Dáil Éireann díospóireacht -
Wednesday, 11 Dec 1974

Vol. 276 No. 9

Health Contributions (Amendment) Bill, 1974: Second Stage.

Minister for Health (Mr. Corish)

I move: "That the Bill be now read a Second Time."

The explanatory memorandum which has been circulated to Deputies with the Bill describes the categories of persons who are liable to pay health contributions. It also describes the services to which they and their dependants are entitled. There is no need for me therefore to reiterate these facts in this debate.

As the House is aware, health contributions were introduced in 1971 as an additional source of revenue for financing health services. The rate of contribution has remained unchanged since that time.

In the same period however the cost of providing health services has risen dramatically. In 1971-72 health expenditure amounted to £86 million. This year it will rise to approximately £166 million on a 12-month basis. This figure represents an increase of £80 million in three years, equivalent to a growth of 93 per cent.

The Exchequer has borne almost all of this increase in health expenditure. Since 1972-73 the proportion of expenditure met from rates has been significantly reduced. The rates contribution has diminished from £36 million in 1972-73, the last budget year of the previous administration, to £13.5 million in the period April-December, 1974. At the same time the revenue from health contributions has remained almost static. The Exchequer therefore has borne an increasing proportion of the rapid rise in health expenditure during the period because of the Government's commitment to phase out health charges on the rates. Overall this has been a desirable development. The fact that the Government are phasing out the rates contribution means that we are abolishing the most regressive element in the health financing system and shifting the balance very quickly in favour of an overall progressive revenue scheme. This is to be welcomed.

I am aware that there was considerable debate in 1971, when the House discussed the proposal to introduce health contributions, and many Deputies questioned whether this was the most equitable way of finding additional revenue. There were valid arguments put forward then for and against the proposed health contributions and I can still see merit in many of them.

It is evident that the provision of limited eligibility services at 15 pence a week and £7 a year has been exceptionally good value and compares very favourably with private health insurance schemes. In addition health contribution means that we are abolishing the most regressive element in the health services, thereby allowing them to develop faster than would have been possible if we had relied exclusively on the Exchequer for funding.

On the other hand however it was argued that health contributions were really another form of taxation and that the flat-rate contribution was regressive since it did not take account of the income of the contributor. When the scheme was introduced in 1971 it was argued that, since the contributions proposed constituted a regressive alternative to taxation, it would be better to rely exclusively on the Exchequer for health services revenue.

As I have said, there is some merit in both sides of this argument. Accordingly I propose to begin shortly a review of the present system of financing our health services. This cannot be done in isolation of course, so I propose to link it with the review of the financing of our social welfare system which has already been announced.

The purpose of this review will be to see whether the present system of financing our health services can be improved. The present flat-rate health contributions scheme will be examined in that context.

The situation at the moment is that, of the total sum of £166 million for the health services in 1974-75, about £120 million represents the cost of hospital and specialist services, maternity and infant care services and the drugs subsidy scheme, which constitutes the services to which persons with limited eligibility are entitled. Of the £120 million it is estimated that about £72 million would represent the cost of services for persons with limited eligibility. But health contributions only amount to £5 million at present.

If this Bill is passed as proposed, health contributions will go up by £3½ million to £8½ million in a full year and will account for only about 10 per cent of the estimated cost next year of providing the limited eligibility classes and their dependants with hospital and specialist services, maternity and infant care services and the drugs subsidy scheme.

So, in fact, the financing of the health services is moving towards a situation where it virtually depends on the Exchequer. I hope that my review will analyse this trend in all its implications and will help us to form final judgments on the future financing of the services.

At this point I should like to point out that two serious anomalies exist at present in the entitlement provisions for our limited eligibility health services. The first is the differing upper income limits for eligibility which exists for differing groups of people. For insured, non-manual workers the upper income limit at present is £2,250 per annum. For non-insured persons, other than farmers, the upper income limit at present is £1,600 a year. This is an anomaly which must be removed as soon as possible so that the upper income limit is the same for both groups.

The second anomaly is the existence of any upper income limit to entitlement to limited eligibility health services. As Deputies are aware, this anomaly is not of my making. It is the policy of this Government to abolish income limits entirely as soon as agreement can be reached with the medical profession. Discussions will begin again on this question when the review body, which I set up, issues its recommendations.

I indicated earlier the rate at which health expenditure has risen since 1971. While, as I mentioned in my Estimates speech, growth in real terms over the range of services has been significant, the fact remains that rising costs have also pushed up expenditure.

The House is aware of the current world economic situation which threatens all economies with a recession of major proportions. The effect of the present downturn in the world economy is evident in our country and the Government's analysis of the situation, and the policy objectives they have set themselves, have been set out in their recent White Paper, entitled A National Partnership.

Over the next two years little real growth can be expected in the OECD group of countries, of which we are one. Obviously this will have serious Exchequer implications, particularly in relation to the growth in tax revenues and, consequently, for the resources available to finance State services.

As I stated in my Estimates speech, this new situation, imposed by external events, will have a direct bearing on the funds available to meet the costs of the existing health services and to finance their expansion.

In these circumstances I view with deep concern the scale of demands which are presently being made on resources which are far less than they would have been in normal world economic conditions.

