daniel J.
• Mooney, Patrick.
• Ó Briain, Donnchadh.
• O'Malley, Donogh.
• Ormonde, John.
• O'Toole, James.
• Ryan, James.
• Ryan, Mary B.
• Sheridan, Michael.
• Smith, Patrick.
• Traynor, Oscar.

Níl

• Belton, Jack.
• Burke, James.
• Byrne, Patrick.
• Byrne, Tom.
• Carew, John.
• Coburn, George.
• Coogan, Fintan.
• Cosgrave, Liam.
• Costello, Declan D.
• Costello, John A.
• Crotty, Patrick J.
• Dillon, James M.
• Esmonde, Anthony C.
• Fagan, Charles.
• Flanagan, Oliver J.
• Giles, Patrick.
• Hogan, Bridget.
• Hughes, Joseph.
• Jones, Denis F.
• Kenny, Henry.
• Lynch, Thaddeus.
• MacEoin, Seán.
• McMenamin, Daniel.
• Mulcahy, Richard.
• Murphy, William.
• O'Donnell, Patrick.
• O'Higgins, Michael J.
• O'Higgins, Thomas F.
• O'Reilly, Patrick.
• O'Sullivan, Denis J.
• Reynolds, Mary.
• Rooney, Eamonn.
• Russell, George E.

Tellers:—Tá: Deputies Ó Briain and Hilliard; Níl: Deputies O'Sullivan and Crotty.

Question declared carried.

Amendment negatived.

Question proposed: "That the section stand part of the Bill."

Mr. Kyne

The Minister's outlook in regard to the first amendment was that we should depend upon the attitude of county managers in dealing with the increase from 6/- to 10/- per day for patients. On the second part of Section 1 his attitude was that the county manager should not have the right to decide whether the charge of 7/6 should be put into operation. I suggest that these two conflicting ideas, one in one part and one in another part, indicate that this is merely an attempt to secure more money for the purpose of economising on Government funds.

It would be preferable if the Minister were honest and said: "Look, the county managers will do exactly what I tell them. I am telling them to increase the middle income group charges to 10/- a day in future; charge all X-rays at 7/6; make the charge for specialist visits at 3/- for the first visit and 2/- for every subsequent visit. That is my way of contributing to balance the Budget." If it were said like that, I could understand but it is being cloaked up and make to seem as if something good were being done for the middle income group and the ordinary working people.

We are opposing this section because we believe it is bringing about a worsening of conditions. It is going away from the Health Bill of 1953. Let there be no mistake about it. It is not being done with the intention of helping any section but it is being done with the intention of taking the load off the Government.

Dr. Esmonde

Section 1 deals with the parent sections, 14 and 15, in the 1953 Act. As I stated on the Second Reading, I am often asked by people: "Who is eligible for treatment under certain sections?" I want a definite ruling from the Minister whether a person, who has what is known as a health card, is exempt from all health charges whatsoever. I was specifically asked this question the day before yesterday. I was approached by a constituent who has a health card and who had to attend for specialist treatment at two separate hospitals. In both cases he has been sent a bill. For the purpose of getting it on the records of the House, I want to ask whether a health card exonerates a person entirely from all payments?

Mr. Dillon

In matters relating to this code, I am as innocent as a child, but I have a fair experience of life in rural Ireland. My experience in the part of rural Ireland where I live was that, prior to the implementation of this whole Act, any poor neighbours of mine, if they fell ill, if they had defective sight or if there was something seriously wrong—anything that required to be done was done and if they were not able to afford to pay for it, they did not pay for it. Whereas those of my neighbours, whom we all knew were perfectly well able to pay for whatever attention they wanted, got that attention, and they got the bill. There was a fight they could all join in but, finally, they paid the bill. The neighbours knew perfectly well they were well able to pay the bill.

Now a situation has arisen in my part of the country where a person, whom I know perfectly well to have no means whatever, is suffering from rapidly failing sight. She attends at the local dispensary for specialist service, believing that there is now available to her something which she never had before. When she gets there she is informed by the specialist that there is a queue waiting which will occupy the doctor's time for the next four months and that, if she will get into the queue, he may see her some time next November. As a matter of fact, that is quite impossible because it is not impossible that the girl will lose her sight if she waits so long. Of course, some of us get together, take her down to Sligo and pay a specialist in Sligo to see her and will have her sent to hospital in Dublin, if that is necessary.

The impression I get of this section, and of the code, is that those who really want treatment cannot get it and that a great many people who ought to get treatment for nothing are liable, under this new arrangement, to be levied by the local authority in a sum that they will be extremely hard pressed to pay. I wonder would the Minister examine this whole question with a view to determining are the people who are entitled to get benefit getting it. Are the people who can afford to pay for it paying for it and are those who cannot afford to pay for it allowed to get it without being constrained to pay more than they can afford?

