The debate that has just concluded on the Credit Union Bill dovetails perfectly into the debate on the health services. The principle is exactly the same: it is one of mutual help. That is the principle underlying Fine Gael health policy as distinct from the Government's policy which is one of creating classes or divisions and projecting them into the future, divisions which were regarded as respectable in Victorian ages but which we do not regard as having any proper application to our needs today. We find utterly unacceptable the evidence, which the Minister says he has, which to him indicates that hardship is seldom caused in the middle income group through family doctor's bills. If it be that hardship is seldom caused it is because in many cases people do not undertake the liability of family doctor bills. They avoid that hardship feeling they are not in a position to bear the cost. Not infrequently a breadwinner or a mother postpones medical attention. It is not an irregular thing for an adult with family responsibility to put off consulting a doctor hoping the ailment will pass or else they endeavour to cure it by being their own home doctor. In a significant proportion of cases this leads to ultimate hospitalisation. It is in order not to impose on families the necessity to postpone medical attention that we in Fine Gael have been advocating that to be a worthy one a medical service should include people who were formerly excluded and whom the Minister seeks to exclude in the system he regards as an advance.
He says in the same paragraph as he evidences that no hardships exist, that it is his intention not to include these people within the ranks of those who will enjoy medical services in future free of charge in respect of a particular service. The Minister says it is intended that better and more formal arrangements should be made to assist persons in the middle income group in obtaining drugs where undue expense arises. I am considerably worried about the interpretations that can be put on this. "More formal arrangements" may mean that help in the provision of drugs and medicines will be given if and when expenditure on drugs and medicine exceeds a specific figure. I think the Minister in his introductory remarks or on some other occasion said it was his intention to provide that where expenses on medicines and drugs went above a certain ceiling help would be forth-coming.
It is vital that the level of this ceiling should vary according to the number of dependants and according to the length of time a person's income may be reduced through illness or injury. Perhaps the Minister proposes to provide for all these things in his regulations but we have the fear, enlightened by experience, that no matter how well-intended the regulations are some people will be outside their scope and some harm will be done because ceilings will be fixed too low. We appreciate that the present system has been unsatisfactory in more ways than one and for a service to be successful it must be easy to use and clearly understood by those intended to benefit under it. I am certain that our present health service is not easily understood nor easy to make use of. It is not even understood by public representatives who are members of health authorities. I suppose we must try to avoid that situation in future but the danger is that once we begin fixing regulations the Department of Health like the Department of Social Welfare will become a purely accounting agency, forgetting that its primary purpose is to relieve human misery, and that it will be obsessed by the obligation that lies on every public authority to render a true and exact account according to the letter of the law, and that such concern will get priority over what should be an equal concern, the spirit of the law.
We are glad that at long last it is proposed to make improvements in the district nursing service so as to provide free of charge to a larger number of people home nursing services for the aged and chronic sick. Again, this is to be one of the three classes which now exist in relation to health services. We think the home nursing service if limited to aged and chronic sick will be insufficient. Many family problems arise particularly in large urban centres where the spirit of good-neighbourliness does not operate, not because people are not charitably inclined, but because they do not know their neighbours' problems. The result is that frequently in these centres mothers of young families neglect to look after themselves medically and hesitate about lying up in bed, as they might be medically advised to do, because there is nobody to look after the children or themselves while the mother is confined to bed and the father at work.
It is highly desirable to have a nursing service available so that in cases where mothers of families find themselves, through illness or injury confined to bed, a nurse or home service is available to look after the children. At present what not infrequently happens is that if such a crisis comes upon a family in an urban centre and there is no relative available to come and stay in the home the children are put in institutions or in reformatories, which is unfair to the children and to the mother. It does not help the mother because she is worrying about the children and the children are worried about the absence of their parents. I should like to see an extension of the home nursing service to provide for people in such circumstances.
