Dáil Éireann díospóireacht -
Wednesday, 23 Apr 1975

Vol. 280 No. 2

Private Members' Business. - Health Services: Motion (Resumed).

Debate resumed on the following motion:

That Dáil Éireann requests the Minister for Health to make a regulation under subsection (3) of Section 45 of the Health Act, 1970 specifying that the following classes of persons shall be deemed to be within the categories mentioned in subsection (1) of Section 45 of that Act:

(1) Persons over 65 years of age

(2) Widows

(3) Persons suffering from any long term illness

(4) Families where the weekly income of husband and wife after deducting rent, rates, ground rent, mortgage repayments and expenses necessarily incurred in travelling to and from work and an amount of £4.00 per week in respect of each child with no income under 18 years of age, does not exceed £40.00 per week

(5) Single persons, living with relatives, whose income does not exceed £20.00 per week and

(6) Single persons living alone whose income after deducting rent, rates, ground rent, mortgage repayments and expenses necessarily incurred in travelling to and from work does not exceed £20 per week;

and requests the Minister for Finance to assent to the making of such a regulation.

—(Deputy Haughey.)

Mr. Coughlan

In the limited time at my disposal it is practically impossible to cover all aspects of the motion in the name of Deputy Haughey but, while being effective, I shall be as brief as possible. Yesterday we heard a lot about guidelines and we are limited to guidelines on this issue now. We are moving into wider areas that involve the entire health services. Most of the speakers yesterday should have been more enlightened. The more I think of the motion we are discussing the more baffled I am about what the whole thing means.

Members whom we might have thought were aware of the present day situation, particularly in such a vital area as health services, showed they were totally uninformed about what was being discussed. I do not know if this was deliberate ignorance of the situation. These are the people who are supposed to tell their constituents the situation with regard to medical cards and the health services generally. The lack of knowledge displayed yesterday by Fine Gael speakers in particular baffled me. It is a matter for the Minister to bring the issue into the open and to have a full and frank discussion on the health services. I can easily understand the predicament of ordinary people with regard to the health services when Deputies display such ignorance of these matters.

I intend to substantiate my statements with regard to Deputy Haughey's motion by proof and figures and, most important, from experience. I wish to be as informative and constructive as I can and I hope those who should know more will take even half a leaf from a book of 25 or 26 years' experience with regard to public health matters.

I wish to correct some statements by Deputy Moore with regard to hospitalisation and home treatment. There are cases where home treatment should be used—for example, for geriatrics and for people suffering from mental illnesses. Home care is an asset that should be used as much as possible but it is not up to any lay person to decide that a patient should not remain in hospital but should be sent home. The only person entitled to make that decision is the medical person involved.

I was surprised at the statement made by Deputy Moore that we have too many beds. The position is the reverse. For the last 20 years in my area we have sought extensions for the regional, voluntary and maternity hospitals. We have met the present Minister and his predecessors with regard to our request for extensions. If that is the experience of Deputy Moore in Dublin, I wish it applied to the rest of the country also. We must get our priorities right where the health services are involved. In many of our hospitals—perhaps not so much in the voluntary as in the regional—we have to accommodate people in corridors. The simple reason is we have not got enough accommodation in the public wards, in the semi-private or private wards.

With regard to hospitalisation generally, there should not be worry or distress on any breadwinner or anyone else because he has to be hospitalised. The financial problems of people occupying public wards are taken over by the health boards. I am sorry that Deputy Moore harped on the financial problems at home. They are not the fault of the health boards. They may be due to domestic matters, the weekly income and other things. They are not due to hospital charges if patients are in public wards which are free for everybody. However, some people will not go into public wards—they opt for private and semi-private wards. Then when the bill is presented to them they come to us and when we make inquiries we discover they opted for semi-private wards.

With regard to the dental services, numerous statements have been made. Here again we must get our priorities right. I have never heard of anyone dying from toothache. I have made suggestions over the years and I do not know whether the Minister will find it possible to implement them. His predecessors failed to do so. There are prostheticians, the dental mechanics. In Europe, particularly in Switzerland, they serve an apprenticeship of three years. They can handle dentures and fittings of all kinds. Here we do not train them in that way and if we did it would help to solve many problems.

Deputies Haughey and Moore spoke about a charge of £3 per week. I checked on this by telephone with my health board in Limerick this morning and the sum is between £3 and £5 a week and if it is anything more than that, half of the figure is returned in full. Apparently it all depends on the approach of the different CEOs. We have rectified our problem in Limerick because we insist that members of the staff, particularly the junior members, male and female, attend health board meetings in rota. In that way they learn of the human aspect of the work of the board and the human problems that have to be dealt with. Then we have the co-operation of the staff who know from attending our meetings that there is not a straight line down the centre.

I am sorry I have not enough time to go into more detail. I hope the Minister will take our views into consideration. All of us have been speaking from experience of health service administration.

Mr. Meaney

This motion is very timely. My special concern is to get some streamlining of the qualification conditions. For instance, there is a hardship clause. Deputy Coughlan spoke about the human element, but superintendent officers and their assistants have to remember that there is an auditor who may come along and ask why they have given medical cards in certain cases and reprimand them. At the moment the qualifying guidelines are very low. In my area, to qualify for a medical card the income must not exceed £24.50p. That is very low. Social welfare payments are allowed to be added. Ten years ago we had a set qualifying limit but this has gone by the board because of inflation and steeply rising prices. Even after five months of exhortation it is difficult to get the limit raised.

