I move:—
That a sum not exceeding £6,132,050 be granted to complete the sum necessary to defray the charge which will come in course of payment during the year ending 31st March, 1960, for the salaries and expenses of the Office of Minister for Health (including Oifig an Árd-Chlaraitheóra) and certain services administered by that Office including grants to local authorities and miscellaneous grants.
I feel it will be to the convenience of the House if I begin by quoting some of the more important vital statistics in respect of the preceding calendar year. At this stage, the figures are provisional but any subsequent adjustment which may have to be made will not affect the general picture.
The number of births registered in 1958 was 59,510 as compared with 61,242 in the preceding year. The birth rate, while lower in 1958 than in 1957, continues to be higher than in adjoining countries.
The number of marriages in 1958 was 15,111, compared with 14,657 in 1957, an increase of over three per cent.
The general death rate in 1958 showed a slight increase over the previous year—12.0 against 11.9 per 1,000 population, due mainly to an increase in the number of deaths from diseases of the heart.
Deaths from the infectious diseases continued to decrease. In the case of tuberculosis they fell from 696 in 1957 to 584 in 1958, thus reversing the slight upward trend which appeared for the first time since 1943, in 1957. Deaths from influenza fell from 687 to 311. Deaths in children under 2 years old from diarrhoea and enteritis and in children of all ages from whooping cough, diphtheria, measles and scarlet fever fell from 150 to 121. Deaths from poliomyelitis numbered 9 against 13 the previous year.
Another satisfactory feature was the decline in maternal deaths to 61, which, though still too high and comparing unfavourably with the figure in some other countries, was a considerable improvement on the figure of 81 for 1957.
Finally, mortality from cancer fell to 4,683 as compared with 4,819 in 1957.
The major development in the health services in 1958/59 was the enactment and bringing into operation of the Health and Mental Treatment (Amendment) Act, 1958. The implementation of this Act was necessarily made coincident with the raising of the income limit for compulsory insurance under the Social Welfare code from £600 to £800 for non-manual workers. It extended the benefits of the Health Act, 1953, to the additional group of persons thus brought into insurance, to the dependants of that group, and to noninsured persons and their dependants whose family incomes, broadly speaking, did not exceed £800. These groups were absorbed into the scope of the services in the last quarter of the financial year without any major upset to those services or any diminution in the standard of those already provided for the group previously eligible.
During the year I received the report of the committee set up by my predecessor to consider the fluoridation of water supplies. The task entrusted to the committee was to investigate whether by this means the incidence of dental caries—in nontechnical language, teeth decay— particularly in young persons could be reduced substantially. The report has been published and copies are in the Library. I am sure Deputies will join with me in paying public tribute to the members of the committee for the careful and efficient manner in which they dealt with the problem. Their recommendations, all of which were made unanimously, have been accepted by the Government and legislation to give effect to them is in course of preparation.
Another body which deserves public thanks is the National Organisation for Rehabilitation. It is the body which again was set up by my predecessor to consider the question of rehabilitation and whose interim report has been before me for some time. Unfortunately the issues with which it deals are not as clear-cut or as readily capable of solution as the issues with which the Fluoridation Committee had to deal. As Deputies can readily appreciate, rehabilitation is not only an extremely complex subject but is also one of immense scope. At one extreme we have the self-rehabilitating individual who, if he should have contracted a cold, is glad to cure himself with a jorum of punch and, maybe, an aspirin before going to bed; at the other extreme, however, we have the seriously disabled person who must have complete re-training to enable him to follow a new occupation, where this happens to be feasible; or, where this is not feasible, as occasionally happens, to help to make him less dependent on others in merely living. Since rehabilitation covers the entire field of doing everything reasonable to repair the ravages of physical or mental defect or disease, it will be readily understood how vast and difficult the problem is. The interim report on the subject is still being examined and, while that examination is proceeding, I do not think it would be appropriate to publish it. Apart from anything which may or may not have been dealt with in it, I should stress that through the medium of the hospital services and through a variety of voluntary agencies, many of which receive subventions from public funds, a great deal is already being done in this field.
During the year, my Department had to deal with some complaints about the manner in which the health services have been operating. The majority of the complaints which I receive on this score relate to entitlement to services under Section 14 of the Health Act, 1953. Some complain that too few, others that too many, are accepted as entitled to these, that is, broadly, to the full range of free medical and hospital treatments. Others complain that, although entitled to dental or ophthalmic services, people have experienced difficulty or delay in obtaining those services. Still others allege they have been charged too much by health authorities for the hospital services provided for them; so that some who regarded themselves as entitled to financial help towards the cost of services availed of in voluntary hospitals, found they had to meet bills altogether beyond their expectations. I propose to deal separately with each of these types of complaint. In passing, I should say that, happily, there were few complaints regarding the standard of the services provided.