The Minister says in paragraph 61, on page 38 of the White Paper, that "Treatment of defects found at school health examinations is similarly free, whatever the parents' means." I should like to think that was always so but I have brought a case to the Minister's attention which he is going to look into and I would be very interested as to the outcome. Certainly in relation to some of the defects found at school health examinations in the Dublin area, the parents have been charged with the cost of maintaining children in institutions for the treatment of their defects and such charges have been imposed after an examination as to means. I have known of cases of this kind and it is undesirable that this should be so. Perhaps the health authority has made a mistake and if so, I hope it will soon be corrected. I would urge, if a mistake has been made, that refunds be made in all cases in which charges have been made.
The cases to which I am particularly referring are those relating to mental retardation in children who require to be educated in special institutions. These institutional services have not been made available to all parents in the Dublin area and this is not as was intended, as far as we know. We are glad that the abominable and irritating charges of 7/6 for an X-ray and 2/6 for other visits to the out-patient department are being abolished. They should never have been imposed. We are told that the amount collected last year under this heading was £48,000. I do not know what the cost of administration was but I imagine that when the cost of administration and the inconvenience caused to the sick and to the hospital authorities are added, the gain would be negligible and certainly not commensurate with the revenue secured.
It is clearly indicated that this White Paper "The Health Services and Their Further Development" is a political document. That is indicated by the fact that in all of this book, which consists of 67 pages and 133 paragraphs, only one paragraph is given to the only advance in our health approach for several decades past. I refer of course to the Voluntary Health Insurance Scheme. That Board was vigorously attacked by the Fianna Fáil Party when it was set up, just as the Fine Gael health policy was also vigorously attacked. When legislative proposals were brought in, the Fianna Fáil Party still said they could not understand it and that the scheme would collapse. It is interesting to note that the same kind of remarks were made about the same health policy ever since 1957. We were told that it would be utterly impossible to abolish the dispensary system, that it had to be retained, and that no modification was possible. Now, nine years later, we find that some modification is permissible. The Voluntary Health Insurance Scheme has been a great success and what we in the Fine Gael programme, in the great O'Higgins social reform, seek to achieve is to extend to all the community, irrespective of means, the benefits now available under that scheme.
It is interesting to note that the Minister is pleased with the Voluntary Health Insurance Scheme and also pleased to note that the board continues to improve its benefits and is now considering an extension of its field of activity so as to offer protection against abnormal medical expenses outside hospital. One wonders if the Minister pondered on why the board is considering this. As I understand it, there are two reasons. One is to improve the service which is available, but in addition, to reduce the rate of hospitalisation which exists under the Voluntary Health Insurance Scheme and the system under which the benefits are available only in the event of hospitalisation. This has led to doctors inquiring whether people are insured under the scheme and, on finding that they are, encouraging them to go into hospital in order to get in hospital free, or at a considerably reduced rate, medical attention which could be given at home, but if given at home would require perhaps the daily attendance of a doctor or nurse and payments in full for all drugs and other attention. This is the justification for the Fine Gael approach to health. We want to get rid of any system which encourages a high hospitalisation rate. The Minister is not doing that in his proposals and that is why we find a great deal of them utterly unacceptable.
In paragraph 115 of the White Paper, certain figures are given for the estimated cost of the improvements. When we saw a table of estimated cost, we thought that although apparently the Minister had been avoiding providing us with details, that at last he was going to get down to it, but we were sorely disappointed. While the Minister gives global figures for improvements in the general medical service, he does not say what the levels are to be for medical attention, drugs, medicines and other services. He gives a global figure of £1,500,000. This is the man who with all the resources of the State behind him, with a five year Committee behind him, with all the facilities of the Statistics Office behind him, challenges the Fine Gael Party to spell out penny for penny and benefit for benefit the details of their policy. This is the Minister who produces at public expense and with great ballyhoo a White Paper which does not tell us what the ceilings are to be for his health services, although he gives us global figures. To my mind, it is the height of audacity, to put it mildly, for the Minister to make such a challenge.
