In view of the different amendments which have been tabled —and one amendment appears more or less in the form of a motion—I wonder would it be possible for you, Sir, to indicate at this stage the order in which the amendments will be taken?
Health Services : Motion (Resumed).
Yes. First of all, the amendment to delete "June" and substitute "November" will be taken. The question will be "That word proposed to be deleted stand". If it is negatived, then the motion: "That proposed word be there inserted" will be put. If that is accepted, we will have to put the word suggested into the Labour Party amendment.
For the sake of brevity, suppose we assume that the amendment relating to "June" and "November" is defeated?
Then we take the amendment to the amendment.
Then the main amendment?
Then the main amendment, yes.
In the certain event of the main amendment being defeated, the motion will be put?
When Deputy O'Higgins has finished, we will have a vote?
Yes. First of all, as the mover of the motion, I should like to express my appreciation to Deputies who have joined in this debate and who have faced up to their responsibilities as members of this House by considering carefully and responsibly this very important social problem of how best we should organise our health services. It was the object of my Party, the Fine Gael Party, in tabling this motion at the outset of the new Dáil that there should be a fruitful discussion and, we hoped, an acceptance by the Government of a policy in which we sincerely believe. I appreciate that, generally speaking, there was an effort on the part of Deputies on all sides of the House to discuss this matter objectively and properly.
Before I deal further with the motion and the amendments, I should like to correct one or two misapprehensions which were expressed by Deputies with regard to our proposal. Yesterday evening, while expressing his appreciation and support for the services envisaged in our insurance proposals, Deputy Tully said that it was like asking for the moon because they could not be achieved. He said he could not see how these important services could be provided for a total sum of £8½ million when the cost of the present services to the State totals £18 million.
There is a misapprehension, I fear, in Deputy Tully's mind with regard to that, because that is not our proposal. At present, the cost of what are known as individual health services carried in the Health Estimate—these are the domiciliary medical services, the dispensary service, the mother and child service, institutional services, and so on—total roughly £3 million and that £3 million at the moment is divided into two, half paid by the State and half paid by rates. The figures are very rough, but the balance represents the cost of maintaining our hospitals and institutions. Our scheme is directed towards the cost of individual health services. Institutions will still have to be maintained, financed and paid for in the way in which they are at present paid for. So that, in fact, what is involved in our proposals is an increase in expenditure on health of the order of around £5 million a year and that additional expenditure will be financed, as we propose, on the basis of an insurance approach; in other words, on the one-third approach, that the State will pay one-third, employers one-third, where people are in employment, and employees one-third, where that is possible. So that, in fact, there is no impossibility in that.
Undoubtedly, you cannot have better health services without an increase in expenditure and what we are concerned with is to achieve better health services and to achieve it in a way in which it is possible in our society. Obviously, everybody would love to have all the services increased, without having to pay a penny for it. Unfortunately, the facts of human society do not permit that and, if you desire to improve the social structure, you have to face up to the way in which it is to be paid for.
We recognise and believe sincerely that once you have the main burden of the financing of health legislation falling on the taxpayer or the ratepayer, falling on a few, if you like, you will always be up against any improvement in the service; you will not, in fact, get such an improvement. I do not blame people for it but the fact is that the taxpayer or the ratepayer today would start a revolution in the country if he were told that he had to face immediately an increased expenditure on health of the order of £5 million or £6 million. It just could not be done.
Nevertheless, the services which we ask for are of the most rudimentary form, the most elementary form in any civilised Christian country. It is essential, in my view, that an ordinary person of limited means should be able to face the prospect of sickness or illness in his family with some mental calm. It is wrong, in my view—and if something is not done about it in the near future, it will lead to serious problems—to continue a system whereby a worker's child or a worker or his wife falls sick and they have to face the prospect of paying for a doctor. I am not suggesting that the doctor's fee will be exorbitant—it probably will not be—but the visit of the doctor to the house means for that worker a prescription for a drug or medicine at the chemist's shop, which often he is unable to face.
It is no good going around the place in blinkers. It is wrong to have that gap and that defect in our health services and that is what is there and that is what will remain so long as you have the Health Act, no matter what changes you bring into it, in its administration or so on. The Health Act does not cover domiciliary medical service for persons except those who can show that they are totally unable to provide for themselves. That was one misapprehension that was in the mind of Deputy Tully and, perhaps, in the minds of others.