The White Paper clearly indicated the limits which are now imposed on the growth in real incomes for the entire community. It appealed for moderation in income demands and I reinforce that appeal here today. It pointed out we are affected not alone by world inflation but by world recession as well, and I wish to emphasise those points again because they relate to the purpose of this Bill.

The Bill provides for an increase in health contributions to a level of 26p per week or £12 per annum. As incomes have risen substantially since 1971, when the present rates were established, these increases are not inordinate, but clearly there is a limit to the point to which the contributions can be raised and also to which the Exchequer can be asked to finance the health services.

For these reasons I trust that the cost of the services will not escalate beyond the point where future developments may have to be curtailed.

I trust, too, that the House will take account of the review which I will have undertaken of the principles underlying the Bill, of the factors which have caused me to seek these increases, and of the purposes to which the revenue will be directed.

I therefore commend the Bill to the House.

Mr. O'Malley

This Bill was circulated about two weeks ago with an explanatory memorandum which makes its objectives clear and, surprisingly enough, it has received very little publicity because it is a Bill that is of significance in more than the field of health. This is a taxation Bill for the imposition of taxation and the fact that the taxation is called a health contribution rather than income tax does not render it any less a taxation Bill.

It comes less than a week after the imposition of £27.5 million extra taxation on petrol. It comes on the very day on which £2.4 million subsidy has been taken away by the Government from butter with a resultant increase of 4p in the £ on butter. Therefore, with the £3.5 million extra which this Bill is designed to raise for the Exchequer added to the £27.5 million which the petrol taxation brought in last week and the £2.4 million which was gathered by the Exchequer today by the Government taking the subsidy from butter, we have a total taxation raised—assuming this Bill passes—of £33 million within a week. The Government have come along with this further penal taxation on the less well-off people in the community— because the best-off 10 per cent about whom there was so much talk before are not included in this and are not penalised by it; it is the limited eligibility classes who are penalised and who face an increase in their weekly or annual health contribution of over 80 per cent. These, for the most part, are ordinary workers who every week are having deducted from their pay income tax, social welfare and health contributions. Now, they find their health contribution is to be increased by over 80 per cent. It is exactly the same to them as if they were called upon to pay an extra 11p a week in income tax.

In the light of what has happened in the last week as a result of a deliberate Government decision to put up the price of petrol by 15p per gallon and the price of butter by 4p a pound and now this Bill, the people and, in particular, the workers who have no option but to pay this increase because it is deducted from them at source are, and are entitled to be, very some over another example of this backdoor taxation. It is introduced in the form of a Health Bill which I can only assume is designed to put some colour on it other than what it is, taxation of the people. Up to now very few people have realised, even though the Bill was published a fortnight ago, exactly what it proposes to do and I think that when people do come to realise what it means— many of them may not do so until after the deductions are made from their pay—there will be an outcry against this proposal to tax workers.

Many people have said that it is an extraordinary form of socialism that is being practised by this Government when they seek to give free or almost free hospital in-patient services to the top socio-economic group even though there is no demand for them and, having failed to do that—they are still apparently determined to do it as soon as they can—in the meantime they impose higher charges for health services on a much less well-off and much larger group in the community. Presumably this is some form of socialism but I wish that the Minister who again today lectured us about the necessity for restraint in wage claims and so on would explain to us what precisely is his thinking on health matters when on the one hand he is trying to confer benefits on the well-off or comparatively well-off and on the other hand at the same time trying to charge the less well-off 80 per cent more for the privilege of free medicine.

This is nothing but a clear demonstration of the sort of muddled thinking besetting this Government, not just in matters of health—although it is probably clearer here than in other Departments—but in other Departments also. We have this sort of ad hoc solution to problems while the big problem facing this Government today and for the past few months is a grave shortage of money which will become worse, quite clearly, from what we have heard and seen. In order to raise more money they are prepared to resort to all kinds of subterfuges and one of them is the present Bill because the Minister for Health has been Minister for Health for 20 months now and the first piece of legislation in relation to health that has reached the floor of this House is the miserable, hypocritical Bill we have today with its two sections imposing higher charges on the limited eligibility class which constitutes about 55 or 60 per cent of our population.

That miserable piece of legislation is the only contribution the present Minister has made to the health legislation in 20 months. If this is the only performance of all the promises that have been made, it is a sorry state of affairs and I should be very much ashamed to be judged as Minister for Health if this was my only contribution to health legislation in 20 months.

This Bill is as much a subterfuge as increasing the price of butter was this morning and the performance we had last Wednesday night in bringing in under an Act, where it was not at all appropriate, a massive increase in taxation on petrol. More than £33 million has been raised this week by the Government in taxation without any reference to budgets or anything else, and this is the most cynical and the most blatant effort of all.

The figure is given in the explanatory memorandum and in the Minister's speech that the yield from health contributions is £5 million a year. I am surprised to see that because only ten days or so ago we had a Supplementary Estimate which we agreed to without any discussion on the basis that there would afterwards be a full discussion on the Health Estimate, which unfortunately we have not had. That Supplementary Estimate, which was very substantial, included provision for £500,000 for the shortfall in health contributions in the current year. The Estimate was revised to provide that only £4½ million would be obtained, and the reason given for that shortfall by the Minister—at the time I demonstrated it to be untrue— was that he had been allowing for further contributions from the 10 per cent who do not qualify for limited eligibility. As that category had not come in or been brought in, the Minister said the shortfall had arisen.