I suggest that it has become necessary for the Minister to tie the limit either to the cost of living index or to increases in wages so that the qualifying figure can be raised as the cost of living increases. We should not have this yo-yo business where a man may get an increase in wages and be deprived of his medical card because of that. There should be a definite link between the qualifying figure and the cost of living index. I do not think Deputy Haughey went out of the way when he considered the proper income limits for people to qualify for medical cards. He advocated that the weekly means of a husband and wife, after deductions for rent, rates, mortgages and expenses of travelling to and from work, should be £40 a week.

In the Southern Health Board at the moment the allowance in respect of a child of under 16 years is £2.25 per week. You would pay more for a fair meal in the Oireachtas restaurant. If the child happens to be older than 16 years he or she qualifies for a medical card in his or her own right and the parents would be allowed £3.25 per week. That is a miserable figure when one considers that the boy or girl has reached manhood or womanhood. Deputy Haughey has not gone out of the way in recommending that the figure should be £4 per week. The £40 per week income cannot be regarded as out of the way.

Apparently one-third of our community are medical card holders and I should like the Minister to tell us what the cost would be if we included another third. Somebody has said it would not cost more than between £13 million and £16 million a year.

The improvement suggested in the motion would benefit many people. A medical card holder living in rural Ireland or in a city is entitled to free transport to hospital whether it be by ambulance or by a local hackneyman who has a contract with the health board. There are many people in my area who cannot qualify for this, people with £28 or £29 a week. They have to hire a car at a cost of £9 or £10 for each journey.

If they had medical cards they would not have to spend that money. I know people who have had to forego visits to clinics because they could not afford to pay the travelling expenses. The motion recommends that persons over 65 years of age should qualify for medical cards. I agree with that. It is a sad day when a retired roadworker, with ten years' service, and his wife do not qualify for medical cards. Except for a very few, people over 65 should get medical cards. Indeed it would be as well to include everybody because the few in the upper income group will not avail of them anyway. A single person or a widow has very little hope of getting a medical card. That is all wrong. Such a person may be 68, 70 or 72 years of age, perhaps living alone in a council house. How many of us in this House think there is something wrong with us and go for a check-up? Those people dare not think there is something wrong with them because the cost of finding out is too high.

We heard a lot of talk about the contribution towards the cost of drugs. The amount is very small. If a doctor gives a prescription to a man with a family and he goes to the local chemist and gets it processed he is lucky if he does not have to spend £8 or £9 immediately.

Every Deputy should be whole-heartedly behind this motion. When we were arguing about raising the income limit for medical cards this year we were told that the health boards did not have enough money to provide hospital treatment for all the categories that would be included. That is sad. The Department and the Minister have trimmed down the estimates for all the health boards and that is a sad reflection on our community. Each individual should have as many days as are due to him on this earth and he should not be deprived of one of them because of the lack of a proper health service. The idea in Deputy Haughey's mind is that we should base the qualifying limit on the take-home pay of a worker. This is a good motion and nobody should refuse to support it.

Let me return to the question of travelling expenses. If a medical card holder is referred by his doctor to a hospital he can avail of the service provided by the health board. The local hackney man who has a contract will call for him. Is the Minister aware that in north Cork alone last year that service cost over £44,000? I regard it as money well spent but that amount of expenditure would not have been incurred if we had some of the services available in the town of Mallow. This is an old chestnut. An announcement from the Minister on the question of Mallow Hospital is long overdue. We are expecting it every day. It is costing £44,000 to convey the people of that area to Cork city, to Tralee and to Limerick. It is estimated that it will cost at least £70,000 in the coming year.

Is the Minister aware that the present population of the Mallow catchment area qualifies it for a fully-equipped maternity hospital? That is something on which the Department should make a decision very soon. The Department should announce that they accept this idea in principle and that in due course they will provide the necessary money to build that hospital.

I must praise the home assistance officers and the superintendent assistance officers for their devotion to duty. They are excellent men. they are very humane men. They act within the guidelines. Any politician who goes to them with a deserving case is listened to. I am speaking of my own area. I am speaking of the men I know. I want to put on record my appreciation of the way they carry out their duties. Would the Minister arrange with the Minister for Posts and Telegraphs that when a home assistance officer has been appointed he is immediately provided with a telephone? Lives often depend on the way those people carry out their duties and it is ridiculous to put them on a waiting list for telephone service.

It is very important that dental treatment should be provided free for people. Dental treatment nowadays is very costly. Deputy Coughlan said he never heard of anybody dying of a toothache, but there is more to it than that. If a person has not got a medical card he may be covered by insurance but he will have to pay for dental treatment for his wife and family.

The Minister should lower the qualifying age for medical cards. It is now 16 years of age. Children get the benefit of the medical service when they are in the primary school but, once they leave school, they do not qualify for a medical card until they are 16 years of age. For about three years they are in a kind of limbo if their parents can afford to provide them with the necessary medical attention. I suggest that they should be entitled to qualify for medical cards when they leave primary school. The State has no commitment to those children during the three or four years before they qualify at the age of 16.

