Léim ar aghaidh chuig an bpríomhábhar
Gnáthamharc

Seanad Éireann díospóireacht -
Wednesday, 15 Mar 1978

Vol. 88 No. 8

Health Contributions (Amendment) Bill, 1978: Second and Subsequent Stages.

Question proposed: "That the Bill be now read a Second Time."

Again, I must apologise for the absence of the Minister for Health. He is ill and asked me to take this Bill on his behalf and introduce it in the House.

It was made clear when the original Health Contributions Bill was being debated in 1971 that the rates of contribution would have to be increased as time progressed. The rates provided for in the 1971 Act were 15p per week or £7 per year. As Senators are aware, the rates have in fact been increased at intervals since then. They were increased in 1974, in 1976 and in 1977 when the rates of contribution became 39p a week, or £18 a year. The Bill now before the House provides for an increase in these rates to 50p weekly and £24 annually, with effect from 1 April 1978.

The explanatory memorandum which has been circulated with the Bill defines the groups of persons who are liable to pay health contributions and outlines the services to which they and their dependants are entitled. Persons who hold medical cards are exempted from paying the contributions.

The present system for determining "limited eligibility" is a complex one which contains many anomalies. In the couse of the Second Reading debate in the Dáil some Deputies were critical, for example, of the position of non-manual vis-á-vis manual workers in so far as eligibility for services is concerned.

However, the Minister for Health has recently announced that it is the Government's intention to replace the present flat-rate social welfare and health contributions by a fully pay-related scheme. The Minister hopes to put forward proposals at an early date based on a report from an inter-departmental working group set up to work out the details of such a scheme. It is expected that the introduction of this new pay-related scheme should eliminate many of the present anomalies and should make it far easier for everybody to understand.

Health costs are rising rapidly. When health contributions were first introduced, public non-capital expenditure on our health services was £86 million, of which the Exchequer contributed £45 million. In 1978 it is estimated that non-capital expenditure on health services will be of the order of £365 million, of which all but about £20 million will be borne by the Exchequer.

Specific "limited eligibility" services are hospital in-patient and specialist out-patient services, maternity and infant care services and the drugs and medicines subsidy scheme. The estimated cost of these services for 1978 is £265 million. The total yield expected from health contributions in 1978, based on the increased rates provided for in the Bill, is of the order of £16½ million, or about 6 per cent of the overall cost of providing "limited eligibility" services. From the contributor's point of view, therefore, it is clear that he is getting extremely good value for money.

The extent of the increase in the cost of hospital and specialist services must be a matter of serious concern and it is a problem to which the Minister for Health will be devoting close attention. There are many factors which influence costs and, I think it appropriate that I should mention some of them. They include:

— the inflationary effects of pay and price increases;

— the extra demands for services arising from the increase in population and other causes;

— the need to improve the standard of institutional care for the aged, chronic sick and the handicapped and the provision of homes for the ambulant aged to replace substandard accommodation in county homes;

— the advances in medical technology involving more sophisticated techniques and equipment, more specialised staff and greater use of intensive care units;

— the increases in the numbers of accidents;

— the provision of improved care facilities for infants at risk;

— the need to provide on an increasing scale services for persons suffering from illnesses caused to some extent by excessive drinking and smoking;

— increases in the levels of hospital personnel so as to ensure that good standards of service will be available.

I trust that I have explained some of the reasons for the increased rates of health contributions proposed in the Bill and I commend it for approval.

While much of what the Minister said in his statement is true, nevertheless one finds it difficult to welcome a measure of this sort coming at this time, in complete isolation from the budgetary provisions which provide the money necessary for these services. This tax, as we may call it, should not be seen directly in relation to the health services. It is purely a measure of taxation levied against a particular group of people. It is not related to the services given in return for the money spent. In pointing out the facts and figures relating to the health services, the Minister pointed out clearly, in the sums he mentioned, how much out of tune this charge is with the cost of the health services. It is not, nor is it claimed to be, related to any inflationary trend, any increase in the standards of living, wages or anything else. It is purely a measure of taxation, which is being used with other areas, where somebody decided we could safely levy a new taxation or increase an old one without attracting too much attention, something for which we could say a service would be rendered. There is no indication of where one can reasonably associate this increase with the service given.

We are talking about an increase of 28 per cent. In money terms this is not a vast sum yet it is so out of tune with all other costs, expenses and increases that it must be regarded as an inflationary measure and one which will be, and can be, used, and rightly so, by people arguing for increased wages and services. It can be taken as a guideline of the increases which the Government have in mind when they sit down to levy taxes. However, it is very far from the figure the Government concede people need to get by way of increased wages or social welfare allowances.

It is a wrong system of raising money. From the very start, I could never see much sense in it. It is true to say that even the people who pay it do not get a return for their money. You are entitled to the health services whether you pay this money or not. On the other hand, if you pay it, as many people do, it does not automatically establish your eligibility for these services.

