Wednesday, 29 May 1957
Dáil Éireann Debate
Minister for Health (Mr. MacEntee): I move that the Bill be now read a Second Time. The purpose of this Bill is to permit certain moderate increases to be made in the charges fixed for institutional services, that is, hospital services, under the Health Act, 1953, and to enable small charges to be imposed in certain cases for specialist services for out-patients, which at present are provided free of charge for those who are eligible to receive them.
Under the Health Act, 1947, provision was made for a completely free preventive, diagnostic and treatment service for infectious diseases, including tuberculosis. That service will continue as heretofore to be provided free of all cost to the individuals concerned. The free service includes small-pox and B.C.G. vaccination and diphtheria immunisation. It includes mass-radiography and other chest X-ray examinations undertaken under the tuberculosis scheme. It includes treatment in sanatoria and other chest hospitals for tuberculosis and treatment in fever hospitals for the other infectious diseases scheduled at present, including measles, whooping-cough, scarlet fever, poliomyelitis and so on. All these will continue, as I have said, to be free.
The next important group excluded from the Bill are school children, in respect of defects discovered at school health examinations. Any treatments required for such defects will continue, as at present, to be provided free of charge.
The next two important groups excluded are mothers and infants up to six weeks for whom free services are provided under Sections 16 and 17 of the Health Act, 1953. General practitioner maternity and infant care and specialist and hospital treatment will continue to be free for all the present eligible groups here also. Where, however, a choice of hospital is exercised  under Section 25 of the Health Act, 1953, there is a change to which I shall refer later.
In addition to all the foregoing important groups, all persons in the owner income group will continue to be entitled to all necessary services free as at present—general practitioner services, medicines, hospital services and specialist services including X-rays.
Who, then, are affected by this Bill and in what circumstances? Broadly speaking, they are a relatively limited number in the middle income group. Moreover, even these are affected only in respect of a limited range of medical needs which excludes infectious diseases, maternity and the treatment of the school children.
Expenditure on Government services as the House is well aware, has continued to increase, and this increase has not been matched by a corresponding growth in revenue. Consequently, expenditure has been outstripping income and in recent years the ensuing deficit has had to be met by borrowing. It is quite clear that this position could not be allowed to continue. Borrowing to meet expenditure which should properly be met from revenue is at any time a dangerous procedure; in existing circumstances it is one which no responsible Government could adopt. We know also that in recent years savings have been much below the level necessary to finance essential capital works. It is imperative in our present circumstances that all available savings should be used for productive capital investments; and any diversion of such savings to meet expenditure which should properly be met out of revenue means deferring much-needed capital projects and postponing still further the expansion in production which is fundamental to our prosperity.
In these circumstances, it was quite clear when the Budget for the present year was being considered, that the Government had no option but to balance  the Budget for the coming year, and balance it, if possible, by reducing charges on the Exchequer. In considering the ways and means to be adopted towards this end, they decided that certain beneficiaries of the health services, who may be presumed to be in a position to do so, should make some contribution—a very modest contribution indeed—towards the reduction in charges which was required to ensure a balanced Budget.
The Bill provides for an increase from 6/- to 10/- in the maximum daily charge for hospital services, excluding those which I have specified, given to persons in the middle income group. The charges will not apply, even in respect of the range of hospital services which I have mentioned, to all persons in the middle income group. Health authorities have considerable power in this regard. They have power to decide that, in addition to those in the lower income group, hospital services can be given free of charge to persons in the middle income group if their circumstances so warrant. This provision in the 1953 Act, I should like to emphasise, is not altered by the Bill. Further, the charge of 10/- a day will be a maximum charge—it is important that we should be clear about that—and it is open to health authorities to charge less in any particular case. In reply to a recent parliamentary question on the matter, I mentioned that a tentative estimate of the numbers involved or affected by the Bill was about 17,000. This figure includes an estimate of the numbers receiving treatment in mental hospitals who may be affected by the increased charges.
The Bill will make perhaps an important change in the position in relation to specialist services. At present, specialist services are provided free of charge for all who are entitled under the Health Act to receive them. This position—again I want to emphasise—will continue to obtain where those services are supplied to in-patients, but, under this Bill, persons in the middle income group will have to contribute to the cost of specialist services, excluding,  once again, infectious diseases and maternity as I have mentioned, which they receive as out-patients. The charges to be made will be fixed by Order but the payment to be collected may not exceed 7/6 for an X-ray examination and 3/- for any other specialist service. I should say that it is my intention in the Order to fix 7/6 as the charge for an X-ray examination, 3/- for any other initial specialist service and 2/- for any return specialist service received within a specified period. To take a specimen case: if a person is referred to a surgeon for a specialist opinion and if, after examination, he considers an X-ray examination and a return visit to him necessary, the total charge will be 12/6, namely, 7/6 for the X-ray plus 3/- for the initial visit plus 2/- for the return visit, should that be necessary. To take another example: Suppose a person is referred to a specialist physician and he has to see the patient three times, the total charge will be 7/-, namely, 3/- for the initial visit plus 2/- for the first return visit plus a further 2/- for the second return visit. It will be conceded that charges of this magnitude should not impose a grave hardship on persons in the middle income group.