And still is.
I hope I have dealt with that. Perhaps I will talk to the Deputy some time. I do not want to delay the House unduly. Another misapprehension that was mentioned by some Deputies was that, under our proposals, contributions would have to be exacted from those who at the moment get such services as are there free and without charge, that is, medical card holders. That is not so. That is not intended and will not happen. In the way we organise our society, there are clearly defined categories of persons who are amongst the poorest of the poor. They are: the unemployed person—he is known; he has not got to prove himself in any way, apart from registering as unemployed; he is out of a job and he is known; the figure is known; the people are known—home assistance recipients —they are established under one branch of our social activities; old age pensioners—they, again, are known; there is no question about them. The other category of very poor people is, surely, land holders whose valuation does not exceed £15.
These are, clearly, the poorest of the poor and, in fact, of the total number of medical card holders in the State at the moment, 271,000, I have little doubt that the vast majority are already covered by these categories. There may be other cases that it is not possible to define or put into immediate categories. We bear that in mind, but, in relation to all those people in those circumstances, they will get the same services as everybody else but no contribution will be taken from them. They will be carried under the scheme by the insurance fund.
I shall not chase all the points that were made in the debate but certain points were made by some of the Deputies opposite who from time to time did commit the venial sin, if you like, of forgetting their objective approach to this debate.
The Minister for Health, speaking on behalf of the Government, started off by making the debating point that I had changed my view in relation to the Health Act and that having left that side of the House and come over here, I was now opposed to the Health Act, and he made the case that, as Minister, I was in its favour. I would just like, for the record, a Cheann Comhairle, very briefly to re-state the facts.
When I became Minister for Health, in 1954, I was faced with absolute chaos, so far as the health services of this country were concerned. There was a smouldering, bad row going on between not only the doctors, but with the nurses and every other service in the State concerned with health. No arrangements, good, bad or indifferent, had been made by my immediate predecessor to bring into operation the services laid down in the Health Act. Apart from necessary arrangements with the professions concerned, there were not even the hospital beds in the country to provide for the operation of the services. I was aware, as a Fine Gael Deputy, and as a Fine Gael Minister in the inter-Party Government of the day, that a majority of this House had voted in favour of the Health Act. We had not; we had opposed it; but a majority of this House had passed it and it was, therefore, my duty to see that it went into operation.
That did not mean that I was in its favour. I was not, but I was concerned to discharge my duty to this House and I proceeded to do it. I, first of all, sought time and I did it by coming into this House and stating precisely what I had in mind. I asked the House to postpone the operation of the Health Act for which my predecessor had made an Order bringing it into operation on August 1, 1954. He pressed the button. It was to be a delayed explosion. He left office and pressed the button, in the hope that the bomb would go off when his successor was there. If it had gone off, health services in this country would have disappeared.
The Dáil, in its wisdom, gave me the right to bring in the Health Act in my own way and in my own time.I proceeded as a matter of urgency with the hospital building programme and I proceeded to have discussions with those who were to operate the services. After all, the necessary medical care cannot be given to sick people by a policeman; it is necessary to have a doctor. You cannot send a soldier to act as a nurse in the hospital; you must have nurses. I had to get the co-operation of these people and the Minister was rather unfair when he quoted a speech, which I made as Minister in 1955, in which he said that I had expressed approval of the Health Act. I did no such thing. If he had read fully the passage in the speech from which he was quoting, he would have read to the House these words:
Accordingly, in order to avoid complete chaos in this country, and particularly in order to avoid unnecessary hardship being imposed on persons and classes who up to 12 months ago were being provided with services, I found it necessary to move in this House a Bill entitling me as Minister to build a scheme out of the Health Act bit by bit, according as the necessary facilities would become available. In doing that, I did not express any approval of the methods contained in the Health Act for the achievement of better health services in this country. In fact, I still regard the Health Act as not being the best course for achieving even the limited aim that it sets out to achieve.
Would the Deputy give the reference?