This scheme was introduced without any proper machinery or means being established for collecting the money. Throughout rural Ireland every day we meet people who have health problems. They go to somebody they think knows something about the matter and ask if they ought to pay the £12, the £18, or now the £24 — the amount changes so rapidly that people cannot even keep track of the figure. They wonder if they are entitled to the services because they have not paid their contributions. Some people should have paid yet never got a bill or a demand of any sort. Other people are getting demands while at the same time, their land valuation, means, or income puts them outside the group who are eligible for the services. A large number of people who have got demands for this money consistently through the years have never paid it. There is no proper machinery to collect it. For this reason the whole idea of this comparatively small separate system of taxation should be looked at. We have a Government abolishing some systems of taxation, for instance, the rates on houses and, at the same time, starting to build up another system which takes money mostly from the same people without having established any proper machinery for collecting it. As time goes on the Government will have to face up to the fact that there is no alternative to the establishment of proper machinery for collecting this money. It is going to cost money. I cannot see the justice in a system where one-third of the people in rural Ireland are liable to pay this but are not paying it, and have never paid it, and at the same time it is being demanded from many people who should not have to pay it. For all these reasons it is not a good idea.

It is time the Minister conceded that the question of the manual and non-manual worker is going to change and that he is going to take a look at a pay-related scheme. The question of manual and non-manual worker is already out of date and it becomes more out of date every day that passes. It is a carry-over from the days when there was thought to be some essential difference between people engaged in different types of work and when there was usually an important differential in pay. That is an entirely wrong concept on which to base any benefit, charge or tax.

I welcome the Minister's suggestion that the system of charge and eligibility is going to be replaced by some sort of pay-related system. At a time like this, the whole question of how this money is being spent should come into question, but perhaps that widens the debate into a gereral discussion on the health services, which the Minister almost did here in his statement. For the amount of money involved, the Department of Health and the Minister could spend the time and expertise required to solve this problem and the problem of collecting this money. They should also make some effort to streamline the health services, particularly the general medical services where there is so much left to the judgment of the people on the ground and where there can be such vast differences in the amount of money being spent from one area to another and from one dispensary area to another. All that requires a great deal of looking at and a straightening out.

A vast amount of money is being expended on drugs for medical card holders and people who are eligible to get assistance and free drugs under some circumstances, even people who fall into the category we are debating today. A lot needs to be done to streamline this whole area. It is not within the competence of the individual health boards to solve this probblem. It is a matter that must be looked at from national level, from the source where all the money is being provided, to see whether this money is being used in the best way and for the benefit of the people who are genuinely sick and requiring treatment. There are so much abuses in all this area, so much careless spending while at the same time so many other services require to be strengthened and expanded that the whole question of the spending of the vast amounts of money in the area of health needs to be re-examined.

One area mentioned by the Minister was the question of the care of the aged. I would like him to bear in mind that in the past few years we got a rapid extension of the welfare home facilities, county home facilities and geriatric hospital facilities, which provide for older people. I would like to see more emphasis on day care centres and day hospitals where older people are brought in and given the medical services they require and the facilities of a hospital — day room, occupational therapy, physiotherapy, or whatever is available for that day — and then being allowed return to their homes. As I go around the country and look at the welfare homes, I see too many people there who I honestly believe could live in their own homes, given the facilities provided by day care centres.

Would the Senator agree he is broadening the debate——

I accept that.

Acting Chairman

——to the extent that if pursued by other Senators it might keep us here too long?

I accept that I am widening this debate. I was making reference to the Minister's statement where he spoke about the question of homes for ambulant people and the aged and the need to replace substandard accommodation in county homes. I have made the point.

The other point he mentioned was in regard to medicines and hardship. I would like to draw his attention to the severe cases of asthma one comes across every day. It is not a prescribed illness and should be included. This was possibly recommended at an earlier stage in another debate. The Minister made a brief reference to it in his statement. Those are the remarks I would like to make.

It is regrettable that we should have such a rapid rate of increase at a time when everybody is trying to attune the economy and people's thinking to lower increases in wages and a lowering of the rate of increase in taxation and when inflation is not as rapid as it was. Now we introduce what is an inflationary trend of 28 per cent of an increase and seek to relate this to the sort of service that is being given when in reality it is just an ordinary everyday taxation measure which has nothing to do with the health services and does not mean that people will get any extra benefit or any extra services of any sort.

I was somewhat amused that Senator McCartin should open his remarks by protesting that this measure should be introduced other than at budget time. I remember making a similar protest when the Coalition Government did it in 1974, 1976 and 1977. I cannot remember whether Senator McCartin joined me in that protest. I would agree with a lot of what he says about the collecting of this money. I believe the Health Contributions Act 1971 was a very useful measure. It eliminated a considerable amount of distress in that people qualified for specialist and hospital services who otherwise would have had to join the Voluntary Health Insurance Board. I know from my experience as a member of the health board that even yet there are many people who pay this contribution through their insurance stamp and do not know the benefits they are entitled to. I found this out particularly in the recent past when medical cards were under review. I met many people who in that review lost their medical cards because their income had increased and they were of the opinion that they would now have to pay for hospital services. The very fact that they are paying it through their stamp shows they simply do not take the time to study what they are entitled to. Many of these people would be put to enormous expense had this Health Contributions Act not been introduced by Fianna Fáil back in 1971.