At present persons eligible for hospital services provided by a health authority may elect to obtain these services in an institution of their choice. If they do so, the health authority pays to the hospital or nursing or maternity home chosen by the patient the capitation fee which they would pay for patients sent to an appropriate hospital by them, less 6/- a day. In practice, if the health authority pays 18/- a day to the hospital for a patient sent there by them, they pay 12/- a day to the hospital or home chosen by the patient exercising his choice and the patient normally pays the balance, 6/- if he is a patient in a public ward of the hospital. As a corollary of the increase of 4/- a day in the maximum charges for hospital treatment in a hospital to which a patient is sent by a local authority, the health authority subvention in respect of patients choosing  their own hospital or nursing or maternity home will be reduced by 4/- a day.
It may assist in putting the proposals made in this Bill in their proper perspective if I give some indication of the increases which have taken place in expenditure on hospital services since the Health Act, 1953, was passed.
The net cost to local authorities of the hospital treatment of patients entitled to services under the Health and Mental Treatment Acts in the year 1952-53 was in round figures £7,276,000. The corresponding figure for the current year is £11,210,000, an increase of almost £4,000,000 or about 54 per cent. Some people seem to consider that we should adopt the principle that charges once fixed are immutable——
Mr. MacEntee: Yes. I was saying, Sir, that some people seem to consider that we should adopt the principle that charges once fixed are immutable and should thereafter not be increased under any conditions whatsoever. I am not prepared to accept the view that charges are sacrosanct and I consider that we must have regard to the increased cost of hospital treatment in dealing with this matter.
It should be borne in mind that, even in the case of the small number  of people who will in future be paying the maximum charge for hospital services provided for under this Bill, the amount which they pay to the hospital is still only a fraction of the total cost of their treatment and maintenance in the hospital. The simple arithmetic average of the daily average costs in 1955—the last year for which figures are available—in the nine Dublin general hospitals works out at 31/5, so that persons paying 10/- a day will be paying less than a third of what the service for them is costing.
It will be clear from what I have said that not alone will the number of people who will be affected by the increased charges not be large but, in general, the charges which these people will be called on to meet cannot be regarded as onerous. The estimated annual saving to the Exchequer— £90,000—will be accompanied by a similar saving to local rates.
Mr. T.F. O'Higgins: I wonder did the thought cross Deputies' minds as to the kind of reception that might have been given to this Bill, were it introduced eight or nine weeks ago by me as Minister for Health? I have no doubt I would have been told that this Bill was aimed at destroying the Health Act and was a Bill designed to tax the sick. It is pertinent to note that this Bill is introduced by a Fianna Fáil Minister for Health and a former Fianna Fáil Minister for Finance. It is a Bill in which, for the first time in this State, money is sought from those who are sick. It is a Bill in respect of which, for the first time, the health services are called upon to contribute towards the budgetary position of the State. It is, therefore, a very significant step, and, in examining whether it is a good step or not, it is necessary for us to clarify our minds.
Some years ago, members of the present Government Party sought electoral support from the people with the slogan that health should not depend on wealth. They assured the people of this country that under the Act it is now proposed to amend—the health Act of 1953—for large sections of our people absolutely free health services  would be provided. The family doctor, we were told, would have been available, free of all charge, the services of the finest specialists in the country, and the slogan “free specialist services” became a principle of Fianna Fáil. They left office, of course, without providing these services and it became necessary for me and my colleagues in the previous Government to take such steps as were necessary to make these services actually available to the people.
This was no easy task and my task was made more difficult by the suggestions I had to encounter from the Fianna Fáil Party, suggestions that I was out to destroy the Health Act and out to deprive the people of services that Fianna Fáil would provide for them. My task was not made easier when the Minister for Lands, Deputy Childers at that time, was able to go around the country in the year 1955 saying that the Government's attitude to the Health Act was a crooked one and that Fianna Fáil did not believe in any cheese-paring on health services. My task was not made any easier when the present Minister for Finance, Deputy Dr. Ryan, in the same year, 1955, told the people that I in a short space of a couple of months had done everything possible to strangle the Health Act.
Despite these suggestions, the country knows now that I left office with the Health Act services actually in operation and not just something promised on election posters. I left office with free specialist services provided for those designated under the Health Act, with a maternity service working fully and availed of by a growing number of expectant mothers, and supported in peace and understanding by the medical profession.
Despite all these suggestions, the Health Act services had been introduced. Health was removed from controversial politics and solid achievements had been gained. Here, to-day, there is an end to a very sordid story. Health is no longer a matter of political significance to the Fianna Fáil Party. No longer is it possible to seek electoral support because of spurious claims made in relation to health services. Health can now go on the  upper shelf and, if necessary, the sick may be taxed to provide the necessary revenue.
