Thursday, 24 October 1929
Dáil Éireann Debate
“To delete all words after the word `That' and substitute therefor the words the Dáil declines to give a Second Reading to the National Health Insurance Bill, 1929, until proposals have been laid before the Dáil providing for—
Dr. Ryan: I did not intend to intervene in the debate, but I do so now owing to some reports which appeared in the Press. I would not like it to be thought that I would support the amendment if the same medical benefits were to be straight away extended to towns and country districts as outlined in the Report. In the amendment we ask that proposals be laid before the Dáil providing for the administration of national health insurance through one society and also for medical benefit. We, of course, would naturally hold ourselves free to consider these proposals when they come before us in order to see whether or not we could agree with them. Deputy O'Connell yesterday spoke of a State medical service and, so far as I personally am concerned, I believe that that would be an ideal solution; but as this Bill is dealing with insured persons, I do not know whether we could really bring in an amendment for a State medical service under the Bill. We can only deal with insured persons. As I am not, and never have been, a dispensary doctor, I will not be taken as prejudiced when I say that generally I never found any fault with dispensary doctors, but what I say is wrong is that people who are insured and working for their living should be tainted with pauperism if they have to employ a medical dispensary doctor as at present. It is, on the other hand, rather unfair to ask these people to pay a medical doctor in the ordinary way. There is a difficulty which I believe could be got over.
It has been pointed out that we do not want to have overlapping by having insured people going to dispensary  doctors and also having doctors for the destitute poor. It should be possible for a Government department to formulate a scheme that would combine both systems and prevent overlapping. We have experience of the medical dispensary system and we know what is good and what is bad in it. We could easily get evidence as to how the panel system is working in England. It ought to be possible for a commission, or for a Government department without a commission, to arrange a scheme that would combine the good points in both and have no overlapping. That, of course, is approaching a State medical service but if it must be called a State medical service we are getting nearer to our ideal. I think that the question of overlapping could altogether be avoided. The great difficulty is that towns and cities are well-placed for a panel system such as operates in England, but there would be practically no advantage in having a panel system in country districts. In towns with a population of 3,000, 4,000 or over people would, at least, have a choice of doctors. That would be a great advantage under medical benefits. At present people are confined to one dispensary doctor unless they are prepared to pay. It is possible that in most towns the dispensary doctor would be the best doctor and would be chosen by the people if they had a choice under the panel. The fact that people would have a choice and also that they feel that they are paying for medical service which they are getting in towns would remove the stigma of pauperism which they have to endure at present.
It is a different matter in the country. In the country districts where you have only one doctor within a radius of six or seven miles, if the benefits are brought in they would not be any great advantage to insured persons because they would have to go to the same doctor in any case. The only advantage would be that they would not be going to him under the Poor Law as at present but would be going as a right under the insurance scheme. I do not know if  people in the country districts as a whole are prepared to pay for that right, so that any scheme that would be introduced would have to take into account the difference between conditions in the towns and cities and the country parts of this State. I would not like to be taken as voting for this amendment if that were to be considered as approving of the scheme outlined in the report. It would appear from certain reports in the Press to-day that we are by this amendment approving of the scheme outlined in the report. It is just to make my position and the position of other members of the Party clear that I rose to speak.
General Mulcahy: I suppose it is due to national pride that we all seem to realise that none of us here would be guilty of the National Health Insurance Act of 1911, with all its faults and limitations. On all sides, just as the persons who put that report together, we are out for the ideal. It is not necessary for a Government to wait to know whether the ideal is feasible or practicable or whether it is money or anything else that is the difficulty. Once you are a Government you must have courage. The rest is quite simple, and the most complicated scheme can be put together, of course subject to whatever criticism may arise afterwards. We are dealing with the 1911 Act, and the present Bill will secure that every insured person in future will be an ordinary insured member. There will be no discrimination, such as there was before, between exempt persons and deposit contributors or persons like that. An insured person will simply be an insured member and in the case of women, women, on marriage will get a gratuity that is actuarially equitable. If they come back into employment after that, they will come back as new members. It secures that there will be very much less non-compliance, if any at all, and it secures that if good care is not taken of the finances of approved societies, the want of care can be brought home by audit, to the persons actually responsible.