It is true that the method of collection lends itself to improvement, particularly in the small farming section. This money is collected by the health boards. The method of collection may vary from health board to health board but in the north western region it is very unsatisfactory. For example, people who may be substantial businessmen and who may have small farms as well will receive a demand for this payment. Many of them in the past paid it in the belief that this would entitle them to hospital and specialist services for themselves and their families. In paying it they did not read the small print at the back of the demand note which stated that if their income was in excess of whatever it was at the time, even by paying the demand they were not entitled to it. In this way the health boards are protected. If a person receives a demand it is natural that he or she may believe that in paying it he or she is entitled to the service. There is a considerable amount of small print at the back of the demand note and I would say very few people ever read it.

Then we find people who have no income whatsoever receiving demand notes. Small farmers on the dole and having medical cards year after year receive this demand note, receive threats to prosecute, and so on. They do not understand what it is all about. Many of us meet these people from time to time. These are not just isolated instances. I would ask the Minister of State to draw the attention of the Minister for Health to this matter and to tell him that the method of collection of this contribution, in the farming section at any rate, is in need of immediate reform.

As Senator McCartin said, there are many people paying this contribution who should not be paying it. I have come across medical card holders who paid this demand because they felt that once they received it they should pay. I have come across business people, whose income is completely in excess of the standards, who have paid this demand in the belief that they were getting something for nothing. Then we find there are many people who could avail of the service but who do not pay. I also find that the bookkeeping for this particular collection must be very poor. I have written year after year to the health board pointing out that certain people were in no way obliged to pay this money and I received replies that they would be struck off, only to find the following year that the demand was being sent out again. It would be a very useful exercise on the part of the Minister for Health to institute an investigation into this type of collection and possibly co-ordinate it throughout the country. The Minister mentioned the various factors which influenced increased costs today. I agree that the aged could be card for without so much State investment, that more emphasis should be placed on the home, that the numbers of home helps should be increased and that the number of nurses from the psychiatric hospitals — and there are a number of them in each region visiting patients after they leave hospital — should be increased. There are many old people being looked after by their relatives who do not want them to go into welfare homes or other institutions but who receive no payment for them whatsoever. This should be investigated. These people should be encouraged to keep their aged at home. They should not be discouraged to such an extent that they encourage the aged to go into institutions. I realise I cannot develop this too far because it would not be relevant to the Bill.

One particular item which was referred to by Senator McCartin — I say that because he may not now tell me I am out of order — is the cost of drugs. That matter will have to examined. If it was restricted it might not have been necessary to increase the contributions under this Bill at this stage. In the North Western Health Board region alone the cost of drugs in 11 months was £1.75 million. I realise that in fairness I cannot develop this matter too much but there is a lot that could be said about it and I hope that this is one of the many avenues which the Minister for Health will investigate in order to cut costs. It is a pity that this increase has become necessary. It is now £24 annually. When one considers that the only alternative to paying this £24 annually, or 50p per week, would be to join the voluntary health insurance one must appreciate that there is a great saving. It would cost a family at least three times as much money to join the Voluntary Health Insurance Boards. For that reason I feel I must welcome the measure and certainly say that its introduction the first day has saved a considerable amount of money for a certain section of the community who will be caught very bady.

At least in the case of the Social Welfare Bill which we have just discussed there were some increases in benefit payments visible in return for the increase in contributions imposed. In this Bill there are no such increases in benefits and there are no extra services at all available for the contributors in return for what is quite a hefty increase. While 50p per week and £24 annually may not seem exorbitant amounts, yet the increase involved in those new figures does add up in conjunction with the other increases already imposed in the ordinary insurance contributions.

As a matter of fact, this increase from £18 to £24, and from 39p to 50p, does represent the largest percentage increase for any one-year period since the introduction of the Bill back in 1971. After a four-year period the rate went up from £7 to £12 yearly in 1975, and from 15p, the initial rate, to 26p weekly after a four-year period. In 1976 it went from 12p to 15p and from 26p to 33p and in 1977 the yearly rate went up by approximately 25 per cent in the case of the annual rate and roughly 18 per cent in the case of the weekly contribution, but now we have an increase in the annual contribution of 33? per cent and in the case of the weekly contribution an increase of 28 per cent. All in all, the largest percentage increase for a one-year period since the scheme was introduced back in 1971.