I wonder what all the pother was about over the years. I wonder how the Fianna Fáil Party can square their consciences in this regard. Do Deputies remember the Committee Stage of the Health Bill, 1952, now the Health Act of 1953? Do Deputies remember the then Minister for Health pointing a finger of scorn at these benches, describing the Fine Gael Party as frauds and hypocrites? Who were the frauds? Where are the hypocrites? What Party and what men have, in fact, contributed consistently and honourably towards improving health services? Who now finds it necessary to come into this House with a Bill to tax the sick?
I have no doubt that the people will judge this issue fairly and squarely. I have no doubt that the people will regard the action of the Fianna Fáil Party over the years in relation to health services as something despicable. Only 12 months ago the Fianna Fáil Party were asking for two things, mutually contradictory. One member of their national executive was demanding that I should initiate here State medicine and that we should provide free services for all, irrespective of means. That member of the Fianna Fáil Executive is now a Deputy of this House. He is no longer a member of Fianna Fáil, but, so long as he remained on the Fianna Fáil National Executive, he was permitted to make demands of that kind. There are others in the Fianna Fáil Party who apparently think that the actions taken in providing health services in recent years were so radical that they must now be retarded.
I cannot guess what judgment the people may pass on those who have, with utter disregard, made health the plaything of politics. Thanks be to God, my Party have been consistent in this matter all down the years. My Party have provided solid achievement and we have not sought to seek passing political advantage in doing so.
This Bill is a Bill designed to destroy the principle of free specialist services contained in the Health Act. It is a  Bill designed, too, to impose a considerable increase in the charges that sick people in hospital may have to pay. The Minister said that the increase from 6/- to 10/- was a moderate increase. It is an increase of more than 50 per cent. and it is an increase in a charge that has not yet been even 12 months in operation.
Do Deputies realise that prior to the enactment of the Health Act, 1953, every insured person—800,000 in all— was entitled to go into the leading teaching hospitals in this State and receive there absolutely free hospital treatment for a period not in excess of, I think, six weeks? Every insured person had that benefit prior to the enactment of the Health Act, 1953. When the Health Act was brought into operation a maximum charge of 6/- per day was provided, a charge which could be imposed on such insured persons.
It was my responsibility to try to bring some order into the chaotic health conditions which I found in 1954 and I sought approval from the Dáil to delay the imposition of that charge, until it was possible to provide all the services. Accordingly, on 1st April of last year, when the full services under the Health Act were introduced, this charge of 6/- per day became payable under the Health Act of 1953. That is slightly over 12 months ago. Do Deputies recall the storm of criticism that arose when last year persons in the middle income group, particularly insured persons, found that in respect of their own treatment or the treatment of their children or dependents in hospital, they had to pay two guineas per week? Indeed, the suggestion was made that it was some charge that I had imposed upon them; people were so charitable with regard to health matters while I was Minister for Health. Nevertheless, we find now that this charge of two guineas per week which was recently imposed and which has aroused some disquiet and dissension, particularly amongst the trade union movement, is now to be increased by more than 50 per cent. and rises to 10/- per day.
The Minister says what is perfectly  accurate: “Of course, this is a maximum charge”. He points very properly to the provisions in the Health Act which entitle health authorities to refrain from imposing any charge, if they so wish. That is a section which does not operate. I hope the Minister is not so foolish as to think that health authorities anywhere in the country refrain from charging the full 6/- per day because, once they decide to impose a charge, it is all or nothing. One object, I understood, of the Health Act was to get away from the system whereby public representatives were asked to make representations, to pull the county manager's cost and try to get something off a hospital bill. Indeed I remember Deputy Burke, who is here listening, making that point when I was being accused in this House of destroying the Health Act. Now it is suggested, when the charge is increased from 6/- to 10/- a day, when a person may be charged £3 10s. per week, that that should not cause any trouble because, after all, the charge is not mandatory. I assume that county councillors again will be encouraged to go around with a hospital bill and try to become popular on the shillings they can get off it.
This increase will represent a very serious burden to many people. I know well that the charge of 10/- per day does not represent a third of the cost of treating a patient in our teaching hospitals. I well accept what the Minister says when he says that the cost in a Dublin hospital now runs over 30/- per day. But is that an argument? Is it not the object of health legislation to provide assistance to classes whom this Parliament regard as needing assistance in the provision of health services for themselves? It is because the cost in hospital is so high that health legislation is necessary; it is because it costs over 30/- in a Dublin hospital bed that it is necessary to have a Health Act. If the cost of treating and maintaining a patient in a Dublin hospital was only a matter of a few shillings, there would be no need for health legislation because it would not have political significance. It is when the charges increase that this kind of legislation is necessary.
 Long before the Health Act, the State always recognised the fact that many sections of our people cannot afford to pay the full cost of their hospitalisation. For many years before the Health Act, the principle of paying the deficits of the voluntary hospitals was fully recognised and to-day every hospital authority knows well that the difference between its revenue from patients and the sum of its expenses will be met sooner or later by deficit payments from the Hospitals' Trust Fund. I know that efforts are made to prevent that being an assurance to each hospital authority, but the plain fact, of course, is that they know well that sooner or later the Minister for Health must come to their assistance.