General Mulcahy: Outside that it deals with the sanatorium benefit and with insurance committees. The points that have been at issue in the debate are (1) that no action is taken to bring about the unification of societies, and (2) that no action has been taken about the securing of medical benefits. Exception is taken to doing away with the sanatorium benefit as a benefit under the Act, and to the suppression of insurance committees. The question has been raised as to the compensation to the employees of insurance committees. I said yesterday I was prepared to bring in an amendment which would give the Commissioners power to give certain compensation to employees of approved societies who were disemployed as a result of voluntary amalgamation taking place within a limited period, and that would give power to the Commissioners after that to bring about compulsory amalgamation. After a discussion with the Ceann Comhairle in the matter I find from him that the outline of the Bill as introduced is too restricted to allow of an amendment of that kind to be brought in on Committee. I have further discussed the matter with the Commissioners of National Health Insurance, and what I have decided is that I will take steps to put before the House immediately after the Christmas Recess a separate Bill containing proposals with regard to amalgamation along the lines that I outlined here. I think that as we cannot get it in this Bill that is the most satisfactory way to deal with it. I do want to make that position clear.
With regard to the criticism that has been levelled about removing the sanatorium benefit from the Act, we have to take to some extent the history of sanatorium benefit and the history of the development of schemes for the treatment of tuberculosis here. The Tuberculosis Act of 1908 gave county councils power to institute  schemes for the purpose of dealing with the treatment of tuberculosis cases. When the 1911 National Health Insurance Act came to be formulated it was realised that the 1908 Act, in so far as dealing with tuberculosis was concerned, had been a failure for the reason that the entire financial burden of the carrying out of schemes under that Act was left to the local authorities.
Therefore, when the 1911 Act was being dealt with—they were not clear as to what the commitments of sanatorium benefit would be—sanatorium benefit was introduced. Immediately after doing that and making provision for giving sanatorium treatment to insured persons, it was made quite clear that it would be necessary to make effective provision for sanatorium treatment in the case of ordinary tuberculosis patients who were not insured. The result was that in 1913 provision was made for fifty per cent. of any expenditure by the local bodies in the case of tuberculosis schemes to be borne by the State. Arrangements were made that the insurance committees that dealt with National Health Insurance would work in with the local bodies. The development of the treatment of tuberculosis by the local bodies, and also the actuarial and general position with regard to the treatment under the 1911 Act, were such that in 1920 in Great Britain sanatorium benefit was removed from the Act without any reduction of the contribution from the insured person. Here the matter has continued as it is until now. At the present moment the amount of money at the disposal of insurance committees for the treatment of tuberculosis cases amongst insured persons is £27,000 approximately per annum. In the year 1922-23 the amount of money given by the State as the fifty per cent. share of the total expenditure on tuberculosis schemes throughout the country was £21,000. So that whereas perhaps not as much as £27,000 was being spent by insurance committees in 1922, about £42,000 was being spent by the local bodies  on general tuberculosis schemes. But the position here in the matter of the treatment of tuberculosis is very much improved since then. Whereas there was £21,000 given in State grants in 1922-23 as the State part of the scheme, the actual expenditure in 1927-28 was £41,000. The estimated expenditure during the current year as a result of the State grant is £59,000. So that the position to-day is that while the insurance committees are spending £27,000 a year they have at their disposal between local bodies and the. State approximately £110,000, which is being spent on the treatment of tuberculosis cases throughout the country, apart altogether from the moneys that have been spent on the building of sanatoria throughout the country. Now, four-fifths of the £27,000 that is at the disposal of the insurance committees is actually handed over by the insurance committees to the local bodies dealing with tuberculosis schemes.