In regard to Section 14—that is, in regard to the medical card—complaints, Deputies will have seen from replies I have given to Parliamentary Questions from time to time that the number of persons covered by medical cards, relative to the entire population, varies very widely from area to area. In some areas, more than 40 per cent. of the population is covered by medical cards; in others, the percentage is less than 20. Strangely, in the areas in which the percentage covered by cards is highest, the number of complaints that medical cards have been refused is as great as, indeed, if not greater than, the number in the areas in which the percentage is lowest. While I must stress that, as Minister for Health, I have no appellate functions whatsoever in regard to such complaints, I do, whenever the circumstances seem to warrant it, pass on representations to the appropriate manager for his further consideration, and in that respect I am bound to say that, in general, managers have seldom failed to convince me of the correctness of their decisions.
The second type of complaint to which I have referred is the complaint of difficulty and delay in providing dental and ophthalmic services for eligible persons. Here the hard inescapable fact is that money cannot be found at present to provide a comprehensive and readily-available dental service for all who may need it. For that reason, it is settled policy to concentrate so far as possible on the children and to provide only a limited or in some cases an emergency service for other eligible groups. It is inevitable, therefore, that many persons in need of dental services cannot get them immediately, but must wait until their turn comes. The situation in regard to ophthalmic services does not, in general, give rise to the same volume of complaints. In some areas, however, there are long waiting lists, and in these I am hopeful that measures will be put into effect to improve the position.
The next type of complaint is that eligible persons who receive treatment in local authority hospitals are charged the maximum amount which the law allows—I am not dealing here, I should say, with maternity cases where treatment in a public ward is free or with infectious diseases including tuberculosis, where it is also free—but the law is quite specific on the question of charges. A person who is covered by a medical card is automatically entitled to free treatment. If he is an eligible person, but does not hold a medical card, the maximum charge is 10/- a day. But that limit of charge is subject to an important proviso which is often overlooked: to wit, that the person concerned does not obtain private or semi-private accommodation. Apart, however, from this condition, 10/- per day is the maximum permissible charge. Moreover the 10/- per day is not an invariable charge; it must be adjusted to the patient's financial circumstances. This was clearly contemplated by the Act; so that the practice which until recently was common, of automatically furnishing a patient with a bill computed at the rate of 10/- per day is, in my view, indefensible.
It has been contended that a charge computed at the maximum permissible rate is in the nature of a provisional assessment, which can be reduced when the patient, or a councillor or a Deputy on his behalf, makes representations. Not only do I not accept that contention, but I feel that the practice of overcharging in the first instance is very objectionable; for it may lead a patient to believe that he has received through improper influence, something which he would have received as of right. The patient, on admission to hospital, makes a declaration as to his circumstances, and, in my view, he is entitled in law to have his account made out on the basis of that declaration.
Of course, the patient's declaration should be checked, and in most cases can be checked, I think, even during his period in hospital. If it is found to be incorrect or misleading, he can be reassessed. If there are good grounds to suspect that he deliberately made a false declaration in order to get something to which he is not entitled, he should be prosecuted. During the year I caused a letter to be addressed to each county and city manager, drawing attention to this matter; and I feel that in those areas where the offending practice was current, it has now been ended. If it should happen, I should be glad to hear evidence to the contrary and I shall deal with the position accordingly.
Probably the largest number of complaints received during the year related to eligible patients who, either themselves or through their family doctor, had made their own arrangements to enter hospitals of their own choice. In most of these cases, the arrangements were made without recourse to the local authority. In consequence, the patients were faced with bills considerably greater than they had expected from the hospital, or from the hospital doctors, or, in many instances, from both.
To elucidate how this can occur, I shall take the case of an eligible patient who enters a hospital of his own choice and accepts treatment in a public ward—it is important to note in this connection that I am dealing only with treatment in a public ward. In this case, the local authority pays the hospital for the patient's treatment at a reduced rate, which is equivalent to the rate it would pay for him if it had sent him to hospital, less 10/- a day. The patient himself is then personally liable to the hospital for a charge of 10/- a day.
In order that there may not be any confusion between this charge and the other charge, I want to make it clear that in this instance the patient has entered the hospital of his own choice and the charge is not "a sum not exceeding 10/- a day" but a flat 10/- a day. The amount paid by the health authority, plus the patient's 10/- a day, covers all charges and the hospital cannot charge anything extra for special services, X-rays, drugs, etc. It is not permissible either for the doctors who attend on a patient under this arrangement to charge any fee for their services in the hospital, since there is an element for remuneration for the doctors in the amount paid by the health authority to the hospital. I want to emphasise that in those circumstances in general no charge beyond the permitted 10/- per day is made. The complaints I have received in relation to cases of this kind have, in the main, arisen from misunderstandings, and all of them have been or will be put right.
So much for the patient who accepts treatment in a public ward. Where an eligible patient accepts treatment in a ward which is designated or described as private or semi-private—and in some hospitals wards which are described as semi-private may be quite large wards indeed—the patient is liable to the hospital authority for whatever charges it chooses to make, over and above the subvention which in the case of a general hospital is 8/- per day which is paid to it by the health authority. Furthermore, the patient is liable also for the fees charged by the doctors who treat him in hospital. This, as everyone knows, may be a costly business for the patient. But once he has accepted private or semi-private treatment, he has no escape from the liability which he has thereby incurred; and the Minister for Health cannot do anything to help him. To adapt perhaps a little crudely an old saw, he has selected his bed and must pay for it.