Accordingly, the argument advanced by the Minister with regard to the actual cost of treating an in-patient in the Dublin hospitals or elsewhere is, in my opinion, not an argument at all. What we have to remember is that every worker in this city, in this county and in this country who has not a medical card—and if he is in insurable employment, it is unlikely that he has a medical card—must, in respect of the illness of his wife, himself or his children, face a charge of £3 10/- per week. If two children get sick, it is double the amount. If the insured worker himself gets sick, his own wage may cease to be earned, but nevertheless he will have to pay £3 10/- per week. That is a serious increase and it is no good suggesting that it is something so small as, perhaps, to be disregarded.
May I say to the Minister that if he proposed to impose this charge on a certain section of the agricultural community—and I represent them—I would not oppose that in any way? I believe there is a certain section of the farming community—I will not mention a particular valuation limit because valuations change in different parts of the country—who are entitled to benefits under Sections 15 and 16 of the Health Act and who could afford to pay more. I do not believe that section is very large. I believe there are many farmers with valuations of £20, £25 and £30 who at the moment  find it very difficult to carry on. To them, this increase will be quite a serious imposition.
The Minister—and, may I say, I have some sympathy for the rôle the Minister has to play in this final chapter of the Health Act story—pointed out that many services still remain free, small-pox vaccination, B.C.G., mass radiography and all these public health services. May I say to the Minister: thank you for nothing? The public health service in this country was developed and built up long before the Fianna Fáil Party came into office. It was developed as a State service.
This State and every other State, I think—certainly, in Europe—recognise that, in relation to infectious diseases, free services must be provided because the State itself and society has a very definite interest in the provision of immunity. It is for that reason, on sound national grounds, that the provision in relation to infectious diseases of free vaccination and immunisation was, and has always been recognised here, and when the Minister comes in with his little taxing Bill and says: “I am not interfering with those free services,” I say to him: “Thank you for nothing”.
The Minister goes on to say that also excluded from these increases is the maternity service, that is, the general practitioner service. That is a service in respect of which I had considerable difficulty in providing something that would work and be accepted by all. I am glad that service is now in operation and working successfully, but it is a general practitioner service, service based on the family doctor. If specialist assistance is needed, then, under this Act, a charge must be imposed, and I want to remind Deputies that whatever discretion is given to health authorities in respect of a charge for persons going into hospital, under this Bill, if it is not amended, it is mandatory on them to charge for specialist services. They have no discretion, in that respect; they must impose the charge nominated by the Minister.
The Minister has told us he intends to fix a charge of 7/6 for X-rays, 3/- for the first visit to the specialist and 2/-  for each return visit. That may mean in the one example the Minister has given, merely a payment of 12/6. 12/6 to a £50 farmer in, perhaps, one of our north-eastern counties, might be something that he would regard so lightly as not to affect him, but 12/6 to an insured worker who is worried about some pain he may have and who has to go to see a physician or surgeon and be X-rayed, can be quite a considerable charge. In any event, whether it is small or big, they will have to pay now because this is a mandatory charge.
The Minister also said that free specialist services and free hospital service would still be continued for the lower income group. That comprises persons who were formerly described as the public assistance class, persons who formerly benefited under the Public Assistance Act of 1939. In addition, the Minister told us that free services would continue to be provided for school children in respect of defects discovered at a school health examination. Again, I would say to the Minister: thank you for nothing. Those free services were there long before the Health Act. For many years, although people apparently do not know this, and it was not desirable they should know it, one third of our population, 30 per cent., were entitled to and received absolutely free hospital services and free specialist services. These are the people who were entitled to benefit under the Public Assistance Act, 1939. They are now the people described in the Health Act as persons in the lower income group, evidenced by the possession of, or entitlement to, a medical card.
The Minister says they will continue to have free hospital treatment and free specialist services. They always had those things and in fact many of them had them more easily prior to the Health Act than they have had them since. Again, in the case of school children, it should be known that the school medical service did not originate under the Health Act of 1953. It was there, I think, since 1919. Certainly, it was there for many years before the Health Act. Every school child in the national school was for many years  entitled to free hospital treatment and free specialist services in respect of defects discovered at a school health examination. The Minister says that will not be interfered with. That is no concession on the Minister's part.
I do not want to prolong the debate on this Bill. It is introduced by a Fianna Fáil Minister. Had I introduced it, as I have said, bedlam would have been let loose. Had I in any way suggested that some charges could be imposed on some sections under the Health Act, I would have been told that it was my antipathy to the Health Act which was governing my motives. I did not introduce it; it is introduced by the Party which made slogans out of health a few years ago, which told us that health should in no way depend upon wealth, which made a principle out of free specialist services. It is introduced by the Party which at one time found health legislation to be popular.
I may say, and I make no concealment of it, that when I was Minister for Health, I always anticipated a case might arise in which an increase in some contributions should be made, but I proposed to consider such an increase when a scheme of voluntary health insurance was available to the people. If an attractive scheme of health insurance at a reasonable premium were available to the people of the country, then I could see a case being made, for instance, for increasing the charge on certain categories of farmers under the Health Act. We may have—I hope we will have, in the near future—such a scheme. To the extent that these increases will encourage people to insure, it is welcome. However, these charges are being imposed now on all sections who benefit under Section 15, on all insured workers, on all farmers, on all persons whose income is less than £600, the self employed. Each such section now has to face an increase.