Volume 151, at column 1553 of the Official Reports. I made the position perfectly clear and the view which my Party and I expressed when speaking to this motion is consistent. We were against the Health Act when it was introduced. As a Party in the inter-Party Government, we did our best to make it work. I undertook in 1954—if there is a political point to be made out of it, I will give it—particularly to the Labour Party, as a matter of political honour, that before we left office, so far as I could, I would see the services promised in the Health Act in operation. I was able to achieve that, not as an election stunt, as the Minister for Finance said today, but at the beginning of April, 1956, before there was any discussion about a general election. I was able to make the necessary orders providing that the different sections of the Act went into operation, not on paper but as a real measure with the co-operation and understanding of all professions and bodies concerned and with the necessary hospital buildings completed.
It is my complaint now, and the complaint of my Party, that since that, despite the efforts, this Act just cannot do it; it cannot provide the service because the policy is faulty. You cannot make a silk purse out of a sow's ear and that is what is facing this House. It is unnecessary to go over again the defects of the Act but remember under the Health Act—and it is no good saying it is not there as the Parliamentary Secretary to the Minister for Lands wishfully said last night—a free medical service, a service without direct charge, is provided only for those who can prove themselves to be paupers.
That is not true.
The Parliamentary Secretary says it is not true. That is what——
Thirty per cent. of our people are not paupers.
Thirty per cent. of our people are put in the position under the Fianna Fáil Health Act that they have to try and prove themselves paupers.
They have to try to prove themselves to be paupers.
Unpalatable as it may be, and no matter how it may make the Parliamentary Secretary wriggle in his seat, may I say again that here is a phrase which was borrowed from the Medical Charities Act, 1851——
Legalistic argument.
——that medical services should only go to "those unable by their own industry, or other lawful means, to provide for themselves." I invite the Parliamentary Secretary to take down the Oxford Dictionary and look up the definition of a pauper. He will find that a pauper is a person who is unable, by his own industry or other lawful means, to provide for himself. Do we not know it? There are unfortunate people who may be able to pay something, some portion of a doctor's fee, part of a chemist bill, but they will not get a medical card because they have not shown that they are completely unable to provide for themselves.
Thirty per cent. of our people have them.
That is part of the policy of the Health Act and can people not realise that? Are we going, by committees and window-dressing, to allow that system to continue? No amount of window-dressing or changes in administration can affect the written word of the Health Act, because it is there and it is the law.
Again, under the Health Act, and no change of administration will alter this, there is no medical service provided for what are called the middle income group. The middle income group are not persons of affluence. Generally speaking, they are the generality of producers in the country, the workers, the small farmers, those engaged in different industries and trades. They total some 1,600,000 people. These, the backbone of the country, representing at least 50 per cent. of our people, under the way we organise our health services at the moment, receive no help whatever in relation to medical service outside hospital. I think it was Deputy Hogan who made this point very succinctly, that the result is that we drive those people into hospital. Sickness in the family means large medical drug bills, apart from fees for medical treatment. What happens inevitably is that that possibility is not faced and the simplest thing is to go into hospital, and into hospital they go.
We have today, as a result of a faulty medical service for the poor, operated through one doctor who frequently cannot meet their requirements, and as a result of no medical service for the middle income group, a very high hospital intake. Look at our bill for hospital maintenance. When I was Minister for Health it was £7½ million or £8 million in 1954. Each year it is increasing by sums of the order of £2 million. It was £10 million last year; this year it is going to be £12 million and next year it will be £14 million. Up it will go each year, because more people are there.
Our hospital beds are always full and the costs of medical treatment and hospital maintenance are just mounting all the time. We are paying now in the cost of health services largely for the maintenance of institutions. Should we not have a look at why that is? Should we not try to bend things the other way? Instead of maintaining the system of services that tends to force people into hospital, should we not have a look at them before they go into hospital and try to bring about, if it is within our means, the development of services that will keep them out of hospital?
That is what we have in mind. We want to build up, through an insurance scheme, a proper medical and nursing domiciliary service so that, when sickness affects a family, the worker whose wife or child is sick or who fears sickness himself will not be afraid to call in a doctor, that he will be able to go to the doctor of his choice and say to him "I do not feel too well", or "One of the kids is a little bit sick", that the doctor will have the interest to visit that person and will not be hesitant, as he should not be, in prescribing a necessary drug or medicine or whatever it may be, so that, by a simple operation of that kind, frequently the recourse to hospital may not arise.