Of course we know that that is not correct, because the Minister had separately estimated for their contributions when he was costing the scheme and announced that the net cost of it would be £1.8 million. We know the tremendous difficulties experienced by the health boards in trying to collect contributions of £7 a year from farmers and others. There was no difficulty in collecting it from workers with weekly wages because it was taken from them at source with their income tax and various other deductions. But the farmers, who are the principal category paying the £7 a year, found it very difficult if not impossible to pay their contributions this year because of the general economic mess in which they found themselves.

Unfortunately, even though the Supplementary Estimate was moved here and was agreed to by me and this side of the House in order to try to keep the health services going, the Minister again today trotted out the old figure of £5 million. Is that figure right and, if it is, why was the Supplementary Estimate for £500,000 moved, supposedly to cover the shortfall? We are told that the increases proposed in this Bill should bring in an extra £3.5 million to bring the total up to £8.5 million, but we were told ten days ago that only £4½ million is being got in at the moment. I cannot follow this sort of reasoning. I wonder if the Minister can, or whether he will explain why there is this serious discrepancy in the figure and why the House was asked to vote a Supplementary Estimate of £500,000 when the Minister had to come back to the House ten days later to tell us the original figure was right.

One of the reasons why this shortfall occurred—if indeed it was there, because it seems to have been contradicted—is that the smaller farmers found it impossible this year to make their payments. Now they are being asked instead of paying £7 a year to pay £12. Does the Minister seriously think he will find it easy to collect £12 a year when he was not able to collect £7 a year? Does he think that farmers and others who are hard hit at the moment—God knows, there is hardly anyone who is not in that category— will willingly pay up this £12 a year, a further form of taxation, even though it is under another name? Does he think that the difficulties of collection which he spoke about earlier will be lessened by increasing the contribution by more than 80 per cent?

If the Minister were sincere in his desire to provide health services for all who need them, he would have begun by providing them free for those who do not have them free at the moment but who were making these payments. Even if he could not at the start cover the whole of the limited eligibility class, would he not, as I have suggested in relation to the general medical service, begin by taking half of that class and giving them free services both under the GMS and by abolishing the contributions they have to make at the moment?

Has the Minister any realisation of the difficulties ordinary people are in at this time in trying to make ends meet? There are an awful lot of workers, particularly in rural areas, who have to depend on their cars to get to and from their employment, and if they had not their cars and the wherewithal to drive them they would lose their jobs. Still, a brutal increase was put on them last week. Another increase which affects everybody in the country was imposed by the Government this morning on the price of butter. Now we have this final straw this afternoon—virtually every insured worker except those below the miserable figure which is the income limit for medical cards will have to pay 11p in extra taxation out of his pay packet each week. And in the very speech in which the Minister introduced this further measure of penal taxation, he made yet another appeal for restraint in wage demands.

Mr. Corish

Income demands.

Mr. O'Malley

Are wages not income?

Mr. Corish

"Income" embraces everybody.

Mr. O'Malley

It certainly embraces wage earners because they are the people who were being told all the time in the past couple of months by the Government that they had better restrain their demands. How can the unfortunate people restrain their demands when more and more tax is being milked out of them every week? How are they expected to live? In the past week they have already contributed more than £33 million in further taxation and now they are being asked to restrain their demands.

This Bill and the whole thinking behind it—the speech of the Minister in introducing it—are in my opinion nothing but hypocrisy. It is incredible that taxation of this nature would be imposed for health services by a Labour Minister for Health and that in the same speech by which he introduces and commends it he asks those affected by it to restrain their demands for higher incomes. They cannot restrain their demands for higher incomes. It is not the Arabs, world inflation or external circumstances that are driving them into that position. In the past week I have given three uncontradictable examples of the Government taking £33 million, at least, in extra taxation from the wage earners. They have to pay that much more.

How can they be expected, if they are to maintain any kind of standard of living, to restrain their demands for more income? The Minister has shown amazing hypocrisy in saying here today what he said in relation to those people, because if wage demands are being made there is no one factor that has driven those demands more than this Government in the past 20 months, a Government which have taken these incredible decisions in the last few weeks. The Government themselves are the major factor in driving up costs and wage demands.

I was glad to see in the Minister's speech that he realises an anomaly in the matter of eligibility, because on today's Order Paper I had a question to him on that point. Unfortunately it was not reached. The fact that I had it there may have helped to inspire the Minister to refer to this anomaly in his speech.

Mr. Corish

The Deputy is always helpful.

Mr. O'Malley

In Question No. 84 today, I asked the Minister

if he is aware of the hardship suffered by non-insured persons, such as widows, with incomes marginally over £1,600 in paying for medical services in full; and if he will amend the health services regulations to entitle them to limited eligibility.

It appears to be the intention of the Minister to do that and to bring them up to the ordinary figure everyone else is at of £2,250 for insured non-manual workers. In the last year I have come across several instances of people who are certainly not well off, including the instance of a widow with quite a large young family whose total pension came to just over £1,606, being denied limited eligibility. She incurred some extremely heavy expenditure, which she could not hope to bear, in the provision of medical services for herself and her children.