In paragraphs 116 and 117, we are told that the further extensions of the services should not be met in any proportion by the rates and a great deal of boasting and ballyhoo has been engaged in that connection, but the truth of the matter is that as a result of this great social advance, moryah, seven-eighths of the health services will still be paid for out of the rates and out of the fund which is now financing it. There is no great significance attached to it. We will have an improvement of only one-eighth. Seven-eighths will still have to be borne by the existing financial arrangements. We are told in big, black heavy print that all this will involve some increases in health rates in areas other than the West.
Why has the Minister not been honest enough to emphasise that? He has been boasting, because the local elections have not yet taken place, that there will not be any further additions to the rates because of the health services but here we are told there will be increases in health rates in certain areas. Will the Minister tell us precisely which areas will be milked to meet the arrangements he has in mind.
On page 61, in a paragraph entitled Planning Capital Expenditure, we are reminded about a White Paper on public capital expenditure published last August in which it was recommended that priorities would have to be established. Just when are this Government to establish priorities. We have heard this cliché about priorities being established for years but the Government decline at all times to accept as a priority the health and social welfare of our people. The result is that we find ourselves at the lowest point of social security payments among nine European countries recently referred to in the OEEC General Statistics Report for January, 1965. Let us take these statistics for a moment. We find Ireland is the lowest, with six per cent of gross national product devoted to social security payments, including health. Austria, akin to us in wealth per head of the population and in potential, expends half as much again as we do. Its figure is 9.2. West Germany is at the top with 10.4. Denmark, so often compared with us, is at 6.8. They are all higher, Ireland being at the bottom.
We in Fine Gael feel the Government have got their priorities wrong or confused because they have not put things right before now. I should like to express the hope that physiotherapy will soon be included as one of the services paid for by the public health fund. It is extraordinary that physiotherapy has not been paid for in that way heretofore. If this were done, many people could be got back again to productive work.
The Minister says in the White Paper that the optimum unit the new regional health authority will be expected to cater for will be 250,000 people, though he mentions that the Dublin Health Authority cater for a bigger number. He should consider seriously whether the Dublin Health Authority are an economic unit or whether they could be made more economic with greater benefit to the sick and to the administrators. In Britain, the optimum is 250,000 and, rather than have one health authority stretching over Dublin and part of Wicklow, it would be much better if we had two. In health matters, particularly, it is very important to have a personal service, a more direct relationship between the administrators, the professional workers and the sick people. Then you would have a human system and we in Dublin would get out from under the monstrous cloak in which the Dublin Health Authority are wrapped at the present time. I ask the Minister to take a very careful and objective look at the Dublin Health Authority. They have been in existence sufficiently long to say whether the right decision was taken to establish a unit of such size. I am not quite sure what the figure is but I suspect the authority cater for between half a million and three-quarters of a million. The Minister might get a more efficient system if he were to modify it considerably.
We in Fine Gael are seriously concerned because the services are so hedged with restrictions as to cause grievous doubts as to whether they can achieve their objectives. Putting it mildly, we said the same about the 1953 Health Act — that it would not achieve its much boasted about objectives. We were proved right in almost all points. It has taken Fianna Fáil a long time to admit Fine Gael were right in 1953. It would reflect a lot of credit on the Minister now if after 13 years he accepted our submission that he cannot make a silk purse out of a sow's ear. His predecessor tried it with no success and the Minister will not do any better.
The sooner the Minister gets rid of all the hedging restrictions, the sooner will we have a health service worthy of the country. The only thing we can say in favour of the Minister's proposals is that one-third of a service is better than none. It is certainly better than promises. We know that most of what is being boasted about will not be implemented for a few years yet, if even then. We can only hope that by then the wisdom of a better approach will have yielded fruit in the mind of the Minister, that he will forget about the miserable White Paper, that he will simply regard it as a necessary and compelling link he had to establish between his predecessor and the future which must be a more progressive one. We know the Minister is capable of better things but we believe that out of loyalty to his Party and to his predecessor, he did not want to throw his predecessor out with the dirty water. When he brings in worthwhile, progressive legislation we will not criticise him.