We are all anxious that the allowance for home treatment should be expanded. We must try to keep our people out of hospitals and institutions. A son or daughter may have to give up a good job to come home and look after the old person. The allowance in this respect should be increased. If you had to go into hospital for a week or a fortnight, you would feel very sorry for yourself when you got the bill if you were not covered by insurance or a medical card. Regardless of cost, we should provide for our people in a right and proper manner.

I have great pleasure in supporting this motion which also refers to persons suffering from any long-term illness. In the recent past the Minister has expanded the category of people who qualify under that heading. People who are asthmatic do not qualify. The scheme should be further extended. The guidelines set down for the categories who qualify are not very clear. As a matter of fact, some of them are rather contradictory. The Department should look again at how the medical officers assess in what way people qualify. The Minister can get the facts from our advisory committee in Cork. We went over this in detail. I have great pleasure in supporting this motion. I hope the House will accept it.

Minister for Health (Mr. Corish)

I welcome the debate which has been initiated by Deputy Haughey. It covers one aspect of our health policy. Of necessity it is a short debate. We have had varied contributions from some Members of the House who spoke more or less in broad terms rather than in the specific terms of the motion. I welcome the views of those who have contributed to the debate. There seems to be a little difference of opinion on the matter of medical cards. Deputy Byrne talked about abuses in the issue and the use of medical cards. If there are such abuses they should be reported to the medical health board in the area. As a public representative I do not believe that there are many such abuses. Naturally there will be some abuses in any Government or local authority operated scheme.

I should like to give the House some of my views, my ideas and my problems which have to be faced in the matter of social policy. It is abundantly clear from the motion and from the contribution by the mover of the motion that he wants to move away from means testing for medical cards in respect of certain categories. That is significant in itself. The principle of means testing was enshrined in the White Paper of 1966. That principle was central to the policy of the last three Fianna Fáil Ministers for Health. It was enshrined in the White Paper published in 1966 and copper-fastened in the Health Act, 1970, both of which state clearly that entitlement is based on ability to pay or means testing.

In this motion Deputy Haughey seeks to disregard that principle for all widows, for all those over 65 years of age, and for all those suffering from long-term illnesses. It is easy to find out the number of widows and those over 65 years of age, but there is a difference of opinion as to what should be regarded as a long-term illness which would qualify for benefit. It is suggested that these three groups should get medical cards regardless of their income. That is an interesting departure because the last three Fianna Fáil Ministers for Health argued—and I use that word deliberately because these words were included in the White Paper—that it was unnecessary and undesirable to give medical cards without a rigid means test.

Section 45 (1) of the 1970 Act which refers to full eligibility is definitive in its phraseology. It provides that for the purposes of full eligibility only persons who suffer undue hardship will be entitled to qualify. When Fianna Fáil were in Government at that time, and Deputy Haughey was Minister for Finance, it was envisaged by the Government and the Minister for Health—I forget who it was—that only 30 per cent of the population could become eligible for medical cards. That was a global means test in itself. This motion is in contrast to that when one has regard to the number of people Deputy Haughey wants to become eligible. This motion would increase the number eligible to from 60 per cent to 65 per cent. Fianna Fáil thought that was undesirable and unnecessary in 1970. It appears to me that Deputy Haughey is departing from previous Fianna Fáil policy in that he favours no means test for some groups and he wants to move away from the 30 per cent of the population mentioned by the Fianna Fáil Government. I welcome the change of heart. He is entitled to change his policy and this is, I suppose, a step in the right direction.

I believe the Government should not tie themselves unduly to rigid selectivity in health matters. Reference was made to the hardship clause. What I describe as guidelines should be guidelines and, if there is hardship, the CEOs should be in a position to remedy the hardship. Where there is a long history of illness or shortage of money to be taken into account the CEOs, through the health board officers and the home assistance officers, should be able to identify those who suffer hardship, even if they do not qualify under the existing guidelines for medical cards.

The guidelines should be reviewed at intervals. They should be flexible. They were criticised by those who contributed to this debate. As far as my term of office is concerned, these guidelines have, with the initiative of the CEOs, been improved to meet the increase in the cost of living. When discussing health—all health is expenditure—it is not possible to focus on just one aspect alone. One must consider it in conjunction with other aspects. I am concerned with a wide range of services. The general medical service is one. I am vitally concerned about that. I am, however, forced to look at the needs of other services and determine priorities. There is no bottomless purse available in relation to my Department any more than there is a bottomless purse available to other Departments. I cannot do all I would like to do within a given time. One can, however, by steady progress and initiative ensure real improvement.

There is an unceasing demand—I do not object to it—in questions addressed to me for more money for this, that and the other, all very desirable; but there are other areas and a number of health services that have been neglected in the past which are badly in need of development. It will be readily agreed that psychiatric services have been neglected, not perhaps deliberately but they have lagged behind in comparison with other services. The psychiatric services need to be developed and it is no secret that that development will cost a great deal of money if we are to bring them up to an acceptable level. It will take money to provide training and employment for the handicapped. This is an urgent human and social need. It will take money to implement the various proposals made by the working party on the training and employment of handicapped people.