I do not claim to know intimately the circumstances in urban areas. Most of my life was lived in rural Ireland and anybody who shares my knowledge of rural Ireland will know that there are a great many people in rural Ireland who try to keep up the best appearances they can, but very often the burden of unexpected illness is wellnigh intolerable when it comes upon them. Their neighbours know it and, under the old dispensation, such cases were provided for by the fact that there was plenty of testimony forthcoming that, whatever the appearances were, these people honestly were not in a position to pay as a result of family responsibilities or something else.

There are also in rural Ireland lots of people eminently skilled in making a poor mouth. These are the people very often who get in at the expense of the person who appears to be well able to pay but who, in fact, cannot. I am not at all sure that the code as at present established, or as proposed to be revised under this, contains the flexibility that it used to have. This much is certain: whatever the reason— and I am not prepared to certify that we know what the reason is—before this health code came into operation none of my neighbours went uncared for.

Since it came into operation, very deserving cases are informed that unless they wait four or five months they will not get what they want. I do not think the proposal contained in this section will put right that wrong. I think what will happen under this new departure is that the present difficulties will be further excerbated—that the person who has to keep up a decent appearance and bear the burdens as far as he can will be soaked still further, while the skilled wangler in rural Ireland will do as well or better than he did before.

It would do this House no harm, if people do not feel free on the far side to testify here to what they themselves know of their own areas in various parts of rural Ireland, if at least at their own Party meeting or in the confidence of the Minister's room they would tell him whether what I say is true or false. I suspect there are many Deputies who know what I am saying is true. It would be a salutary step if someone would set his hand to putting right what is wrong, so as to secure that those who cannot afford the cost of the treatment the maintenance of their health requires, shall get it if needs be for nothing. I do not think that is happening now.

These are the people I worry about; these are the people for whom, in our own unorganised methods of the past, we were able to cater in rural Ireland. I ask Deputies on all sides is it or is it not true that, prior to the enactment of this whole health code, since the hospital accommodation was expanded to the point where we had room for everybody who required hospital treatment, five years ago, any poor labourer in rural Ireland could get treatment, and we would fight out afterwards whether he should pay for it or not? We who knew them were able to ensure in our own areas that those genuinely unable to pay were not made to pay. Is it or is it not true that at present many of those people are not getting the treatment they require and to which they should be entitled?

If that is the fact, is it not time the Minister, instead of authorising others to raise the charges on those who cannot afford even the charges at present levied, should address himself to the general problem of providing for those who want treatment and cannot pay for it—treatment that is at present being postponed in favour of treatment of those who might be able to look after themselves if they were required to do so?

Mr. Desmond

As Deputy Kyne has said, we are opposing this section, and for a clear reason. We recall what was said when the Health Act was originally introduced and we in the Labour Party supported it. We remember the accusations by Fianna Fáil when in Opposition about the slowness of the then Minister for Health in introducing the various benefits set out in the Act. I can recall many prominent members of the Fianna Fáil Front Bench taunting members of the inter-Party Government about slowness in introducing those benefits. They suggested, even asserted, that the inter-Party Government did not intend to put into operation some of those specialist services. Now we are not even at the crossroads; we are back beyond the cross itself. Instead of enjoying the advantages provided in the Act itself when introduced, it is the other way round.

A Deputy from Cork spoke here to-night. I do not want to speak behind his back, but, as I am a colleague of his, he will not mind, as both of us are members of the one Board of Assistance. I give him credit for his activities on that Board of Assistance when he, in company with other members, including myself, had very good reason on many occasions to complain about the unsatisfactory system regarding medical cards and the examination of the means of applicants for cards.

In regard to a charge of 7/6 for an X-ray, I know myself—and perhaps I have reason to know—that sometimes one X-ray will not show a positive or negative result and three or four may be needed. For instance, a very common complaint in modern time is the stomach ulcer or duodenal ulcer, Now, an X-ray will show fractures or broken bones very quickly, but in some other complaints—as I know myself—three or four may be necessary. Take the case of the road worker cited by my colleague to-night. We all know of cases where a man may be at work and hoping for the best, knowing that if he gave up employment, maybe with the county council, he may lose his job—or, what is equally important to him, he may lose holiday pay on a Church holy-day if he gives up work for a period, to go for a medical examination. In his case, because of total family income, he may not be allowed a medical card. He must pay, first of all, for the services and advice of his local doctor, and then for the X-ray; and also lose a day's pay. Because he is not in the labour category under the Act, he may have to pay that 7/6 about which there has been so much said to-night. That is a common case known to members from Cork on opposite sides of this House to-night. We know also of the long delays—sometimes necessitated by circumstances—in the examination of the means of those persons, even when they apply for the card, prior to going for an X-ray, at a time when they must pay the 7/6.