The Minister goes on to refer to what he calls the second anomaly, the existence of any upper income limit to entitlement to limited eligibility. That is a very major topic which we debated here before and no doubt will debate again. It is an expression of the Minister's doctrinaire approach to the health services. Unfortunately in no way can it be seen as an expression of concern for people who need help because in his doctrinaire efforts to give the better off people the benefits of limited eligibility he is giving them something which for the most part they do not want and he is proposing to do it, as I pointed out before, at the expense of the less-well off who will be shoved further back in the queue, the queue for the limited facilities which are available in our hospitals, hospitals which are grossly overcrowded and unable to cope with those entitled to institutional services at present.

I would have thought that if the Minister wants to distribute largesse as far as entitlement to hospital services is concerned, that largesse should be given in the first instance to those who are least well off and that a large proportion of the present limited eligibility class should in fact be given free services without any contribution at all. Before we saw socialism in practice by this Government, I understood it to mean trying to help those who were least well off and to give the most help to those whose need was greatest.

Mr. M. O'Leary

The Deputy's education is advancing.

Mr. Coughlan

A lot the Deputy knows about it.

Mr. O'Malley

We now have the situation in which the actions of the Minister are the direct opposite. Instead of relieving the burden on the least well off of the limited eligibility class, he is today asking the House to agree to adding to that burden. He is increasing their contributions by over 80 per cent and the services they are going to get are certainly no better, and indeed on the Minister's admission today and on his Estimate speech a fortnight ago, we cannot expect any improvement in the health services in 1975 because of general economic conditions. When the Minister says we cannot expect any improvement, I think it is fair to assume from that, from what we have seen over the past year or so, that that will really mean in practice that we can expect a significant disimprovement because the waiting lists seem to grow and grow in every part of the country and the problems of getting into hospital seem to become increasingly difficult and unfortunately those at the lower end of the scale are the people who suffer most by this.

I hope that as a result of what I hope will be a full debate on the Bill the 1½ million or more people who are to be affected by these increases will realise what this Bill is about, will appreciate that further taxation to the tune of £3½ million a year is now being placed on them by the Government and that all these things are being done surreptitiously in the past week, just a month or so before what is officially to be the first budget of 1975. Deputy Lalor expressed well the other day the feelings of pretty well everyone in the country, that fixing a budget for January 15th or any particular date really does not matter very much because virtually every day is budget day in this country now. This is the third instance in a week of concealed taxation being placed on the people by the Government or by a Minister who, to my mind, has reached the ultimate in hypocrisy when in doing this and taking a further 11p per week out of the wage packets of ordinary workers, he has the effrontery to ask them to restrain their demands.

The Government more than any one factor are pushing up prices which in turn are causing greater wage demands, and they are doing it not because of outside influences about which they talk so much, but because they need more money in order to try to keep this country afloat and are prepared to get that money by any means, surreptitiously or otherwise, while trying to cod the people into the belief that they are really doing something for their benefit. The people are awakening to this situation very quickly and it is at the end now of a sore and sorry week for us all that we come to the realisation that here under this new brand of socialism is a further imposition on those who are least well able to bear it, allegedly in the interests of health. The amount got in, even if the Minister were to get his whole £8½ million, is only a very small proportion of the cost of health services for people in this class, and if the Minister has any humanity in him or any genuine desire to help those so badly hit at the moment as a result of Government activity in recent times, he would, instead of increasing these health contributions by more than 80 per cent, in fact be abolishing them altogether.

We cannot see our way to support or even to be neutral about a Bill such as this. Our position is that we are totally opposed to it and we regard it for what it is, a surreptitious backdoor method of imposing further taxation, except that in this case it is being imposed on a large group of people who above all others are less well able to bear it. We will vote against the Bill and against each section. We think that for the Minister to try on this effort of penal taxation and in the same speech to ask the workers affected by it to restrain their demands is the ultimate in hypocrisy.

Mr. Coughlan

I wish to speak for a moment or two on something I know a little about. I have served for 25 years as a member of a health authority, as a member of a health advisory board and in a regional health board. Before Deputy O'Malley leaves the House—I am sorry he is running away from it—I want to give him a few lessons on what health is about. It is typical of him to make these charges without foundation and what I consider the ultimate of hypocrisy is the manner in which the Fianna Fáil Party and their spokesman on health will make a filthy allegation, unfounded, unsupported, with regard to health. I was a member of a mental hospital board. We were promoted into a health authority. Then we moved up into a regional health board. I can speak from experience. My first concern is for the patient. Everything after that is supplementary. We must first of all have regard to the patients. Deputy O'Malley knows absolutely nothing about it. He is not a member of any health board. Because of his villianous attacks he is thrown in for political purposes. Health is above politics.

Physical or mental ill-health is a problem. Some of it can be cured. In some cases it cannot be cured. I refer particularly to mental disorders. Most of us who have been associated with health services know the position better than any medical man. We meet the people every hour of every day. We know how they complain and how they think. They come to us as their public representatives more often than they go to their medical consultants because we can talk sense to them and can listen to them. We have extreme endurance and patience with unfortunates. We do not think of money or any other aspect. We think of the person who has a complaint, whether it is real or imaginary. If it is real we try to solve it. If it is imaginary we talk about it and discuss it with the patient.