It is a taxation measure, pure and simple, a taxation measure to which there was no reference in the budget although there was reference in the same budget to increases in benefits under the Social Welfare Bill. There was no reference whatsoever to the increase in the contribution that would be required either under the Social Welfare Bill or under this Health Contributions Bill. This is something the Government will have to remember when they introduce future budgets, that the public will not be blinded to this deliberate failure to disclose increases in contributions.

It is high time that the distinction that exists in this Health Contributions Bill between manual and non-manual classes should disappear. Such a distinction is neither appropriate nor desirable in the times in which we live, and while the Minister places some hope in that the new pay-related scheme which he will bring in in April 1979 will go a long way towards eliminating many of the present anomalies, I would certainly hope that this anomaly, this distinction between manual and non-manual will disappear once and for all.

In regard to the present administration of the Health Contributions Act, chiefly in the collection of the annual contribution, there is a big percentage difference between the numbers that are liable and the numbers that actually pay their annual contribution. The record of collections in this respect is not at all satisfactory. In Louth we were informed recently that the rate of collection is only about 50 per cent; it could be even less. The experience has been that in the case of many annual contributors such payments are not made until the need for obtaining the benefit under the schemed arises and then people are inclined to pay up and even pay some arrears. Because the sum of £24, which I admitted earlier is a small amount taken in its individual sense, and certainly anybody faced with hospitalisation or any in-patient services is not going to opt out of the scheme which will only impose a burden of say £24 annually and even have to pay one or two years arrears as well, it is possible for many in the self-employed categories to defer making their payments each year.

The fact that collections are not made each year, as was envisaged in the introduction of this scheme, means that the State is losing money and somebody else has to carry the cost of the operation of the scheme and the services which pertain to it. This in the final result seems to be the weekly contributors who have little option but to pay in by deduction each week anyway. The Minister should certainly look at ways to improve the method of collection. There is an unfair system there at the moment and it should be determined as quickly as possible so that all people pay as they are required by the health boards and by the Revenue Commissioners.

There have been hints in the past of a greater share of the cost of health and social welfare services being carried in the future by the contributors rather than the Exchequer. The Minister has not indicated that such will arise in regard to his new pay-related scheme. Perhaps he might be able to elaborate a little upon it. Those hints have been dropped and I wonder if they will apply under his new scheme. It seems to me that an awful lot is depending on this new pay-related scheme in regard to abolishing certain anomalies which exist at the moment, both in regard to the Social Welfare Bill and also this Bill. The Minister has made great play of the fact that what is being imposed now is merely a holding operation, as it were, until this new pay-related scheme comes in, and I certainly hope that all that we hope for will be in it.

There is no doubt that in regard to the operation of the health contribution scheme that there is wide confusion amongst contributors particularly as regards what benefits and services are available, and even as to the eligibility of the contributor under this scheme. Paying the contribution yearly does not make one eligible for the benefits, it only places one in the queue for receiving such benefits and one's eligibility has still to be determined. There is something wrong in this. It would appear to me to be unfair to take money from people, and then perhaps at some future stage tell them that they are not eligible for the benefits.

Certainly for the amounts of money which are involved in the limited eligibility services — the Minister has given an estimated cost for 1978 of £265 million — its recoupment to the order of £16½ million under this health contribution scheme does seem very small, and to know whether or not that very smallness will mean that there will be further contribution levies in the future we will have to await the new pay-related scheme. I have no objection to the amounts that are being asked. My objection is that there is an increase without any addition or extension of the services in return.

I should like to make one point. I welcome the Bill.

I think the Minister is doing his best for the day-centres which, as was mentioned by one of the Senators, are so necessary. He is fully aware of this and he has helped many such centres, as I know, in Dublin and County Dublin and, I am certain, throughout the country. This is a very important point. I feel that 6 per cent is not very much, taking the overall figures that were given to us today. I should like to welcome this Bill and I think the Minister will certainly streamline the health services and will give a great deal of consideration to old people and sick children.

I should like to make a brief comment on a statement in the Minister's speech to the effect that the present system of determining "limited eligibility" is a complex one which contains many anomalies. Every Member of this House, every public representative and thousands of other people realise that "limited eligibility" is a complex procedure and is one that causes a lot of misunderstanding and a great deal of annoyance. We have now reached the stage when there should be a more standard procedure to determine this limited eligibility.

This applies to people who are in the income group where they pay as much as they can and then, because of unforeseen circumstances or because of an extension of a period of hospitalisation or other unforeseen difficulties, they reach a stage when they are able to pay no longer. There is not a sufficiently sympathetic approach to people of that kind. Very often from the point of view of poor law valuation their annual income is only very little above the standard of people who receive medical cards. Because they are even slightly above it they have to pay the cost themselves and they find that they run into something totally unexpected and something which is far beyond their ability to pay. Very often it is a source of great worry, annoyance and disturbance to these people. I hope that the process of determining this will be made more simple and that it will be done rapidly.