Our views on this are well-known, but I want to put a final point to the Minister. In relation to the increase in hospital charges I have had cases myself. Every member of the House, I am sure, who is a member of a local authority meets cases very much similar in this way, of a man or woman in hospital who has been denied a medical card. In olden times, people in this country were known as saints and scholars. Whatever about there being scholars to-day, I am not sure about the saints. We know that, while the whole family income is checked by the local assistance officer it very often happens that the woman in the home, where she has a grown family, is not in receipt of the amount of money which the members of the family are supposed to be bringing in. We know that that happens.

It happens also that one member of a family wants to stand by a parent and very often has to pay for hospital charges for a parent; yet the other members do not pay their way. The Minister may come along and say that they should but the difficulty is that they do not. Under the present system when a medical card is denied to such people they are placed in the position of having an extra burden placed on them.

Finally, we are told that this in itself will mean a saving to the local authority. That may be but it is poor satisfaction to the person who now, under this measure, will be put in the position of having to pay more. It is poor satisfaction for a person to have to pay more, at the most critical period in his life, when he is ill, whether it is for an X-ray, specialist treatment or for hospitalisation. At the same time the person is quite likely a ratepayer. He must, on the one hand, pay more for his medical treatment and while on the other hand he may be told there will be a reduction in the rates, it is no reduction for him because of the extra charges imposed on him. We in the Labour Party say that the Health Act, with its limitations, was at least a step towards progressive legislation dealing with a very important aspect of national life. We supported it but we refuse to support, at this stage, any measure that will in any way qualify the benefits given then, benefits which apparently are being taken away now.

Minister for Finance (Dr. Ryan)

I just want to say a few words in regard to what Deputy Desmond has said. The Health Act, 1953, cannot have made any great difference to the lower income groups. The wording of Section 14, which lays down the classes entitled to free treatment, is exactly the same as the wording used in the Public Assistance Act, 1939, so there is no difference in the world. Therefore, if there is a belief, and it may be true, that people who were getting free treatment before this Act was passed will not get it now, it is due to administration. It is not due to administration centrally but due to administration locally.

Mr. Kyne

Was there not an instruction sent out in regard to certain categories?

Dr. Ryan

No. I am talking about the enactment and the words are the same. It is also alleged, I think by Deputies Kyne and Desmond, and I think by Deputy Dillon, that people are charged in hospitals now who were not charged before the 1953 Act. That is due to administration and not to the Act. The 1953 Act laid it down that the lower income group is in the same position. Under the 1953 Act the county manager could charge—before this Bill came along—I think 6/- per day but he need not charge that. Before the Act was changed he could charge £1 a day and there was nothing to stop him doing so. The 1953 Act limited him to 6/- a day for the middle income group. It did not give him power to charge more. Again, as far as hospital treatment for the middle income group is concerned, they are better off than they were before.

If Deputy Dillon is right in his observations of what is happening in the rural areas, it is due to a stricter interpretation and treatment on the administrative side locally. The county manager, however, is not compelled to be more strict. In fact, he is in certain cases compelled to be more lenient. We come along now and we propose to make a charge for X-ray and specialist treatment for the middle income groups. Before the 1953 Act was passed, they had to pay the full charge. Now we are going back part of the way and we are saying: "You must pay something." That is due to our straitened circumstances. We must not exaggerate this. The total amount the Minister hopes to save is £90,000. We all know that the total amount spent under the 1953 Act was £1,000,000; in fact, I think it was more but our Estimate was for £1,000,000. So, if we are taking back £90,000 out of the £1,000,000 there should not be such a great furore about it. That is my point. It is only a small amount of the £1,000,000 that is being spent, less than 10 per cent.

I have not been here for the whole debate; I came in here to give my colleague some support, but during the short time I was here one would imagine that we were inflicting an intolerable burden on certain members of the public. We do not think that is correct.

Mr. O. Flanagan

Surely the Minister must realise that never before were people asked to pay for X-ray treatment in advance until now. When this section is passed a person must pay his 7/6 in advance.

Mr. MacEntee

There is nothing in the section that says that.

Dr. Ryan

Nothing.

Mr. O. Flanagan

The Minister said that in order to save the local authorities the trouble of running around after people who might not be able to pay he would make them pay in advance.

Dr. Ryan

That was sensible.

Mr. McQuillan

I agree with the point made by the Minister for Finance that the 1953 Act was a step forward. Many of us here were not satisfied that the progress made by the 1953 Act was anything like what it should have been but, at the same time, we accepted that it was a step forward. The step now before the House, however, is going back long before 1953. It is a reactionary step and it is undoing portion of the work, or the progress, that was made by the 1953 Act. On that basis I personally criticise the proposal as strongly as I possibly can.

Progress reported; Committee to sit again.