I did not come into the health service on a two-day apprenticeship like the Fianna Fáil spokesman. I came in here the rough and hard way. I know what health is all about, physical and mental. This is not a political football. In the Mid-Western Health Board we completely rule out politics and on every occasion since the Mid-Western Health Board was formed I have either proposed or seconded a political opponent for the chair—a Fianna Fáil man—because I believe that we are above politics when we deal with the health of the people. On the last occasion of the election of chairman of the Mid-Western Health Board a Fianna Fáil colleague of his opposed his election to the chair. I proposed his election and he is back there. That was because I believe health to be above politics. Fianna Fáil do not believe that. Let me enlighten those who know little or nothing about health, if they are prepared to be educated.

Mr. Callanan

I like to listen to the Deputy.

Mr. Coughlan

I must congratulate the Deputy. It comes well from Fianna Fáil but the Deputy is new to this business. In any matter opposed to Fianna Fáil, whether wrong or right, the Deputy will have to toe the line. I am sorry for the Deputy. I am glad of him but he will change. I think he is an honourable man.

Mr. Callanan

Thanks for that.

Mr. Coughlan

It cannot be said for the majority of Fianna Fáil. I think you are an honourable man.

Acting Chairman (Mr. Carter)

Would the Deputy please address his remarks through the Chair?

Mr. Coughlan

When people talk to you, you must talk back to them. There are eight health boards: the Midland, Mid-Western, North Eastern, North Western, South Eastern, Southern, Western, Eastern. I do not know what their budget is. We shall know when the time comes. I can speak of the health board with which I am associated and of what it costs to provide a service. I am not satisfied that we are giving a full service but within our limitations we have improved astronomically in the last two years. Despite what Deputy O'Malley says, we have given a service and never was income the thumb rule which determined that a person should be deprived of service. Each case is treated on its merits regard being had to the health of the patient and the capacity of the person to pay.

Cases have come from Clare, Limprove erick city or county, North Tipperary. I have met cases where the limit has been exceeded whether in relation to income or valuation or other matters, but despite the fact that guidelines are laid down a human approach is adopted towards the persons concerned. I am sure any Member of this House who is a member of a health board knows how expensive treatment can be, whether in St. Patrick's, Waterford, or anywhere else. In these cases income limits are rarely introduced. We take all cases as they come and we help them irrespective of income or valuations. We are honest about this, not like some Fianna Fáil Deputies. I am not referring to all of them but to the spokesman for Health. He knows absolutely nothing about the workings of a health board. He comes in here to play politics with health. Confound him and damn him for it.

Mr. Geoghegan

They are strong words.

Mr. Coughlan

They are truthful words and let anyone stand up and deny them. I will show hypocrisy for what it is.

Mr. Geoghegan

It is a good job the Deputy is not here.

Mr. Coughlan

He ran away.

Mr. Geoghegan

He will be back to answer the Deputy.

Mr. Coughlan

Let him come back. The people in Limerick told him in the local elections what they thought of him. I will tell him also because I will not stand for hypocrisy. He has made a disreputable speech, trying to decry a man and a Department whose first concern is the patient. This is the time and the place to set the record right.

Our health board region comprises the city and county of Limerick, North Tipperary and County Clare. In that region there were 269,804 people on the 1971 census. When I started with the health authority in Limerick 25 years ago we had less than 100 employees. Today there are 3,000 people employed by the MidWestern Health Board. These people are not wasting their time; they are looking after the needs of the unfortunate people who require help. We do not play politics with these matters.

For 1974 our budget was £9,340,000 and it is now £16,765,000. There has been talk about an 80 per cent increase but the difference in the two budgets is greater than that. An increase of 80 per cent means 11p per week, approximately 2s in the old money. Nobody was more vociferous than Deputy O'Malley when whiskey and other drink were increased in price and he made much play about the old money then. The increase from £7 per year to £12 per year means an increase of less than 2s per week and we all know what we can buy for that amount now.

The institutions in our health board region number 23. We have three regional hospitals—a general, maternity and orthopaedic hospital. We have four geriatric hospitals, two county hospitals, two psychiatric hospitals and three units for handicapped children at Roscrea, Foynes and Ennis. We have made arrangements for construction of a bigger institution and 12 months ago the Tánaiste turned the sod on what will be the biggest mental institution in the country. It is situated in Limerick city. We also have three welfare homes.

Since April, 1971, we have given £24,000 to the Regional Hospital in Limerick on the first occasion and subsequently we gave £42,000 for a theatre and all the necessary equipment. We have spent £29,000 on industrial therapy in St. Joseph's Mental Hospital. We have spent £10,000 on hostel accommodation and £15,000 on renovation work.

We have spent £7,000 in Roscrea, in Nenagh £10,000 and £235,000 on welfare homes in Nenagh and Roscrea. In Kilrush we have spent £168,000. In Ennis we have spent £13,000 on industrial therapy. On rehabilitation hostels and doctors' accommodation we have spent £20,000. We have spent £12,000 on new dental accommodation in Ennis County Hospital. On St. Nessan's Orthopaedic Hospital, Croom, we have spent £52,000. On St. Ita's Hospital, Newcastlewest, we have spent £190,000. We have schemes prepared catering for a new laboratory in Limerick Regional Hospital at a cost of £130,000, for a 50-bed paediatric unit at a cost of £120,000 and a 50-bed psychiatric unit costing £150,000. We are also providing an extension to the staff diningroom at St. Joseph's Hospital. For the schemes I have mentioned the cost will be £700,000.