Mr. Haughey

Will the Minister give a view on that report soon? What is the position about the report?

Mr. Corish

It is being published and I am seeking comments from interested parties.

Mr. Haughey

The Minister is awaiting comments. Will he then publish his own ideas?

Mr. Corish

I will consider the report. Reference was made to home help services within the community care programme which is designed to ensure that the poor and the aged will be looked after and, incidentally, kept out of hospital. Reference was made to a hospital development plan. That will cost millions. We did not have a hospital development plan until 1948 and in 1953 it was dropped like a hot potato because of political implications. Probably what I will decide will also have political implications but I am prepared to face that. The only people who are happy where hospitals are concerned are the people representing Dublin constituencies.

Mr. Haughey

We have not got a hospital on the north side.

Mr. Corish

When I was in Opposition I complained about dental services. The 1970 Act provides for practically everything but unfortunately it does not provide the means. This is one of the big difficulties. The Act is a good one but there is no provision for dental services for secondary schoolchildren or vocational education students. I am trying to recruit dentists to ensure that those entitled to dental treatment in the medical card group and schoolchildren will get it. It is very difficult to recruit dentists. We have advertised and discovered we cannot get enough applicants. There has been an improvement but it is pathetic to meet a holder of a medical card, who in law is entitled to dental services, for whom no dental service is provided.

All these things are very desirable, but funds are not limitless. I must allocate the funds available across a broad range of services and decide on a planned rate of development in line with a system of priorities. The job would be much easier if I could concentrate on one part of the health service. The Deputy in his motion shows just one area. I do not take exception to that. He argued for extending the number of people in the lower income group—widows, those over 65 and those suffering from long-term illnesses. He also wants to ease the means test for married couples and single persons under 65. In principle, I agree with him, but principles are not much good when one cannot produce the cash. That is the reality we have to face.

In Opposition I said I would aim at a comprehensive health service. I still believe that to be a legitimate aspiration and I am glad to see Deputy Haughey is moving in that direction now. His proposal to increase elegibility from 35 per cent to 60 per cent or 65 per cent is something he wants to do in one fell swoop. I have sympathy with the sentiment but there are real and practical difficulties that will not disappear merely because we vote on this motion. Finance is important. The Deputy said he could not put a cost on his proposals. I do not blame him for that because he does not have access to the information I have, but he could have got it by way of parliamentary question. to me, he gave the impression that the cost would be relatively small in relation to the total Health Estimate. My information—I believe it to be accurate—is that the motion would bring into the medical card group 750,000 people which in effect would mean bringing in those who are now in the middle income group.

Mr. Haughey

Is that 750,000 more or altogether?

Mr. Corish

750,000 more. As I say, the Deputy will not have the information I have but the firm information is that in respect of all those people, whether they are sick or not, the cost per year is £19 to £20 per person. That is a minimum cost of £15 million per annum. I believe that is a conservative figure because if guidelines were changed—we know this from the professional organisations—over a certain percentage there is the possibility they will want to re-negotiate a new contract.

Mr. Haughey

The total cost this year is only £18 million.

Mr. Corish

It is £21 million. This £15 million is not available at the present time. I have no hesitation in saying we are going through a serious economic time and I think the Deputy will recognise this. This was spelt out by the Government in the White Paper and in the presentation of the budget by the Minister for Finance. This year the primary object is to maintain the standard of living we have in the crisis that is as serious as the one we had in the 1930s. Any additional expenditure that the Government may allow would not necessarily be given to one Department more than another.

I cannot say if the £15 million were available to me for health that I would devote it to those who would qualify for medical cards. There are other services within the health services now being administered and I do not think I could commend the motion to the House. First of all, there is a legal difficulty that is insurmountable. The motion cannot legally be implemented because it does not provide for a means test. Section 45 (1) provides for a means test and it does not make any difference whether or not you nominate this, that or the other class. My legal advice is that no matter who you nominate to be deemed to be in the full eligibility group there has to be a means test. I have no reason but to believe that the advice I have been given is absolutely right. Section 45 (1) makes it obligatory to take account of the question of hardship for the purpose of qualification for a medical card. That means, in effect, that the first three categories which are mentioned in the Deputy's motion would have to undergo a means test and, in present circumstances, in accordance with the guidelines laid down.

Mr. Haughey

I would not accept that advice.

Mr. Corish

If the Deputy wants to check it with his own legal people I do not mind. A new Health Act would be necessary to implement that part of the motion in respect of certain classes. It could not be implemented under the 1970 Act. I cannot support this motion because it must be done, as I said at the beginning, in consultation with the professions concerned. I do not think a three-hour debate will resolve the question.

My approach to extending the health services is to proceed by way of extensive consultation and involvement of the interests concerned before I ask the Government to commit themselves to a new policy direction. For example, in reforming the psychiatric services I would certainly discuss any proposed changes with the interested parties. In the reform of the children's law and child care that process of consultation has already begun. As the House is aware, a working party has been established, which is meeting very regularly, in order to introduce proper legislation in respect of children.