The whole expenditure, with the exception of about £5,000, on tuberculosis treatment is actually being spent through the local bodies. I think that ought to dispose of the argument that is being used here. that the throwing of this work over on the boards of health is going to place additional work on the boards of health, work that these boards are not able to bear. In connection with that, too, if it were throwing additional work over on the boards of health, the boards of health have statutory powers that enable them to set up sub-committees to deal with that work. Any part of its work can be devolved by the board of health to a sub-committee consisting of not less than three persons. These persons may consist entirely of members of the board of health or members of the board of health and outside people, or that committee may consist entirely of persons outside the board of health. So that if this were throwing additional work on the board of health there is in the board of health now machinery to deal with it. It has been asserted that a right of insured persons,  which is absolutely assured to them and for which they have paid, is being taken from them. That is not a fact, because the National Health Insurance Act of 1911 does not secure as a right to insured persons sanatorium treatment. It does ensure that a limited amount of money is set aside for that treatment, but if that money was set aside, where it does not cover that treatment, then they have to fall back on other means.
The position has been that a number of the insurance committees whether dealing directly with funds themselves or whether handing over their funds to the board of health, have not had sufficient money to deal with all their insured persons and what has happened is that the insurance committees have been in the position of having to discriminate between the insured persons in their area who will get sanatorium treatment and those who will have to run the gauntlet of having to pay something for it if the local body does not give them assistance under their own schemes. Persons may be recommended for sanatorium treatment early in the year when moneys are available for the insurance committees, but towards the end of the year when the moneys are used up persons looking for sanatorium treatment have to come in under the ordinary schemes. If you examine the number of persons insured and the number of persons not insured who are being treated under tuberculosis schemes in different parts of the country, you will see that the percentage of persons who are insured persons is very much greater than the percentage of moneys that are insured moneys as compared with those moneys that are not insured.
You are not taking away from insured persons anything that they actually have at the moment. Instead of transferring them in 1920, as was the case in Britain, you are transferring them here in 1929 when the general public expenditure on tuberculosis schemes has gone up by 500 per cent. and when, apart altogether from the money, you have  more efficient methods being employed for dealing with them. It was suggested here that transferring insured persons to the local bodies would mean taking from them privileges they had under the insurance committees. I think Deputy Corish specially mentioned that. He said they got butter, milk and eggs and other provisions like that through the operation of insurance committees and that they could not get those things from local bodies. Any provision of this nature that is made under an insurance committee is provided on medical advice, and medical advice to the effect that these provisions are required can be and is given under the ordinary tuberculosis scheme throughout the country. If there were people in receipt of eggs. milk and butter in Wexford where there is an agreed scheme between the insurance committee and the board of health, then the patients were receiving them under the board of health scheme and not under any pet arrangement of the insurance committee itself.
General Mulcahy: The county scheme will assist with dispensary treatment, sanatorium treatment, or domiciliary treatment. That deals with the question that in the first place you are taking away anything from them that they have at present, or that they are being deprived of treatment they have been in the habit of getting or could get under an insurance committee.
General Mulcahy: A point, has been raised with regard to the provision of compensation for employees of insurance committees whose services are dispensed with. Section 22 (4) (a) is intended to contain powers to deal with that matter. In connection with that I desire to say that it has to be realised, in dealing with compensation paid to such persons, that out of 31 insurance committees in the country only 6, including 2 county boroughs, have more than £1,000 per annum to administer. Another 6 have between £750 and £1,000. Out of 31 committees there are at least 9 that have less than £750 a year to administer. It will be, therefore, understood that the employees of these local bodies are all part-time, and a large number of them are persons who hold other occupations, sometimes under local bodies.
As regards the question of medical benefits, apparently we all want the ideal scheme. I think everyone realises that whatever scheme of medical benefits may come, it has to be visualised with the background of the dispensary system here. It is suggested that the Committee should put up a scheme for giving medical benefits. A scheme was put up, and the Committee recommended that it would not be put into force without lots of different parties being brought into consultation in order to see how the details of it could be worked out. As I said yesterday, we have not arrived at a point when we could bring forward proposals dealing with medical benefit. The more wasteful the administration of National Health Insurance is, the less  near you will be to the day when you can give medical benefits. It has been explained that very great changes have taken place in the operation of the dispensary system throughout the country and in the general control of public health matters, and that until such time as we have had an opportunity of seeing the effects of this that we cannot safely bring forward proposals for medical benefits.