We have also schemes in progress for St. Camillus's Hospital in Limerick, which was formerly an old workhouse, at a cost of £100,000—this is in connection with the cafeteria and changing room. We are also arranging for the provision of boilers and an incinerator at a cost of £23,000. Work on the welfare home at Newcastlewest is estimated to cost £100,000. Reconstruction work at Ennis Hospital, £530,000, and the health centre in Limerick will cost £300,000.

Up to 30th September, 1974, we had 14,800 medical cardholders in Clare; in Limerick there were 25,577 medical cardholders and in North Tipperary 8,335. This gives a grand total of 48,392, representing 95,753 people which is 35.49 per cent of the board's population and the State figure is 36.04 per cent of the population. There are other boards—perhaps less affluent, I do not know— but as far as we are concerned the patient is our first concern and any damn character, whether inside this House or outside it, who wants to play politics with health, I say a curse on him, a curse on him, and let that go out from me. Inside or outside this House they are not fit to represent anybody and the sooner the people realise that they are a lot of white sepulchres, who will come in here and play politics with the health of the people, the better.

We have produced our guidelines with regard to the issue of medical cards. So have every other board. We will be reviewing those in the new year, bearing in mind the cost of living and all the things that go with the changing times in which we live. I am a man of change. I believe in change. Any man who does not change should have his head examined. I am all for change and we will be changing our guidelines in 1974. It is bitter and sugar is scarce, but the Fianna Fáil Party will take it from me. I know it is galling but, by God, they will take it and the people who are listening to me all over this House on the intercom can come in here and deny what I am saying. I know I am being listened to all over the House tonight. Let the man come back and sit there. I will not stand for this and the people of Limerick did not stand for it at the last local elections and that is what counts. Guidelines are like estimates. There is no line beyond which one can go no further. That does not apply with regard to the health services.

We talked about this and we agreed that a single person living alone with £14 a week or under should automatically, leaving out his circumstances and his problems, be entitled to a medical card. We agreed that a single person living with his family with £12 a week should qualify. We set £20 a week for a husband and wife and we allowed £1.75 a week each for dependent children under 16 years of age, £2.75 for other dependent children, outgoings on mortgages and rents £2.00 a week. They are only guidelines. We met the problems in each individual case and we made our case to the CEO. Humanity was always shown, particularly when people were in distress. Nothing causes more distress than worry about what is to happen. I have very little medical experience except the experience of going into hospitals and meeting people who are physically or mentally ill. If one can say to a sick person: "Do not worry about the bill; we will look after that. Relax there for yourself and we will not send the bailiff to you", if one can give a patient that little comfort, it puts them at least 50 per cent on the road to recovery. When a person is worrying about what an operation will cost, if one can sit at his bedside, as we all do, and relieve him of that worry one is putting that person 50 per cent on the road to recovery.

Many hard things have been said about the medical profession and maybe they look for a lot of it. A former Minister for Health, Mr. MacEntee, had some cantankerous times with the medical profession. My experience of the medical profession is that when people come to me with a bill—a bill for surgery, an anaesthetist's bill, any kind of bill—and say they cannot pay, I take the telephone, ring the doctor involved and I say: "Look, John or Jim, what are you going to do about this?" He says: "Make your own price". That is an arrangement I have with most of the medical men in the city of Limerick.

Dr. O'Connell

One could say the Deputy is a broker.

Mr. Geoghegan

He is worse than a broker.

Dr. O'Connell

Better than a broker.

Mr. Coughlan

You will get a bad apple in every barrel and you will get gluggers in every nest. We had it in Wexford a couple of days ago when I had to come out publicly and denounce them at our health board meeting last Friday. I had to denounce them publicly again when our health board met on Monday night. I denounced them for their lack of interest in the burning question of alcoholism. Letters and telegrams from medical men have reached my house since my pronouncement on Monday night congratulating me and thanking me and saying that they had not woken up to the fact that alcoholism is one of our greatest problems today.

Much play has been made of the increase of two bob a week. The Tánaiste was castigated and we were all castigated and denounced without any proof of what it was all about. They are immature little boys who were thrown into positions because of their sniping qualities.

If they would only come and ask what is it all about. Would they not go to their masters? I am not a dentist, a general practitioner or a consultant. I am an ordinary man with something between his two ears who knows how to use that something. I have no furrow to plough but I know there are others who have a furrow to plough. I attend health board meetings. One day I listen to the general practitioners, the next day I listen to the dentists and the day after I listen to someone else. They are all trying to get ahead. As far as we are concerned we put the patient first and the professional man will have to take his place in the line. He will have to sit back and wait. But he will give a service.

We hear all this outcry now about doctors, consultants and dentists. A former Minister for Health had some little difficulties too with the medical profession and with other professions. We heard nothing at that time from Fianna Fáil. The Minister was right and the doctors were wrong. It is a turnabout now.

This is not indirect taxation. I have proved in my figures and in my association with my board what this is all about. We have relieved the ratepayer of health contributions. We have increased social welfare benefits beyond the wildest imagination of Fianna Fáil, if they have any imagination. We have given the people a health service Fianna Fáil could never have provided for them. All we are seeking is 10p per week. Whatever political capital anyone may try to make out of this, there is one lesson Fianna Fáil should learn. They spent hundreds of thousands in the Cork by-election, but the people were not fooled. Not alone are Fianna Fáil trying to cod the people but they are actually trying to cod God.