May I just say this in conclusion? There has been certainly, in my experience, considerable criticism of the manner in which persons under Section 14 of the Health Act of 1953 became entitled to free medical treatment.  This Bill will result in a considerable increase in the applications for medical cards. In certain parts of the country at the moment, very nearly half the population, half the county population, is regarded as being so poor as to be unable to provide for themselves. The effect of these increases will be to increase the number of people seeking medical cards and therefore entitled to free hospital services.
I do not know whether the amount of money involved in this Bill justifies this departure. It would seem to me that in order to justify a Bill of this kind on purely material grounds, the gain to the Exchequer would have to be considerable. If the amount expected to be raised by these charges on sick people is nothing of any considerable significance, then it baffles me why the obvious administrative and other difficulties should be faced in order to get the sum of money which, in relation to the sum spent on health, is not a significant saving. In any event, I feel that in so far as these increases arise from a Budget and are budgetary increases, they therefore represent part of the taxation imposed by the Budget. They are, therefore, a tax imposed on the sick people of this country. They are imposed when no alternative means of providing health services is available to those people. For those reasons, I feel this Bill should be opposed.
Mr. Corish: Wrapped up in the Minister's speech is the fact that there are to be increases in hospital charges on those in the middle income group, increases from 6/- to 10/- per day. I hate to doubt the integrity of a Minister like Deputy MacEntee, but I am very doubtful of some of the things he said in his speech and some of the figures he gave. He says that 17,000 people will be affected by these increases. I think that is a very conservative estimate, an extremely conservative estimate.
He estimates that he will save something like £90,000 by increasing these daily charges for hospital services to those in the middle income group. My reckoning is that he will save much more than £90,000. There is a possibility,  of course, that he is making his contribution to the effort by the Minister for Finance to have a substantial surplus when we come to the end of the present financial year. I say with all honesty and sincerity, that 17,000 people seems to be a daft figure.
In my own constituency, I think 17,000 people will be affected by the increase in charges proposed under this Bill. There are 90,000 people in the County Wexford, approximately, and if my information is correct there are about 30,000 people who would be covered by the medical service cards. That means there are about 60,000 people left. Those who would be regarded as being in the top bracket would not amount to any more than, at the most, a few thousand and, therefore, the balance are those who will be affected by this Bill and affected seriously by the charges.
The Minister says in the first line that the purpose of this Bill is to permit “certain moderate increases”. A moderate increase to my mind, in any case, would be an increase of 5, 10 or 15 per cent., but here is an increase of over 50 per cent. I do not think that “moderate” is the right description of it. I do not blame the present Minister for Health nor the previous Ministers for Health for the mess that is the administration of the Health Act at the present time. I was one of those, with my Party here, who voted for the Health Act of 1953. I, with the Labour Party, honestly believed that there would be improvements in the health services for the plain people of this country, those in the lower and middle income group. The people were led to believe, and we believed as members of this House, that there would be tremendous improvements in the health services.
Unfortunately, I believe that there is greater confusion. There is not a great political outcry about it nor, thank God, have the health schemes been the subject of political controversy over the last few years, but there is shocking confusion and frustration experienced by people all over the country. People who expected that they would have certain health services  available to them now discover that they cannot get them. I prefaced my remarks by saying that I did not blame any of the former Ministers for that. I would lay the greater share of the blame on the local authorities. The Act was a permissive Act, so to speak. It permitted the local authorities to provide certain things but they have not done that. The determination of whether a person should be in the lower income group or not varies, not alone from county to county, but from district to district.
Mr. Corish: With all due respect, a Leas-Cheann Comhairle, I assumed, having regard to the Long Title of this Bill, that I could comment generally on the Health Act of 1953 and the health services in general.
Mr. Corish: I tried to point out that, no matter what the intentions of the present Minister might be or what the intentions of this House were, the Health Act would be practically worthless unless the members of the local authorities throughout the country did their share and accepted their responsibility for the provision of good health services. However, I shall not pursue that matter but shall make the general comment that local authorities all over the country have not approached the Health Act, 1953, as the majority of the members of this House did when the Bill was passed three or four years ago.
 The Minister mentioned in his opening remarks that certain existing services would continue to be provided free of all cost to the individuals concerned. I should like to ask the Minister a question and possibly he might be in a position to give a break-down of the cost involved in the treatment or the prevention of certain diseases. Thanks to former Ministers for Health, we have been very successful in reducing to a very great extent deaths due to tuberculosis and I wonder if there has been a saving in recent years to the State or to the Department of Health arising from the prevention of tuberculosis. I do not know whether the Minister is in a position to give that information or to give any details of expenditure.
“The next important group excluded from the Bill are school children, in respect of defects discovered at school health examinations. Any treatment required for such defects will continue, as at present, to be provided free of charge.”