I recognise as much as any Deputy the hardship there is in relation to medical expenses. I know this causes hardship for individuals and families and they are not now covered. I want to assure the House I will do all in my power to alleviate and eliminate this handicap where it exists. In this I may say I am at one with Deputy Haughey. Money is an important factor and I do not think there is any evidence to show that the Government have been niggardly in the allocation of money to the Department of Health.

Expenditure on the general medical services, to which the Deputy referred a few minutes ago, was £12 million in 1972-73. In 1975 it is £22 million, which is an increase of nearly 100 per cent in respect of expenditure on the GMS. The number covered in 1972-73 was 860,000, 28 per cent. In 1974 1,100,000 were covered, an increase of 35 per cent. As far as the guidelines are concerned, they were reviewed upwards, needless to remark, in January last year. They will again be reviewed during the middle of the year and the increase in allowances will take account of the increase in the cost of living.

I also increased the list of long-term illnesses. Drugs and appliances are provided free of charge regardless of the needs of those people. That includes about 5,000 people. There is also a scheme of assistance for drugs available to all employed people regardless of means. I will not correct Deputy Coughlan again. I will talk to him in private because my time is running out. We have retained the figure of £4 as a maximum amount any eligible family need pay for prescribed medicines in any month. This was set in April 1972 and should, I suppose, have been raised but we have not done so.

I do not think I was ungenerous to the unfortunate thalidomide children nor was I ungenerous to those who need constant care. A constant care allowance of £25 a month was provided. That costs something like £1 million. I believe these are concrete steps which have been taken in order to alleviate in some way those on whom a big burden falls as far as health costs are concerned.

The total expenditure for the health services in 1972-73 was £112 million. In 1975 it is £203 million. I think, having regard to inflation and everything, that is a pretty good performance as far as the allocation of public moneys to the health services is concerned. In respect of the gross national product that devoted to health in 1972-73 was 4.6 per cent, which rose to 5.6 per cent in 1974. I submit that all this is evidence of my concern for the health services and I want to assure the House that that concern will continue.

I said at the beginning that there are difficult choices to be made in determining priorities in our health services. Deputy Haughey put forward one priority and I have listed some of mine. My job is to make the choice between the desirable options available. It is perfectly clear that we cannot have everything we need all at once. The way in which we set about making our choices, how we generate genuine discussion and study of the choices available, and how we make the best use of our available resources is very important.

I am constantly studying this problem. This is my job as Minister for Health. We have also discussed the question a number of times in this House during the last two years, during Estimate debates, Questions, debates on regulations and again today. I believe the time has come to broaden the debate by extending it to the professions, administrators and members of health boards involved in delivering the services. The beginning of this process of discussion and consultation outside the House will take place at a seminar on health policy on 15th, 16th and 17th May. I hope this will be a major event in the development of our health services. It will provide an opportunity for representatives of the medical and nursing professions, health administrators, representatives of para-medical personnel and the trade unions to come together to out-line their views on the needs of our health services and their future development.

I have felt for some time that it was desirable to have such a seminar with the professional people concerned to discuss fully and freely the problems we face in developing the health services. We will all have the opportunity to explain openly our ideas and hopes for the future in this vital area of social security. I look forward to this seminar. It will be the first of its kind here and one which I hope will achieve significant results. I was pleased with the response to this announcement and to my invitations. I have no doubt that the discussions will be of great value to Members when we come to debate health policy in the future. We will continue to make the necessary decisions but we will all benefit from the advice of the professionals involved. This does not indicate that this House will be by-passed. Having met the different organisations on various occasions and for different reasons I felt it would be a good thing if all the medical organisations joined together in a seminar to discuss health problems generally. Unfortunately, they do not meet together and I only meet them singly. In my view this is a good move but it does not mean that this House will be by-passed or that I am going to evade my responsibility as Minister for Health where these services are concerned.

Mr. Haughey

Will it be concerned with medicine or with the administration of medicine?

Mr. Corish

Administration. It will involve CEOs, consultants, doctors, nurses and para-medical personnel.

Mr. Haughey

It will not be a medical conference? Will it be a seminar on health administration?

Mr. Corish

It will be a seminar on administration and services.

Mr. Haughey

I have not been invited.

Mr. Corish

Would the Deputy like to go? When I asked the Deputy to be chairman of the Working Party on Conditions in the Nursing Profession he did the same thing. Would the Deputy like to go to the seminar?

Mr. Haughey

I would have thought the Opposition would have some function in such a seminar.

Mr. Corish

Yes. It was not out of disregard for the Deputy that I did not mention his name but if he wishes to go he is welcome and I will send him an invitation.

Mr. Haughey

I understood from the Minister's remarks that the invitations had gone out.

Mr. Dowling

I support the motion. Those of us with a social conscience recognise the need for the updating of health factors particularly in relation to the weaker sections of the community, those over 65 years of age. All too soon these people are forgotten. The health factor is an on-going matter and it must be updated accordingly. It was in order for a rigid means test to be applied to applicants for medical cards when the scheme was introduced because there was a situation of complete stability at that time but at present we are told about the tragedy of people being on the poverty line. The Parliamentary Secretary to the Minister for Social Welfare has informed us that many thousands are on the poverty line. Some of the people specified in the motion are on the poverty line.