With regard to the increase from 15p per week in 1971 to 50p now, this constitutes an increase of something in the nature of 233 per cent from 1971 to 1978. The increase from £18 in 1977 to £24 annually in 1978 is an increase of 33? per cent. In the opening sentence of the Minister's speech he said that it was made clear when the original Health Contributions Bill was being debated in 1971 that the rates of contribution would have to be increased as time progressed. The House should have been informed as to how much of this increase would be due to inflation and how much would be due to the fact that more services were being provided. It should have been broken down in that way. People should be told that part of the increase of 233 per cent from 1971 to 1978 is due to inflation and part of it is due to the increased services provided. We have not been told that.

Regarding the increase in the cost of drugs, as a member of the North Eastern Health Board I know that this phenomenal increase is a matter of grave concern at health board meetings. Various members of the health boards, professional and lay people, are of the opinion that some definite action will have to be taken by various Departments to ensure that there is a certain standardisation in the type of drug prescribed and that a constant check is kept on the increase because it is the one item in the health board expenditure that has gone out of control in recent years. It is something that needs attention. This is also a cause of grave concern in Britain. It is something that calls for the closest scrutiny on the part of officials of the Department and of the health board and general help from the Irish Medical Association. It is a matter of great concern to the members of the health boards.

At a health board meeting in Kells this matter was discussed and the opinion was expressed by a number of people that drugs were prescribed much too freely and were being given in inordinate numbers. It is quite a common thing for people to have a lot of drugs in the home. They become ineffective and perhaps dangerous after some time. This is something that calls for the closest scrutiny and examination in order to slow down, if not eliminate, the vast increase in the use of drugs in this country.

I would like to join in a plea to the Minister that people suffering from asthma should be on the list of people for special treatment with regard to allowances and help. Every Member present realises that there are asthma patients who suffer very great trouble and have the greatest difficulty in being able to provide for themselves and getting the treatment that is necessary to make life tolerable. When one is familiar with what some of these sufferers from asthma go through it is difficult to accept that it should be ruled out time after time. The North Eastern Health Board, of which I am a member, made representations to the former Minister for Health to have sufferers from asthma included but without success.

We had a long list of items at the end of the Minister's speech. He said that the extent of the increase in the cost of hospital and specialist services must be a matter of serious concern and it is a problem to which he will be devoting close attention. There are many factors which influence his thoughts.

I realise that a great deal of progress has been made with regard to the treatment of aged people in geriatric units in latter years. It is still a fact that there is a high percentage of aged and ageing people in the more sparsely populated and remote parts of this country who are sent into hospital and who would much prefer to be at home and live in their own environment. What is needed to reduce the number of patients in these hospitals is a further extension of domiciliary care for people of that nature. With more domiciliary care these people would be much happier in their own homes than in hospitals. I do not want to be taken as saying that I am not very pleased with the improvement which is being made in regard to treatment of patients in the geriatric hospitals. I do not think that there is a wrong emphasis and that there is far too great an inclination to send people into hospitals of this kind who could be treated successfully at home and who would live happier lives at home and be much more contented with their lot than they are in these institutions.

I should like to take this opportunity to say a few words about the financing of health services and State health services in general. As we have seen from information supplied to us the cost of medical services for 1978 will be something like £365 million and the contributions will amount to something like £16 million, which is a very small percentage. The Exchequer, in other words, is covering the main cost.

We have had much discussion over the years in this country about medical services but one thing that they learned in the UK is that if you go too far with them you end up with poor services. My information from making inquiries from people in the North of Ireland is that we should not get over-involved in a free medical service. I say this designedly because, through my work in the Dublin North-Central area and the inner area of the city where people are living very close to the poverty line and come under the impact of the social welfare benefits as a result of not leading a full and ordinary life because a lot of them are unemployed, I know that this is needed but I am just raising the caveat and saying that we should not go the whole way and some contribution for health services should come from everybody. We should be seen to pay for it.

The argument that went on in the Dáil about the percentage increase was a matter of playing with figures. We are talking about something like between 7 and 9 per cent of a low income. What is more important, as I see it, is the way we spend this money. In fact, the Minister has given us a listing in his opening statement of where expenditure goes, and you yourself, a Leas-Chathaoirleach, were tempted to have a long look at that.

I would like to take the opportunity on this occasion to draw attention — and I am here supporting the previous speaker — to the amount of drugs that seem to be in the system. I visit a lot of flats in the inner city area as part of my constituency work and I must agree that I have never seen so many bottles of drugs all over shelves. I have seen the effects of it, which is worse. One can understand that people get depressed living, sometimes, in the surroundings that they have to live in and without having the challenge and sense of achievement that having a good job and doing a good day's work gives a person, and that they would have resort to these things. But I think it is a matter that needs very careful watching. The older people, particularly, who are living very often in dread of their lives, sometimes in dread of losing whatever little property they have, resort to these as a means of trying to forget about their problems.