Yes, I say, to be provided free of charge, in theory, because when a defect is diagnosed in a school child, he or she may wait, not alone for weeks or months, but for years before that defect is corrected. Again, I do not blame the Department or the Minister entirely. The fault, in my opinion, lies to a large extent with the local authority who refuse to provide certain of the services which the Minister says that they may provide.
“In addition to all the foregoing important groups, all persons in the lower income group will continue to be entitled to all necessary services free as at present—general practitioner services, medicines, hospital services and specialist services including X-rays.”
Those in the lower income group have the greatest possible difficulty at the present time in having their prescriptions filled by the local authorities free of charge. Many people in the lower  income group when given a prescription by the dispensary doctor discover that the prescription cannot be filled at the local dispensary and that they must, of necessity, go to the nearest chemist and pay for having the prescription filled. I have known recipients of home assistance, recipients of certain allowances from the local authority, people with very small incomes, who have had to pay for having prescriptions filled. If the Minister says that these services are free or should be free he should take steps to ensure that they will, in fact, be free to those in the lower income group.
I shall conclude by saying that, if this Bill means a saving of £90,000 to the Exchequer or to the Minister for Finance, it is a very mean attack on people who can ill-afford to contribute that amount. The Minister in his speech this morning said that local authorities may charge those in the middle income group at the present time anything from nil per day to 6/- per day. I can tell the Minister and the House that so far as my constituency is concerned the maximum fee is always charged. If a person is deemed to be in the middle income group he is charged 6/- per day and when this Bill is passed it will be 10/- per day. The local authority has never, as far as I know, used the discretion given to them in the Health Act, 1953, to have regard to people's means and to charge anything from 6/- down. Therefore, I would say that this £90,000 is a very conservative figure because, if the Minister thinks that many of the local authorities scale their charges up and down between nil and 6/- per day, he is very much mistaken.
If that £90,000 was required, as the Minister suggests, to balance the Budget, I suggest that it could be taken in some other way. For the last two or three weeks and this morning, emphasis in this House has been on the removal of the food subsidies to relieve the Exchequer, to balance the Budget. A sum of £90,000 from people in the middle income group is their contribution towards balancing the Budget but we never hear a word about any sort of contribution by way  of withdrawal of subsidies in other directions.
Let no one take me as being anti-farmer but every farmer in this House knows that for practically everything the farmer does he gets either a grant or a subsidy and it would not be unreasonable to suggest that, if times are difficult, if we are in a financial crisis, the premium for this, the bounty for that or the grant for this or that could easily have been taken from agriculture or some subsidy or grant that is being given to industry could have been removed.
Mr. Corish: With all due respect to you, Sir, the Minister devoted a page of his speech this morning to telling us about the financial crisis and how the Budget must be balanced and what contribution health services should give and I think I am entitled to suggest other means.
Dr. Browne: The provisions of this Bill, according to the Minister, arise out of financial necessity and are associated with the Budget proposals. It is quite a remarkable proposition that sick people, of all people, in any civilised Christian society, should be brought into our considerations in trying to find money to ease the financial situation which was referred to by the Minister for Finance in recent days. In the context, as I said in my speech on the Budget, of the very fine record of legislative proposals of the Fianna Fáil Party, the Government Party, it is a remarkable departure. It is quite a remarkable departure from the magnificent provisions of the 1947 Health Act.
It is a remarkable departure also in view of the over-generous concessions  which were made to people who, I think, were not in any way in need of them, such as the flour millers, the bakers, the shipping companies and such other people. Whatever their case might be, any person with the remotest understanding of the demands of sick people and of health services could not possibly, in weighing up the balance between flour millers and sick people, with a clear conscience, penalise sick people as the Minister proposes to do in this Bill.
I do not think I could agree with Deputy O'Higgins on a number of points which he made. I do not think he can dismiss as negligible the contribution that Fianna Fáil made to health legislation and health services in their time. I would be very proud indeed had I been the originator of the 1947 Act in which it was proposed to bring into operation such things as free health services. That Act was a great credit to Fianna Fáil because of the benefits it contained and the provisions of this miserable Act are all the more highlighted now. With all respect to Deputy O'Higgins, if he had brought in these proposals I think it would have been more in keeping with the attitude of the Party which he represents.
I think that is fair comment because the attitude had been to oppose the extension of equitable health services under the 1947 Health Act. In many ways I think the blame must be shared, again in relation to the Budget, between the major Parties. In the days when Fianna Fáil might have provided progressive health legislation the main opposition did come from those benches. For that reason, I think the provisions in the 1953 Act were emaciated by the time they left this House and they were rendered completely incapable of providing a just and efficient health service. The consequence has been complete chaos in the present blue card system in which there are gross inequities of one kind or another, all stemming from one point that has to be made clear and will be made clear—because of the  inclusion in that 1953 Act of a means test.