Efforts must be made to ensure that the Minister and his Department are made aware of the problems we meet daily. It is not enough for the Minister to indicate that he will oppose this motion. If he opposes the motion it is an indication that he has little or no interest in the sections of the community referred to. The motion deals with the weaker sections of the community who need medical attention. In many cases the people over 65 are forgotten and social workers are unable to locate them. These people have rights and the State should ensure that they get the necessary facilities.

This motion is an effort to prick the social conscience of people in this regard. In the first year of Government by the National Coalition we heard a lot of talk about free health services. What free health services mean and what the people understand them to be are two different things. The people should be made aware of the benefits they are entitled to because a large section of the community are unaware of them. The Minister should not discard this motion simply because it was tabled by Deputy Haughey. He should give it serious consideration and see if reliefs can be given. Two Government back-benchers who spoke seemed to be in favour of the motion and this indicates that there is no clear-cut thought in relation to health factors. Some of those contributions were valid and the Minister should give consideration to them.

No fair-minded Minister could say that people over 65 years of age are not entitled to the necessary medical facilities free. While there are people over that age who have means there are others who are unwanted and turn up in statistics presented by the Departments of Health and Social Welfare as people on or below the poverty line. When we were told that 60,000 people were unemployed some time ago we were also informed that 25,000 people were living on or below the poverty line. Now that we have unemployment running at the rate of 100,000, that figure must have increased drastically. We must examine the situation in relation to present-day circumstances. Change in circumstances and in demand at any given time are factors that must be taken into consideration.

The case of widows must be examined also, as referred to in the second part of Deputy Haughey's motion. We know that many such people are disowned by their families, are living alone and are in need of treatment. I met one widow last week who had to pay for her prescriptions. No doubt she got some recompense afterwards. That woman was suffering from a heart complaint. Her problem was that, when she received her tablets, she took the prescribed amount the first day—that being four tablets daily—and, in order to stretch them out, she took two on the second day, one on the third day and so on until the supply had been exhausted. In that case the prescription and treatment given to that woman were of no value whatsoever because she could not take the tablets in the quantity prescribed. She did not even have the capacity to pay the amount indicated earlier by the Minister which she could later reclaim.

These factors must be taken into consideration by the Minister and he should not classify every widow in the same way. If the Minister said he was prepared to give comprehensive consideration to the various groups, that he would sift out to see if there were deserving elements within those groups, then I would say the Minister was going some way towards meeting their needs and that he had the type of social conscience we are led to believe he possesses. But there are people within each social group who are in great want and who must be facilitated at the earliest possible opportunity.

With regard to long-term illnesses, we have now a new group suffering from one or other type of tropical disease. I refer to men who have returned after service in Cyprus, the Congo and elsewhere. I am certain that in ensuing years we will be faced with a new group of diseases requiring long-term comprehensive assistance. In this respect also the Minister must indicate to the House that he is prepared to up-date and meet this general trend. We will have people with long-term illnesses, new diseases, as is evident now from our people who have returned from service abroad. Were the Minister to indicate that he would undertake a basic examination of deserving cases, there would be some ray of light for them.

Quite an amount was said about medical cards and the difficulty experienced in obtaining them, about their withdrawal and the guidelines attached to their issue. Some of the people indicated in the motion— people over 65 years of age and widows—may have had their medical cards withdrawn for no apparent reason. The Minister is aware, just as is every Member of this House, that the older a person becomes so also the more forgetful he becomes. Such people may not answer letters. Because of literacy problems, some of them may be unable to do so. They may be people who have few friends who could assist them in this matter. There should be widespread examination of the problems outlined in Deputy Haughey's motion, with some indication from the Minister that he recognises that, somewhere within those groups, there are deserving cases.

I know that Deputy Dr. Gibbons wants to speak on this and that Deputy Haughey will be winding up. This serious situation has built up over a considerable period. The withdrawal of medical cards alone would necessitate the putting down of a motion such as this, so that the Minister and his Department would take a new look not alone at the guidelines for their issue or withdrawal but at all matters affecting people entitled to them.

Other Deputies have spoken already on the other aspects of the motion before the House. I would ask the Minister to give us some ray of hope that he will examine in some depth the subject matter of this motion. If he has not sufficient money to alleviate the situation generally, at least he should give an assurance that deserving cases would receive sympathetic consideration at the earliest possible opportunity. There must be identifiable deserving cases in urgent need of attention and of the medical services to which Deputy Haughey referred. The motion has been put down in order to bring to the attention of the Minister the desirability and necessity of up-dating these services.

An Ceann Comhairle

I am obliged to call on Deputy Haughey.

Dr. Gibbons rose.

An Ceann Comhairle

Deputy Haughey is giving way to Deputy Dr. Gibbons.