One thing that was rather clear— I do not know whether anything that Deputy Ryan has said would cut across that—was that most people were agreed that such medical benefits as were provided in the rural areas should be provided through the personnel of the dispensary system, whether it is called a national medical service or a dispensary service, and that it was only in the larger towns that you could have anything like a panel system. Over the greater part of the country everyone seems to be convinced that you must associate your machinery of medical service under local bodies with your National Health Insurance system, and there are very many reasons why you could not safely outline a scheme for giving medical benefit generally in these circumstances. There is one important matter that has to be borne in mind too. It has been explained that over 75 per cent. of the people in rural areas who are insured persons actually do get the benefit of the dispensary system, and there is a large percentage in the city.
But apart altogether from any percentage in respect of whom it cannot be claimed that they get medical benefits, no serious complaint has been formulated that the lack of medical benefits under the National Health Insurance scheme is a hardship to any person. If the provision of medical benefits under the National Health Insurance scheme were a matter of urgency we would have more grounds of complaint than we have that medical benefits were essential, and in the cities, where most people say it is most essential, there are facilities for  medical benefits through organised medical services of one kind or another that do not exist throughout the country. But we have to keep in mind the fact that there would be a stronger volume of complaint about the absence of medical benefits being a hardship on insured persons if there was any serious urgency for dealing with the matter. The absence of any provisions to deal with medical benefits in this Bill is no reason, I submit, to delay in carrying out the economies and the improvements that are proposed.
Mr. Lemass: I would like to ask the Minister a question concerning the abolition of sanatorium benefit. Although insurance funds in the past were not adequate to provide free sanatorium benefit for all insured workers requiring it, nevertheless a certain number were able to secure it. Would it be possible to ensure that a number of insured workers would get free sanatorium benefit under the new scheme in proportion to the State grant which each board of health will secure? There appears to be an injustice, arising out of the fact that the worker will continue to pay the same contribution but will not now even have the prospect of free sanatorium benefit such as he had in the past. Even if every worker was not able to get it, some were, and at least the same proportion should get it, in view of the fact that the money will now be paid to the boards of health.
Dr. Ward: What machinery will be in existence under the Bill for the administration of domiciliary treatment? Is it to be administered through the relieving officers, or will the Minister insist that committees will be set up by the boards of health to replace the committees that are being abolished? If domiciliary treatment is to be administered by the relieving officers, for all practical purposes it will become outdoor relief, and in that respect will become very objectionable.
General Mulcahy: With regard to the last point, there is no provision in the Bill requiring local bodies to make any changes in the method of carrying out their tuberculosis schemes. I think that there are only four or five rural areas in which insurance committees have not an agreement with local bodies to hand over to them the funds at their disposal and to have their people dealt with completely through the local bodies, so that if we take this four or five from the thirty-one, there will be twenty-six or twenty-five areas in which there will be no change. I do not know whether the Deputy means that he is aware of particular areas where there is an agreement between the insurance committees and the local bodies, and where assistance in butter, milk and eggs is given through persons other than employees of the local bodies. On the point raised by Deputy Lemass, it is considered that the handing over to the local bodies of the amounts, or the approximate amounts, at present paid to these local bodies through the insurance committees will be a security that the insured persons in their areas will get the same type of treatment that they have given up to the present.
Mr. Byrne: Arising out of the Minister's reply as regards those who will be disemployed under the Bill, the Minister has referred to Section 22 (4) (a). Might I ask him if he would inform the House of the amount of the aggregate surplus or deficiency, as the case may be, standing to the credit or debit, respectively, of the sanatorium benefit fund of insurance committees? Can the Minister give the House an assurance that under that fund sufficient money will be available to deal fairly and equitably with those who will be disemployed?
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