I fought this issue in the past and I do not agree with Deputy O'Higgins that this is the final chapter. I think we will keep going on and in time we will make progress. In my view, this is merely a step towards the creation of health services which are entirely free of a means test. Because of the educative value of the previous Act in the first place, and this Act in the second place, the people will finally realise the significance of the means test, the injustice that must follow from it, the administrative chaos that is inseparable from a means test and the cost of administrative machinery that has to be maintained in order to administer the means test. All these things must become clear to the people on those benches and to the people in the country and eventually we shall get legislation by a progressive Minister.
I do not agree with Deputy Corish in regard to his strictures on the administration of services by the local authorities. I think we must accept full blame, if we send out a defective Act which it is impossible for them to operate in an equitable way. We cannot blame them; we must blame ourselves. It is no good trying to blame anybody in particular for that Act; we must merely accept that it was a defective Act and I believe that its provisions in time will be completely unworkable. That has an educative value in itself because eventually the people will bring pressure to bear on their politicians and we shall then get a health service of a no means test type which we know will work and which will give an efficient, an equitable and a just service.
Deputy O'Higgins suggested that we should take health services out of politics. Nobody would be more pleased than I if we could do that. There are fundamental differences in this regard. It used to be between the different Parties; now it appears to be between myself and most others in the House. That is unfortunate but in time things will get back to a more normal position and more people will see things as I see them. The fact remains, however, that there is a  fundamental difference between myself and, say, Deputy O'Higgins, or the Minister for Health, at the moment on the correct or most efficient type of health services and the methods by which they can be produced. I believe that they can be produced only by providing a free, no means test type of service and that in that way we shall be on a par with the existing health services in regard to tuberculosis, the fever hospitals, B.C.G. inoculation, poliomyelitis and diphtheria.
I believe that special services of one kind or another should be at the disposal of the individual merely by going in and saying: “I am sick and need this service”. The doctor should then proceed to treat the patient and be later paid either by some form of remuneration by the local authorities or out of the Exchequer or in one way or another. There should be no money barrier between the patient and the doctor.
There has been a good deal of talk here on the doctor-patient relationship and the inviolability of that relationship but there is no greater impediment to a fluid and easily worked doctor-patient relationship than the presence of a money barrier. There is no doubt that many people are denied access completely, in many cases, to the very highest type of qualified doctor and specialist because of the money barrier. The doctor is only normal and naturally he is trying to make as much money as he can in his profession and he proceeds to treat as many of the moneyed people as he can. The poorer sections of the community, the lower income groups have equally a perfect right to be treated by the best type of practitioner and specialist but they are denied access to the highly skilled and highly qualified doctor.
I think nobody can say that the services operated under this 1953 Act are different from the other services. The people who believe that the standard is the same in the free and the paid for services, if they are really honest, cannot tell why they themselves do not believe in going to the dispensary doctor for their treatment  and that of their children, why they do not go to poor law beds and so on.
If they believe there is no difference, they should logically use these services. The vast majority of the people who oppose free health services will not be found in free beds or queueing up outside the dispensaries. I believe this Bill merely maintains this inequity. It merely increases the inequity by increasing the charge. Anyone will tell you that the burden of health services on the people is becoming so heavy that without the other impositions of the Budget at all, ordinary persons must delay going to hospitals because they are frightened of the cost of such a visit. It seems to me to be completely clear that this question of charges must reduce the opportunity of the individual person in the lower or middle income groups of access to an equitable or just health service.
It is for that reason that I cannot agree with Deputy T.F. O'Higgins that discussions on health services could not be called political. It is a very important political matter for us who believe in no means test health services, as I do as a politician and doctor. There is the question of whether we should retain the old variation of the red and blue tickets. It is a very fundamental cleavage. I do not agree with what Deputy T.F. O'Higgins said that the voluntary health insurance scheme will be an answer, even for the reasons I have given in the past on a number of occasions. I do not think that a voluntary health insurance scheme for the people who need it can be provided without substantial Government subsidies or without requiring payments which will be so high as to be prohibitive for the father of a large family.
There is also the big prohibition that in order to participate in any voluntary health scheme the person has to be so healthy that he will not need any insurance. The person who is the greatest risk and who might need a doctor most cannot insure because he is a bad risk. Therefore, I do not think the voluntary health insurance scheme will make any appreciable difference  in providing health services as they should be provided and I doubt if such a scheme would offset the consequences on the people of the impositions of this Bill.
There is one thing which might sway the people who put up the argument that free health services are bad things, that they interfere with the doctor-patient relationship and that they destroy the rights of the individual and other types of nonsense which we have heard from time to time on this question. Medical arguments might weigh with people because they come from doctors and others who might be presumed to speak with such authority that one could not question their arguments. But one argument I think that should weigh with the layman in trying to decide whether a thing is reasonable, whether it is a good thing or not, is whether there is any precedent for this kind of service in our society. If there is such a precedent then that precedent is an accepted precedent, a principle accepted by all those who accept or reject these principles on our behalf. If that precedent in relation to health services is there and works and gives a just and satisfactory service, then surely that must be a cogent and compelling argument to any layman who is trying to work out for himself, in the welter of arguments that have been put for and against health services here and elsewhere, which argument is right.