Dr. Gibbons

I have a few points to make on this motion. First, as the Minister has said, money is scarce for medicine. It is natural also that money is scarce for the people who want to avail of it. Medicine is becoming dearer for this reason. It must be accepted that medical card entitlement must be extended from one year to another. I am one of the doctors who worked under the various authorities who carried on the health services for the past 30 years, from the time of the health boards to the county councils and now back to the health boards. I remember almost 30 years ago, when I sought the appointment I now hold, the then county manager pointed out to me that from the statistics available to him at the time the number of people entitled to free medical services amounted to 15 per cent. At present at least 55 per cent of the people in my area are medical cardholders. This is a strange happening at a time when the country is supposed to be becoming more affluent, with money becoming more plentiful and employment more extensive. That conveys to me but one thing—and it becomes more and more obvious to me within the walls of this House—that the old standard for deciding entitlement to free medical services, which was the inability of a person to provide for his own medical services, has gone by the board and that all the political parties at present are, for all practical purposes, engaged in a race to extend medical services as part of the extension of the social services, the social system and indeed the social philosophy of the country.

It must be accepted that, at a time when hospital expenses are free to from 80 per cent to 95 per cent of the people, the number of medical card holders has been increased. When I started in medicine hospital services were free to the very few only and medical cards—or red tickets as they were then—were much fewer in number. I have no doubt whatever, irrespective of what party may be in Government, that if the money was available we would have a completely free medical service here. I would have no objection to it at present. I would have raised a very big objection to it in the past because under that old system, particularly when the medical card was issued first, I found my private practice being eroded by the extension of the medical card without adequate financial compensation to meet such a contingency. We got the increases sought from time to time but they were not commensurate. Fortunately three or four past Ministers and the Department were wise and farsighted enough to see that the fee-for-service system would be acceptable to the doctors. In this was a built-in compensation for the extra patients on the workload.

Some months ago a conflict seemed to be developing between the doctors and the Minister but fortunately it was settled. The doctors appeared more or less satisfied with it. Much was made of the fact that doctors were earning very big incomes under the fee-for-service system. I tried to get figures before the House and the public although that was not my main aim. I wanted to put on record the back-up behind the earning of those figures. I failed to do that. I realised that the system of Question Time does not permit this. Nevertheless in my opinion there was some unfairness to the doctors in the way the questions were answered.

Last week's Medical Journal published a doctor's income from the medical service over his own name. This is the way the situation should be analysed. I know from experience that anyone who earns good money under this system works very hard. Because I can come to this House I am probably the wrong person to make this case, but these are the facts. If a doctor earns a lot of money in general practice at present he is working very hard. Others are working hard too and are probably not compensated so we cannot make an issue of it.

If I had money to spend on the medical services at present I would try to provide teeth and spectacles for the people who need them, particularly those in the lower and middle income groups. I find it heartbreaking to put down a person's name for a clinic knowing in my heart that he will not be called for examination by a specialist for perhaps six to 12 months. This should be stopped. If the Minister can stop this but does nothing else for the next 12 months unfortunately he will earn the gratitude of so many people that it will sway a general election against us.

It is also heartbreaking when a child studying for his intermediate or leaving certificate examination comes to me and complains that he cannot study because he needs glasses. I put his name down and know that his examination will be over before he is called to see the specialist. I sincerely ask the Minister to try to break this backlog by using whatever money is available to him. There may not be specialists available to examine these people—I am talking about people needing glasses in particular—but a special case should be made for children so that they can be sent to the specialist to have their eyes examined. It could be arranged that the specialist would be paid a fee and these children would get their glasses through the health board. I am speaking now of those with medical cards.

Teeth are another problem. Dentists tell me that teeth for people over a certain age are a poor investment. I do not want to be jocose about this but one might feel that for nutritional reasons a mincemeat instrument would be more valuable to them than teeth although teeth may be necessary for cosmetic reasons. There is another group in the middle income group who, through their own resources, cannot provide themselves with teeth. The Minister should try to provide teeth for them by subsidising them to a certain extent, perhaps 50 per cent, and they will provide the rest themselves. If the Minister did those two things he would be helping more people than he would believe.

There are other points I could make but Deputy Haughey wants to speak. Finally, again I appeal to the Minister if possible to provide the money to break this backlog of people waiting for glasses. If he does that he will be doing a good job for medicine.

Mr. Haughey

I, too, would like to express my appreciation of the manner in which this motion has been dealt with by the House and the attitude in which it has been discussed. I want to make a few very brief comments on what the Minister had to say. We all admit that his announcement about the health seminar was a very good parliamentary tactic to divert attention from the fact that he is forced to reject this motion. It is quite clearly a motion which should appeal to him in every way and of which, he admits in principle he is all in favour. I do not want to make any point about the health seminar, but I would have thought that as a matter of courtesy we, on the Opposition benches, would have been invited to participate. I am certain that is an oversight on the Minister's part because one thing that can be said about the Minister is that he is a courteous gentleman at all times. We will be able to benefit from anything said at that seminar because I presume the results will be published.

I was a little surprised at the Minister's statement that he wishes to proceed in all health matters on the basis of the widest possible consultation with all the professional bodies concerned. I understand that one of the severe criticisms made of him in this regard is that there was no consultation when he extended the hospital service. He made a flat-footed statement to the effect that the extension was to take place without any prior consultation with the professional bodies and organisations concerned.

There is not a great deal more to be said about this motion at this stage. The point made by the Minister about legal difficulties is again a debating tactic.

Mr. Corish

I meant it as a fact.