I cannot see in what way we are wrong in desiring that. I cannot see in what way the people would not be served by such a service. I can see immense benefits from it. There are 14,000,000 working days per year lost at the moment to our labour force; 14,000,000 working days disappear at the moment from our production because of casual or occasional illness amongst workers and hospitalisation of one kind or another. Is it not in the interests of the country to try to obviate that?
We are faced at the same time with a rising hospitals' maintenance bill, costing the taxpayer, the ratepayer and everybody else more and more, merely in discharging the bills. Should we not try to obviate that? Should we not try to dispel the anxiety, worry and neurosis caused to many decent families with the prospect of illness? If we can do that for a cost within our resources, which is going to be spread amongst heads of families, at a limit that can be easily afforded, in my view we should. We will never do it unless we accept the principle of insurance. You are never going to get, in the way in which our system is organised, a situation in which a large sum of this kind can be collected, certainly in taxation. You may aim towards it and you may grope towards it but, as you are groping towards that objective, the other bills are increasing all the time. As I say, no amendment of the Health Act can alter that, because it is not in the Act. It is not the policy and it cannot be provided.
As an example of what I mean, under the Health Act there was to be a dental service, not only for the poor but for the middle income group. Everybody was to get free dental service. Is it there? Is there any hope of its ever being there? We all know it is not and that it cannot be provided because it costs too much. To provide a dental service—and the section of the Act has not even been put into operation—an estimate given to me when I was Minister put the total cost at £2½ million. This equalled the cost of all the other services put together.
Of course, neither I, my successor nor anyone else is ever going to ask the taxpayer to foot that bill for an ancillary health service. Therefore, that section does not apply. It was a political carrot at one time to be dangled in front of the public. Now the carrot is gathering dust in the back shelves. We have no dental service, and so long as we have a Health Act with that policy we will never have a dental service here. There are many other defects in the Health Act to which I have referred and I shall not refer to them again. The fact is they cannot be cured by changes in administration. The policy is wrong, the Act is wrong, and there it is.
Deputy Dr. Browne intervened in this debate after the Minister for Health. I am a little bit sick of Deputy Dr. Browne. He is not here now, but he wraps himself in a cloak of shining white and comes in here, abrogating to himself the sole right to talk in relation to poverty and disease among our people. What is he doing? He is trying desperately to fan up the old flames which some years ago made him temporarily an important person in this country. He says our views here are confused. I am not going to swap epithets with Deputy Dr. Browne, but his solution for our health services is to provide them absolutely free on the basis of the T.B. scheme and other measures in relation to disease. He says that, and he hopes nobody will take him up on it. I will take him up on it. If we are to finance our health services in that way, will Deputy Dr. Browne, some other time when he attends to his duties here, stand up and tell our people what taxation is going to yield a total of £23 million? Who is going to pay for it? Is he going to advocate taxing bread and butter and the simple articles of diet which the poor people have to have?
It does not solve anything saying our proposals are confused or ill-thought out and that we are in some way antediluvian, when he himself has no constructive suggestion whatsoever to put forward in this House. Not even England, that he so greatly admires in relation to social services, would seek to finance health services on the basis of general taxation. They do not do it; they ask the people to contribute on the basis of insurance, and the insurance proposal is part and parcel of the national health services in Britain. Deputy Dr. Browne apparently does not appreciate that. I hope we shall have an end to that sort of arrant contribution. During discussions here Deputy Dr. Browne has never in relation to health matters put forward a single constructive proposal ever since he was Minister for Health away back ten or 11 years ago. He has added nothing except confusion and trouble.
The Parliamentary Secretary to the Minister for Lands, speaking, I suppose from a very old brief, said that under the Fianna Fáil Health Act, all specialist services were provided free. You know, that was the situation when I left off. I brought those services into operation. When a person went into hospital—a person of the middle income group—no charge could be made, but my successor introduced the Health and Mental Treatment Act of 1957 which, in its very first section, provides:
"There shall be charged for specialist services for middle income groups such charge as may be specified by the Minister, and that such charge shall be collected in such manner as may be directed from time to time by the Minister."