This brings me to point out probably one of the worst problems arising from one of the worst drugs of all — drink. The people of this area have nowhere to go to socialise and the obvious place is the pub. I think the Minister might give some consideration to a much bigger campaign against the "round" system. It seems to me that we need some motto like "rounds are rotten". They are rotting this country. People who have a small amount of money are spending it continuously in pubs as a means of forgetting their everyday problems and finding some outlet. That has to be tackled as well.

In complaining about the increases, we talk about the problems of the detention centres. I am not widening the debate too much but I see it every week and hear people talking a lot of social science clap-trap about the process of development of young people when it is really impossible to control them. There is a hard core of people in my area who need to be detained. Any money that can be made available, however it is collected, should go to providing more detention centres. Crash action of some kind is needed in that inner city area. I get more depressed as I see the problem. Periodically I hear statements from Bishops about the Third World and about what money we are not contributing there——

An Leas-Chathaoirleach

The Senator is moving away from the subject matter of the Bill and I must ask him to try to relate more closely to it.

I felt that I had to get this off my chest and I am not taking too long a time. I welcome the move. I enter my few caveats and make my appeals.

I have no objection whatever to the increases. Most certainly I would have to go on record with regard to limited eligibility. One of the most clearly marked international trends in the evolution of health services is towards access free of charge to health services. Our own NESC report last July showed that the coverage for health services in Ireland is less comprehensive than that provided elsewhere in the EEC. Indeed, the general plan in the Community has been towards total coverage for health services. Belgium, France, Denmark, the United Kingdom, and Luxembourg achieved total free service in 1971. In 1976 the Dutch made their health system comprehensive for all categories of risk, and that applied to all sections of the population. It makes Ireland as a member of the Community an exception to the general trend. Our health services appear to be falling or at least remaining stationary. Therefore, if you had a return to full employment it would reduce the percentage in receipt of benefits under full eligibility. Changes in earnings and the failure to adjust income ceilings in line with increases would reduce the scope of the limited eligibility scheme. That is happening at the moment and by next year I can well see that there will be many people who will not qualify, even under £3,000.

In 1974, when the income level for insurance under the Social Welfare Act was abolished the income for limited eligibility for health services was also considered and the decision was only deferred, as I understand it, pending the completion of negotiations with medical consultants. However, we got to £2,250 pending the completion of negotiations, and then the income level was raised to £3,000 in July 1976. Even though we welcomed it at the time — I thought it was a move in the right direction — the flaws are beginning to show up now. If you look at the figures, at present 35 per cent of the population are covered by the general medical service schemes and have full eligibility for health services, but there is great doubt about the extent of the availability of limited eligibility benefits. The Department, I think, said earlier in the year that 50 per cent of the population were covered for limited eligibility. This is not accepted in the trade union movement — indeed the Irish Congress of Trade Unions contradicated it because of the time-lags between the increases in income and the income limit being raised. The Irish Congress of Trade Unions pointed out that in 1958, 90 per cent were covered by free and limited eligibility as opposed to the current estimate of 85 per cent. If that is true, it means that the remaining 15 per cent of the population are responsible for the full cost of any medical service they require and they can only insure themselves against costs through voluntary health insurance or private organisations. It is an intolerable situation in this day and age, particularly in the light of what is happening in the other EEC countries, that workers should have to turn to private organisations to give themselves some protection, and they are not covered under VHI for the birth of a child, for example.

The Minister has said he is prepared to introduce a comprehensive pay-related scheme. I will quote him:

It is expected that the introduction of this new pay-related scheme should eliminate many of the present anomalies and should make it very easy for everybody to understand.

Our argument is not that many of the anomalies should be removed but that they should all be removed. I know it is not easy to do it but we have to go on record as saying that we believe it is a crazy situation. The working party on the definition of limited eligibility were set up in January 1977 by the Department of Health. They have not been able to resolve the problems in relation to the discriminatory element.

I do not know how they can solve such problems in Europe and other places and we cannot. This is a bit of a puzzle to me. However, the only way it can be solved in my opinion is that the income that limit must be removed completely in the case of non-manual workers. That would bring the non-manual workers into line with the manual workers. To keep people pegged down to roughly £58 per week is not unfair in light of the fact that in the recent wage negotiations the Government themselves accepted a £50 level when dealing with the question of stamps. To my mind it is not satisfactory. It would be all the same if you took the limit off and made it £4,000 because you would have problems again next year. The limit must be removed completely if you want to solve the problem totally. I cannot lay enough stress on the question of the anomalies between non-manual and manual workers. There are thousands of them in the private and public sectors. If you walk into the bar here for a drink, the barman who serves you is not eligible or considered to be in the category to qualify.

Getting back to the NESC report published last July, it refused the arguments put forward against the abolition of the income limit. To some extent it exposed the absurdity of the distinction between manual and non-manual employees.