I suppose Deputy O'Malley can spell the word "socialism" and, beyond that, he cannot go. Far be it for me to decry a colleague from my own city, but I will not stand for hypocrisy. The people I represent will not stand for hypocrisy. That was proven beyond yea or nay at the local elections. We are doing a good job of work in Limerick. I visit the hospitals. I have not seen the spokesman for Health in Fianna Fáil visiting any hospitals or attending meetings for alcoholics or anything else. It ill becomes anyone to come in here and try to play politics with ill health. If we want to help we must give. Remember, we are helping those who cannot help themselves. That is our job in life and it is on that we will be judged by future generations. It is on that judgement I will stand.

I welcome this Bill and I congratulate the Minister on what he has done and on the courage he has shown. I congratulate him on his humanity towards those who cannot help themselves. What more can a man do? Bees always gather around the honey. Woe to the people who are making big profits out of the illnesses of others. If I were Minister for Health I would go a few steps further than the Minister has done and I would check every account sent in. I can assure you they would be revealing.

I congratulate the Minister on the way he is handling our health services and I deplore the actions of those who try to sabotage his efforts. They deserve ill of the people. Let us forget about bank accounts and new cars and let each of us apply himself to his vocation, whatever it may be, in a charitable way, without disruption and without sabotage. If we do that we will be a better country. This is what socialism is all about. I shall always be in the forefront of the battle where health is concerned. Only those who have had experience of hospitals can understand what is involved. I spent a Christmas in hospital. I know how onerous the duties of the nurses are. I know what they have to put up with night, noon and morning every day of the week. They give a service. The majority of the medical men I know are service-giving men, charitable men. As I said, there is always one bad apple in a barrel. The ordinary man-in-the-street has nothing but respect for the Minister for Health. He is with him all the time in his battles. We are all with him. I want to refer again to the former Minister for Health, Mr. MacEntee. How ruthless was ruthlessness there? In all my experience in dealing with public health, never have I seen a Minister for Health such as the present Minister.

Mr. Callanan

This Bill increases the contribution by 80 per cent for people in the middle income group. Deputy Coughlan could not lecture me on a social conscience. I was a socialist all my life and I hope to die with a social conscience. I will not take a lecture on socialism from anybody. Deputy Coughlan gave us a long lecture on the amount of money being spent by health boards, and the way it has increased down through the years. I want to compliment the Minister on doing a good job, but his predecessors did a good job too. As a result of all these good jobs being done, there is an increase of from £9 million to £18 million in Deputy Coughlan's health board area. Surely he is not trying to insinuate that the improvement came in two years. Surely that was achieved because other Ministers for Health did a lot for the health services.

I said the other evening that at the beginning I was against the health boards. I have to admit I was wrong and they are doing a good job. Deputy Coughlan mentioned guidelines. I think Deputy O'Connell will agree that if you are over the guideline you are out. I am not a member of a health board. I am a member of an advisory committee. At the beginning the figure was £15. Now it is £20 and we are pressing to make it £25. I hope that will happen. It should be even higher than £25. I am not very keen on bringing in the top-notcher free. I am concerned about the people in the lower and the middle income groups.

At the moment our hospitals are very overcrowded. If I were sure that we had accommodation for everyone I would say that the Minister should include us all. We should move slowly. Road workers are getting over £30 a week now. They should qualify. The figure of £20 is outdated. The Minister should tell this to the CEOs of the different health boards. Deputy Coughlan talked about telling a patient that he was OK, but if he is a little bit above the figure he is not OK unless you can get him in under the hardship clause. I do not see any mention of increasing the figure of £60 valuation. I have condemned valuations before and I condemn them again as the most unfair and unjust way of assessing a person's income. In some cases you would get a valuation of only half a crown for good land and in others you would get a valuation of £1 for flooded land along the Shannon. If a person has a valuation of £61 he is out.

The Minister should move slowly towards bringing us all into the scheme. The person with a big income should be able to pay for himself. The voluntary health scheme is available to him. All my life I was a poor man. I never had a "bob" until I came into this House. We are not too badly paid and I do not mind the Press taking note of that. I consider that I should be able to look after myself. The man struggling at the bottom and the middle income man need help. The contribution is going up by 80 per cent whether it is 2s or 10s or whatever Deputy Coughlan says it is. This is the fact.

I appreciate that the Minister is an excellent Minister. I want to make that clear. I am not criticising him. He is concerned about the people I am concerned about. I am not concerned with people in the very high income group. They can pay voluntary health insurance and cover themselves, and the hospitals will not be overcrowded. They can go into private homes or wherever they like. If they are in the health service they will have to be accommodated. Unfortunately, there is still a bit of social snobbery and I am afraid that the person in the higher income group will get in before the person at the bottom if there is a free for all.

I forget what Deputy Coughlan called the Fianna Fáil Party. I think he said they were trying to educate God. I was always told to say what I had to say in as few words as possible, but he spoke for half an hour and he said nothing. He read out of a paper what the health boards are doing. The members of the Western Health Board have the interests of the patients at heart and the patients come first. Deputy Coughlan is not the only man in Ireland with whom the patients come first. I do not think the Minister should increase the contribution by 80 per cent. It might look small at 2s.

On a short Bill like this, if you cannot say what you have to say in ten minutes, you should not speak at all, so I will not detain the House. I appeal to the Minister to consider what I have said. The lower income group and the middle income group should be moved up and we should forget about the top man and let him look after himself through the voluntary health service.