I moved an amendment to substitute for "shall", the word "may". The Fianna Fáil Party lined up to defeat that amendment. The position now is that there is no discretion on the part of local authorities: these charges must be imposed. Furthermore, they must be collected. There is no question of wiping it out. I have said enough in relation to our proposals. They are clear proposals. They have been called ill-thought out by some Deputies. I can only assure the House that our plan for health took a number of years to prepare. It is well documented; it is fully thought out; and it was not prepared, as the Parliamentary Secretary to the Minister for Lands said last night, on the spur of the moment as an election gimmick. Our views on this were crystallised a considerable time before the election took place.
We are satisfied that inevitably, whether now or in the future, these proposals will be accepted. For that reason, we look with considerable suspicion on the amendment put forward by the Minister for Health and the Government. We are being asked to permit a number of Deputies here to get together and make recommendations to the Minister for Health on health policy. The motion contains our recommendations. We know it is right. We believe the country will think so also and we find it slightly strange that any Government should renege on their own responsibilities. We believe it strange indeed that the Minister should come into this House to throw the health baby at the House and ask the House what to do with it. Surely it has been accepted by this time that a Government are elected to carry out their policy and to bring proposals for legislation before the House. It is, accordingly, a very strange thing that the House is asked to make proposals for legislation to the Minister.
I hope the Labour Party does not fall for that because if it does, it will rue it. If it falls for this stunt put forward by the Government, the Party will be very sorry indeed. Let the Labour Party apply a test to the Minister's amendment: will the Government agree to the Labour Party amendment to have a time limit on the deliberations of this Committee? If it does not, the object of this Parliamentary exercise is to take health out of this House for a number of years, to put it into the political limbo of forgotten things because it is awkward for the Government, because the Minister for Health and apparently the Minister for Finance still believe in the Health Act, though I have no doubt many of the younger Fianna Fáil Deputies realise that policy is wrong. These men cannot turn their backs on it, so it is to be postponed. We believe that is wrong. We have a clear proposal and we certainly do not fall for that sort of inaction on the part of the Government.
In conclusion, may I express my appreciation to the Deputies and the Minister for Health of the manner in which this debate has been conducted? I hope it has served a useful purpose and that, however it is achieved, from the discussion we have had, there will be some change, I hope, urgently and quickly, made in the interests of a proper health service. If that is done, we will feel we have achieved the object we had aimed at.
There are three amendments to the motion. The first is by Deputy Sherwin, and I am now putting that amendment—that the word "November" be substituted for "June" in the amendment proposed by the Labour Party.
I am accepting that amendment which means that the word "November" be introduced into the Labour amendment instead of "June".
Amendment agreed to.
I am now putting the Labour amendment, as amended.
The Labour amendment is a two-pronged one which I cannot accept. It calls for liberalisation which would be contrary to the statute because it would involve the local authorities in difficulties with the Local Government auditor and myself with the Auditor General. I would accept a proposal that the Select Committee should report before November of next year, and if the Labour Party would be agreeable to amend their amendment to impose only a time limit on it, I would have no difficulty in accepting it.
Is November not a time limit?
I am prepared to accept November.
I am afraid I am a bit confused, first, because of the fact that when the Minister for Finance spoke earlier, he made the point that in fact our amendment was unnecessary for another reason—that the county managers were administering the thing and that we should deal with the county managers. Now the Minister for Health says he is prepared to accept a time limit, if we delete that portion. Does he mean he will accept June as the time limit?
No, November.
That means the Minister will accept Deputy Sherwin's amendment and not ours.
The Deputy's amendment has been amended by Deputy Sherwin's amendment. I am agreeable to accept the Labour amendment, as now amended. If the House deletes the words in the Labour amendment following "1962", we can then agree to the setting up of a committee, with the understanding that they will report before November of next year.
We agree with the Minister's suggestion, but I would urge that his Department might ask county managers to deal with the matters provided for in the Act. They are not doing that at the moment.
I am now putting the question: "That the Labour amendment, as finally amended by the deletion of all words after `1962', be added to the Minister's amendment".
Question put and agreed to.
I am now putting the main motion: "That the words proposed to be deleted stand". This is to delete certain words and add the Minister's amendment.
In other words, we vote "tá" and Deputies opposite vote "níl".
I am not quite clear on this. You are now putting the Ministerial amendment?