With regard to the doctors themselves, they seemed earlier to be making the argument that universal eligibility was being rejected by them because it would increase the demand for health services. This is not experienced in other countries. If it can be done in Belgium, Denmark, Holland and the United Kingdom then it must be possible to do it here. The argument of the doctors appears to be contrary to the other health care systems throughout Europe. The doctors determine the demand for the beds and so forth, and the indications there are that the system does not extend the demand on the resources, that it has its own way of levelling out.

I should like to go on record as saying that I realise there is a problem of high administration costs. There is also a problem of administering the system because of its complexities. If the limit was removed I feel there would be a substantial saving. Apart from the fact that this complex programme is costing a lot of money, it is possible to make the argument, and I make it, that if the income limit was removed a lot of the complexities would be removed and the administrative costs would be reduced — that the total cost of removing the income limit may not be as substantial as was at first envisaged.

It is clear from the debate that any measure that deals with social welfare or health benefits is not considered a suitable vehicle for scoring political points. This is of course a budgetary measure and like other Senators I have done my sums. They are quite simple sums. I will not blind you with statistics, but the rise in the consumer price index during the period 1975 to 1976 was 16.2 per cent while the rise in the cost of the stamp for the same period was 25 per cent. In the period 1976 to 1977 the rise in the consumer price index or the cost of living index was 14 per cent and the rise in the cost of the stamp was 18 per cent. When we look at benefits given by the State in those two periods, and I will just mention one, the one with which I am most familiar, the children's allowance, we find that in July 1975 there was an increase of 5.3 per cent in children's allowances and in July 1977 there was an increase of 8.4 per cent. This proves only the need for some sort of monitoring system which would ensure that increases in contributions and in benefits would bear some relation to the increases in the cost of living.

This is an interim measure and we look forward to the new scheme that the Minister hopes to introduce this time next year, and we hope that it will do away with the anomalies and with the faults that exist at present. The faults that exist at present can be categorised under two headings. The first is delay, and one must look under this heading at the appalling waste that occurs when somebody is sent into hospital for tests or for something else, and the delay that occurs when he is left there for several days before somebody has any time to look at him. The second category is one of definition. In this we must include the confusion that seems to exist at present as to who is a manual worker and who is not. Under this heading I agree with a point made by several Senators as to what constitutes a chronic illness and what does not. Many children today suffer from asthma, a chronic illness and a very terrifying one for parents, and yet it does not come under the heading of eligibility as a chronic illness.

Within these limitations I welcome this Bill. I would also like to congratulate the Minister of State, who is standing in today for the Minister for Health and Social Welfare, on the excellence of his brief and to applaud his courage in coming into the Seanad on the Ides of March.

It is an appropriate note to be coming in on, though I think it might have been as well if some other Deputy had to contribute because I do not quite welcome the idea of being a sort of Ides of March speaker. However, there has been a useful and wide-ranging discussion on this measure. From my point of view, standing here for the Minister and not being an expert on the subject, I quite honestly have learned a lot. On the other hand, I have been a member of a local authority and am fully conscious of the many problems that a number of the Senators spoke about.

In general, most of the discussion was on the question of limited eligibility, and as we went on it seemed to become more limited. We now have reached the stage that roughly 40 per cent of the people are on medical cards. That leaves 60 per cent. Senator Harte said that between medical cards and people on limited eligibility we cover up to about 85 per cent. Roughly 45 per cent are covered by the term "limited eligibility", and the number of people who have medical cards in 1978 as against the number of people who had medical cards in 1971 has been increased from about 30 per cent to about 38 per cent. The numbers of people covered under the "limited eligibility" are that little fewer mainly because some of the people who were required to pay as self-employed or as farmers and the people who had to pay through the stamp, have been reduced by reason of the increased amount, that 10 per cent increase that has occurred in the number of people covered by medical cards. Quite a number of views were expressed from both sides of the House on the non-application of health boards to the comprehensive collection of the health contributions from farmers and self-employed. A number of the Senators talked about the fact that there seems to be a degree of indecisiveness in the demands issuing from the various health authorities in so far as people who had medical cards were getting demands for contributions. From that point of view I agree that there is the need for a lot of tightening up. Senator McCartin opened on this.

As I am deputising for the Minister for Health I have the responsibility of reporting on the proceedings to him. Of course, he will be able to read the content of the debate when it is printed. It is quite obvious from the views expressed that there is a pronounced interest in the pay-related scheme which he proposes to introduce this time next year.

Senator McCartin described the Bill as a taxation measure. That is one opinion. I was interested in Senator Markey's follow-up in which he said it was the greatest single annual increase since 1971, from 18p to 24p, an increase of 33? per cent. In fairness, I should point out that in 1975 the then Minister for Health, in introducing the Health Contributions (Amendment) Bill, imposed an increase from 15p to 26p in the price of the stamp, representing 73 per cent as against this year's increase of 28 per cent, from 39p to 50p.

Yes, but it was the first increase in four years.