Mr. Haughey

I have read this section very carefully and it seems to be as clear-cut, definite and precise as any legislation I have ever come across. If there is some doubt in the Minister's advisers' minds about the legality of what I propose, that could be simply cleared up. However, I would have no hesitation whatsoever in stating that if the Minister wishes to make this order, with the consent of the Minister for Finance, as the motion asks, I do not think there would be any difficulty arising from any direction. It is quite clear why the Minister was forced into the humiliating position of rejecting this motion. He had, in so many words, to admit to this House that there is not one penny available to him from the Exchequer at this time to give effect to anything which is so clearly desirable and acceptable as the extensions proposed in this motion.

I was very interested in the Minister's estimate of a cost of £15 million for what I proposed, and that it would bring the number of those eligible up from 35 per cent of the population to somewhere between 60 and 65 per cent. My estimate on both these counts was less. I had calculated that the cost would be in the region of £8 to £10 million and that it would have brought the number of those eligible up to between 50 and 55 per cent of the population. Are the Minister's calculations accurate? Is he taking into account the effect of recent pay increases, particularly the pay increases envisaged under the new national pay agreement? Even if the Minister said to the House: "This motion involves me in an expenditure of £15 million which I cannot afford", I would have thought he would have suggested some amendment to the terms of my motion. In fact, when I was introducing the motion I indicated that some such amendments would be quite acceptable to me. If £40 was too high I would have thought the Minister would have suggested £38; if 65 years of age was too low, he could have suggested amending the motion to 68 or 70 years of age. The simple fact is that here we have a Labour Minister for Health forced by the mismanagement of the country's finances to reject this very commendable improvement in the health services. It proves conclusively and clearly that the finances of the country have been grossly mismanaged by this Government to the extent that a Labour Minister for Health cannot budge one inch on a motion which he admits is entirely acceptable to him in principle.

Question put.

The Dáil divided: Tá, 54; Níl, 58.

Tá

• Andrews, David.
• Barrett, Sylvester.
• Brennan, Joseph.
• Breslin, Cormac.
• Briscoe, Ben.
• Brosnan, Seán.
• Browne, Seán.
• Brugha, Ruairí.
• Burke, Raphael P.
• Callanan, John.
• Calleary, Seán.
• Carter, Frank.
• Colley, George.
• Connolly, Gerard.
• Crinion, Brendan.
• Cronin, Jerry.
• Cunningham, Liam.
• Daly, Brendan.
• de Valera, Vivion.
• Dowling, Joe.
• Farrell, Joseph.
• Fitzgerald, Gene.
• Fitzpatrick, Tom (Dublin Central).
• Gallagher, Denis.
• Geoghegan-Quinn, Máire.
• Gibbons, Hugh.
• Gibbons, James.
• Gogan, Richard P.
• Haughey, Charles.
• Healy, Augustine A.
• Herbert, Michael.
• Hussey, Thomas.
• Kenneally, William.
• Kitt, Michael P.
• Lalor, Patrick J.
• Lemass, Noel T.
• Leonard, James.
• Lynch, Celia.
• Lynch, Jack.
• McEllistrim, Thomas.
• Meaney, Tom.
• Moore, Seán.
• Murphy, Ciarán.
• Noonan, Michael.
• O'Connor, Timothy.
• O'Kennedy, Michael.
• O'Leary, John.
• O'Malley, Desmond.
• Power, Patrick.
• Smith, Patrick.
• Timmons, Eugene.
• Walsh, Seán.
• Wilson, John P.
• Wyse, Pearse.

Níl

• Barry, Peter.
• Barry, Richard.
• Belton, Paddy.
• Bermingham, Joseph.
• Byrne, Hugh.
• Clinton, Mark A.
• Conlan, John F.
• Coogan, Fintan.
• Cooney, Patrick M.
• Corish, Brendan.
• Cosgrave, Liam.
• Costello, Declan.
• Coughlan, Stephen.
• Crotty, Kieran.
• Cruise-O'Brien, Conor.
• Desmond, Barry.
• Desmond, Eileen.
• Dockrell, Maurice.
• Donegan, Patrick S.
• Donnellan, John.
• Dunne, Thomas.
• Enright, Thomas.
• Esmonde, John G.
• Finn, Martin.
• Fitzpatrick, Tom (Cavan).
• Flanagan, Oliver J.
• Gilhawley, Eugene.
• Harte, Patrick D.
• Hegarty, Patrick.
• Bruton, John.
• Burke, Dick.
• Burke, Joan T.
• Burke, Liam.
• Hogan O'Higgins, Brigid.
• Jones, Denis F.
• Kavanagh, Liam.
• Keating, Justin.
• Kenny, Henry.
• Kyne, Thomas A.
• Lynch, Gerard.
• McDonald, Charles B.
• McLaughlin, Joseph.
• McMahon, Larry.
• Malone, Patrick.
• Murphy, Michael P.
• O'Brien, Fergus.
• O'Donnell, Tom.
• O'Sullivan, John L.
• Pattison, Seamus.
• Reynolds, Patrick J.
• Ryan, John J.
• Ryan, Richie.
• Spring, Dan.
• Taylor, Frank.
• Thornley, David.
• Timmins, Godfrey.
• Toal, Brendan.
• Tully, James.

Tellers: Tá, Deputies Lalor and Browne; Níl, Deputies Esmonde and B. Desmond.

Question declared lost.