I am putting the question: "That the words proposed to be deleted in the original motion stand"; in other words that the original motion remain intact.
Question put: "That the words proposed to be deleted in the motion stand".
The Dáil divided: Tá, 44; Níl, 80.
Tá
- Barry, Richard.
- Belton, Jack.
- Browne, Michael.
- Burke, James J.
- Burton, Philip.
- Byrne, Patrick.
- Clinton, Mark A.
- Collins, Seán.
- Connor, Patrick.
- Coogan, Fintan.
- Cosgrave, Liam.
- Costello, Declan D.
- Costello, John A.
- Crotty, Patrick J.
- Dillon, James M.
- Dockrell, Henry P.
- Dockrell, Maurice E.
- Donegan, Patrick S.
- Dunne, Thomas.
- Esmonde, Sir Anthony C.
- Farrelly, Denis.
- Flanagan, Oliver J.
- Gilhawley, Eugene.
- Governey, Desmond.
- Harte, Patrick D.
- Hogan, Patrick (South Tipperary).
- Jones, Denis F.
- Kenny, Henry.
- Lynch, Thaddeus.
- MacEoin, Seán.
- McGilligan, Patrick.
- McLaughlin, Joseph.
- Murphy, William.
- O'Donnell, Patrick.
- O'Donnell, Thomas G.
- O'Higgins, Michael J.
- O'Higgins, Thomas F.K.
- O'Keeffe, James.
- O'Reilly, Patrick.
- O'Sullivan, Denis J.
- Reynolds, Patrick J.
- Rooney, Eamonn.
- Ryan, Richie.
- Sweetman, Gerard.
Níl
- Allen, Lorcan.
- Bartley, Gerald.
- Blaney, Neil T.
- Boland, Kevin.
- Booth, Lionel.
- Brady, Philip A.
- Brady, Seán.
- Brennan, Joseph.
- Brennan, Paudge.
- Breslin, Cormac.
- Burke, Patrick J.
- Calleary, Phelim A.
- Carroll, Jim.
- Carter, Frank.
- Carty, Michael.
- Casey, Seán.
- Childers, Erskine.
- Clohessy, Patrick.
- Colley, George.
- Collins, James J.
- Corish, Brendan.
- Corry, Martin J.
- Cotter, Edward.
- Coughlan, Stephen.
- Crinion, Brendan.
- Crowley, Honor M.
- Cummins, Patrick J.
- Cunningham, Liam.
- Desmond, Dan.
- de Valera, Vivion.
- Dolan Séamus.
- Donnelan, Michael.
- Dooley, Patrick.
- Egan, Kieran P.
- Egan, Nicholas.
- Everett, James.
- Fanning, John.
- Faulkner, Padraig.
- Flanagan, Seán.
- Gallagher, James.
- Galvin, John.
- Geoghegan, John.
- Gibbons, James M.
- Gilbride, Eugene.
- Gogan, Richard P.
- Haughey, Charles.
- Hillery, Patrick.
- Hilliard, Michael.
- Kennedy, Michael J.
- Kyne, Thomas A.
- Lalor, Patrick J.
- Lemass, Noel T.
- Lemass, Seán.
- Lenihan, Brian.
- Lynch, Celia.
- Lynch, Jack.
- MacCarthy, Seán.
- McEllistrim, Thomas.
- MacEntee, Seán.
- Meaney, Con.
- Medlar, Martin.
- Millar, Anthony G.
- Moher, John W.
- Mooney, Patrick.
- Moran, Michael.
- Murphy, Michael P.
- Ó Briain, Donnchadh.
- Ó Cellaigh, Seán.
- O'Connor, Timothy.
- O'Malley, Donogh.
- Ormonde, John.
- Pattison, Séamus.
- Ryan, James.
- Sherwin, Frank.
- Smith, Patrick.
- Spring, Dan.
- Tierney, Patrick.
- Timmons, Eugene.
- Treacy, Seán.
- Tully, James.
Tellers:—Tá: Deputies Crotty and O'Sullivan; Níl: Deputies J. Brennan and Geoghegan.
Question declared lost.
Question: "That the Ministerial amendment, as amended, be inserted in the motion" agreed to.
Main motion, as amended, agreed to.