I accept that. I thought the Senator would draw my attention to that fact, that that is why he spelled out that it was an increase of 33? per cent in one year. When the Fianna Fáil Government went out of office in 1973 there was only a two-year period between that and the time of the next increase. I do not think the comparison stands Senator Markey in good stead because within a year and a half of the Coalition taking office that increase took place. Although I agree that it was the first increase since 1971, I draw the Senator's attention to the fact that it was introduced in less than two years from the time the Coalition Government took office. That represented a 73 per cent increase on the stamp and it was a 71 per cent increase, from £7 to £12, in the annual contributions.

As long as the Minister accepts that it was a 73 per cent increase for a four-year period as compared with a 33? per cent increase for a one-year period, I am satisfied.

As far as the Government are concerned, it was a 73 per cent increase within a two-year period. I suppose we can agree to differ on our individual approach. There were many references to the administrative expense at health board level and the overall pattern in which there may be neglect or otherwise in the different approaches to the collection of money from the self-employed and farmers. In this context we are speaking of an estimated receipt during the year 1978 of £16.6 million, of which £14.3 million will be collected by way of the stamp, £1.3 million by the health boards directly from farmers and £.99 million by the Collector-General from the self-employed. Therefore, a more streamlined and convenient way of collecting that money must be found. I know it is one of the proposals engaging the attention of the Minister.

Senators McCartin, O'Brien and Cassidy all spoke about the inclusion of asthma in the list of chronic diseases. I am conscious that it is a very distressing illness. It does not specifically arise under the terms of this Bill but I will draw the Minister's attention to the views expressed by Senators on the desirability of having it listed as a prescribed illness in view of the undoubted pressures it brings on individual patients and on parents because of its effects on children.

Senator Goulding acknowledged the Minister's interest in day centres, particularly in Dublin, and his unquestioned interest in old people and sick children.

Senator O'Brien had much to say about limited eligibility and in that context I noted that there had been an increase in the percentage allocation of medical cards from 30 to 38. He was supported in his argument by Senator McGlinchey in relation to observations on the cost of drugs, and Senator Mulcahy referred to the demand for drugs. Various Senators had different approaches to this question. Senator Harte, speaking on his own behalf, and probably that of his party, said he did not have any objection to the increase in charges but had much to say on limited eligibility.

Senator O'Brien and Senator Mulcahy spoke about visiting people's houses and seeing presses full of drugs. I have always held the view — and I think it is shared by many people — that anything you get for nothing is not sufficiently appreciated. For the limited eligibility category the contribution is £24 for the self-employed and farmer and 50p per week as a contribution to the stamp. The overall cost of the health services is £380 per contributor. People will value the service more if they have to pay some small amount for it, which is what happens in regard to limited eligibility.

The people we are talking about are those who are entitled to the clinical service, out-patient and in-patient service, but they are not the category entitled to free drugs. I take it that the presses full of drugs which Senator O'Brien and Senator Mulcahy spoke about belong to people holding medical cards. Generally it is accepted that this is not a new development. In the old days with the old dispensary system we had stories told about the housewife who used go to the dispensary weekly to have a chat with other housewives and who on her way home poured into a drain the contents of the bottle she had been given. The visit to the dispensary was only an excuse for a weekly meeting. I do not think we are as bad as that now. The fact still remains that we have always appreciated something that little bit more if we have to pay something for it.

Senator O'Brien asked for an analysis of the reasons for the increase in expenditure since 1971. He asked how much was due to inflation and how much was due to development of services. It would be extremely difficult to analyse this since 1971. There has been an increase of about 320 per cent in the cost of all health services during that period. In the same period the rate of health contributions, and Senator O'Brien made reference to this, had gone up by 230 per cent. So, we still have not caught up on the costs from that point of view.

Apart from the wide use of drugs and what could loosely be described in some instances as the misuse of drugs, a number of Senators referred to the rising expenditure on drugs. This is an issue of great concern to the Minister. It is one that he is endeavouring to apply himself to and in actual fact to the more responsible prescribing and use of drugs as such. Everybody will appreciate that this is a very complex issue and in any event the cost of drugs in the whole context of the health services is not as high as one would imagine. Nonetheless they run at something less than 10 per cent of the total expenditure.

There was the question of the difficulties in collection of contributions from farmers. There are difficulties here particularly where a person has an income as well as the income from a farm. There is also difficulty in identifying what farmers should pay and also in enforcing that collection. Those are all points that, arising from an interesting debate here, the Minister can be looking into. Overall, one of the things that emerges is a sort of a consensus that the amount of increase, while it can be criticised, is justifiable and that apart altogether from the varying views on this question of trying to iron out the limited eligibility aspect, there seems to be general agreement that we are getting reasonably good value for money in this regard.

Question put and agreed to.
Agreed to take remaining Stages today.
Bill put through Committee, reported without amendment, received for final consideration and passed.
Barr
Roinn