Dr. O'Connell

I must congratulate Deputy Callanan on an excellent speech. It was very pertinent and I have no hesitation in endorsing the fact that he is a good socialist.

When this Bill was first introduced into the House in June, 1971, I opposed it. I did so because I thought it was a subtle form of taxation; taxation on the people least able to bear the brunt of it.

We are not looking at the whole question of the health services in the proper perspective but are coming in to this House with a makeshift arrangement, and not doing anything spectacular in the process.

I realise that the Minister has problems in his Department and that tremendous demands are made on him. We know that the health services are ever-consuming in demands on the budget and on the Exchequer. However, I would be dishonest if I did not speak my mind on these matters. I would be dishonest to the House, and to the public, if I spoke out and condemned the Health Contributions Bill in 1971 and now fully endorsed it. If I did so I would be a hypocrite and that I will not be. When I decide to be a hypocrite I will quit this House.

In my view the Minister has been a bit shortsighted in this Bill. I will forgive him because the economy is in such a bad way. We have a crisis on our hands and money must be found rapidly. This is the message that is coming across over and over again. The Minister spelled it out when he appealed for moderation and told us that things were not so good. What this increase will achieve by way of increased contributions to the Exchequer is negligible by comparison with what is spent on the health services. That is glaringly obvious and I am wondering is it all in vain or are we not looking at the whole question of the health services in a proper perspective.

The Bill proposes to bring in a 70 per cent increase. It will be an increase of £3½ million. In comparison with the £72 million that represents the cost of the services for persons with limited eligibility, this £3½ million looks ludicrous. However, what is important is the fact that it is a burden on the people least able to bear it. We are being asked to impose this burden on the ordinary worker, the social welfare contributor, who is not entirely free from burdens. This person is burdened with very high social welfare contributions and many other forms of indirect taxation.

Would it not have been easier, better, and more socially desirable as well as being ideologically so if the Minister asked that this £3½ million be borne by the Exchequer and paid for by way of normal taxation? In this way the burden would fall a lot more evenly on those best able to bear it. For example, I would be paying it but I would not be able to avail of it. I would not object to paying it. I consider it more socially desirable that this money be paid out of the Exchequer and applied by way of increased taxation. I am astonished that consideration has not been given to this aspect because Labour Party policy is that taxation, or the Exchequer, take over more of the burden of the health services. We should not be asking this section of the community to bear this burden; we should be asking the entire community to bear it, particularly those best able to do so. It would have been more desirable to ask the Exchequer to bear this.

The Minister put up a very cogent argument for this increased contribution in his statement when he said that it will only account for about 10 per cent of the estimated cost this year of providing limited eligibility classes. Because of that I would have thought that adding this to the Exchequer would have been the proper way out. The present health contribution, contrary to what the Minister may say, is being paid for by those medical card holders who are unable to pay this. Many of them have had the health contribution deducted from their wages. I have written up to 60 letters to the Department pointing out that many people, in their ignorance, and in the ignorance of their employer, were having 15p deducted from their wages, even though as medical card holders, they were not obliged to pay it.

I saw the terrible, ridiculous blunder made by the Department of Health and the Revenue Commissioners recently. A circular was issued by the Revenue Commissioners to the effect that if employees did not wish their employers to know that they were medical card holders they could notify the commissioners and they would be refunded the money at the end of the year. For some reason this was abandoned; one Department did not know the other Department were operating the system. We should look seriously at this whole question of health contributions. I am astonished that it has taken so long for the Department to examine this aspect because in 1970 the EEC Commission examined the whole question of the financing of the health services. In 1971 The Netherlands, Luxembourg, Belgium and Denmark set up review committees to examine the financing of health services. It is three years since we joined the EEC and I wonder why we have not tackled this matter before now.

I am critical because I wonder what is being done in that Department. Everything is about to be done but matters like this should have been attended to at least two years ago. Our review of financing the health service should have been synchronised with the decision of the EEC Commission but this review is only taking place now. I would like information on when this review will take place, how it will operate, what the terms of reference will be and when we can expect a report. It is not enough that we should be given a two line report to the effect that it is proposed to begin shortly a review of the present system of financing health services. Will such a review be buried or left to lie gathering dust on the shelves of the Department of Health as so many different reviews and documents have in the past? I have noticed in the Department of Health a tremendous deal of inefficiency and it galls me when I think of another review body being set up by that Department.

I would be dishonest if I suddenly warmed to this increase and acclaimed it with enthusiasm. In my view it is wrong to look for £3½ million on the basis of burdening the less-well-off sections of our community. We are not providing anything more for them. The Minister has told us that it is only to keep up with inflation. What we should be doing is carrying out an examination to see if the first Health Contributions Bill was necessary. In 1971 it was estimated that £5 million would accrue from it and it was understood then that it was for the purpose of eliminating the hospitalisation charges and the out-patient services. The most that would be saved by that was about £500,000 because the cost of collecting these services was 50 per cent. Therefore, we got £5 million out of that. I said it was a trick. Deputy Tully, my colleague in Government now, said it was a sham. We all thought it was a trick. It was a subtle form of taxation and I still think it is. I should like to see a much more realistic and broader approach to this whole question of the health services. I should like to have seen that £3 million borne by the Exchequer.

Debate adjourned.