In order to try to assess the right or wrong of these services, I would suggest that anybody who is in doubt as to the evil consequences which must flow from increasing the charges as is proposed in this Bill should consider the remarkable success of the free health services which we already have operating in this country. Nobody, medical, lay or any other authority, has questioned the efficiency and effectiveness of the free, no means test health services. The people are satisfied with them; the medical profession, as far as I know, are satisfied with them. They have provided us with an example of the principle in operation  and working. I refer, of course, to the tuberculosis services, the fever hospital services, the various free vaccination services.
The free fever hospital services have practically rid this country of infectious fevers, and the free tuberculosis services are in the process of ridding us completely of tuberculosis which was such a problem in past years. It will be said this is largely due to drugs and things like that, which, I agree, have been responsible to a large extent. However, the fact that these drugs have been made available to the people is the most important consideration. There is the example of the different countries in which these hospital services have not been made available and where, in consequence, some of the diseases of which we hardly know claim thousands of victims. In those countries, they have not had the dramatic fall in tuberculosis that we have experienced.
That seems to me to be one of the most incomprehensible factors in the consistency with which laymen who consider these questions of health and politics still shy away, refusing to accept the evidence of their own eyes, the irrefutable facts of fever hospitals being closed down, of sanatoria being closed down because of the complete collapse of the incidence of these diseases as a result of the attack made on them by free, no means test medical services.
Consequently, I do not know whether it is any use appealing to the Minister, but I do appeal to him to reconsider the whole question of the health services. When he takes what I believe to be a wrong decision, the people who are hurt are the aged and the sick, the weaker sections of the community who should always be kept outside of any political battles or vindictiveness of any kind.
To impose this charge upon the sick for any purpose whatsoever is a completely and thoroughly unchristian act, particularly in the context of the very considerable concessions which have been made to the very wealthy sections mentioned in the Budget. I find it impossible to believe that there  was any real justification for this relatively trifling sum of £90,000 in a Budget of over £100,000,000. The other day, the Minister mentioned it was £70,000, but I understand it is £90,000 now; but, as I say, that is a relatively trifling sum.
Why has the Minister gone out of his way to rob these unfortunate people for the purpose of finding this relatively infinitesimal sum? His colleague, the Minister for Finance, with whom I fought the Act through the Dáil in 1953, takes away £70,000, £80,000 or £90,000 from a group of unfortunate people in respect of themselves and their children, and at the same time he gave away thousands and thousands of pounds to the master bakers, flour millers, shipowners, company directors and exporting corporations. It is so incomprehensible to me that I find it difficult to follow any sort of logic in the proposition at all.
The proposal reduces any effectiveness there was in the 1953 Act and there was very little effectiveness in that Act. Deputy O'Higgins was right when he said that many people felt that it would have been better if there had been no 1953 Act; that they had been left with the old red ticket system. They felt they would have been able to get whatever health services which were free. Whatever standard of merit there was in it, they felt they got the services before they get them now. Consequently, they feel, if anything, slightly aggrieved with the 1953 Act—many of them because they are outside the means test level. They feel a grievance with those who are just inside it. Naturally, they have a sense of grievance against the person who gets the benefit of the health service relatively easy.
There was a suggestion that local authorities have discretionary powers. I think it was Deputy Corish who said that these powers are hardly used at all. I think I showed in the answer I got to a parliamentary question recently that discretionary powers to extend the health services above the £600 group are rarely used. The difficulty is that the official hand of the local authority is very much bound by ministerial policy.
If the Minister is continually sending  out to local authorities instructions in regard to the necessity for economies in the administration of the services generally, then their reaction is to make sure that they do not transgress the letter of the law to any degree at all. The county manager finds it difficult in those circumstances to administer the law in the spirit in which we sent it out from the Dáil. The result is that in order to be safe and not to find himself censured by the Minister, the county manager feels the best thing to do is to administer the law as he reads it and then let the people who suffer complain to the people who devised and drew up the Act.
I do not think the discretionary powers amount to anything very much, particularly when I recall a remark of the Minister's the other day—I do not want to misquote him—when somebody asked a question and he replied he regretted that the managers appear to be rather over-generous, or some suggestion of that kind. The managers will naturally feel that the Minister does not approve of any over-generous action on their part in the administration of these services. Consequently, the means test is applied more and more stringently as time goes on. It does depend on ministerial policy.
The extension of this means test principle and the increase in these charges will bring, I believe, considerable hardship on many people. As Deputy Corish said, it is additional taxation arising out of the Budget. We were told in the Budget about the inability of the people to bear any further taxation, but this is further taxation, the limitation of these health services along with the increase in the price of bread and butter.
Naturally, I am very surprised indeed that a Bill such as this should come from the Fianna Fáil side of the House because it is not in keeping with its past record in health legislation. It is not in keeping with its past protestations and its ambitions in regard to health legislation. I wonder what has brought about this remarkable change.
Why has the Minister decided to move in this direction? If anything, the charges should have been reduced or  the Act amended to eliminate the charges altogether. I think that undertaking was given by Deputy Dr. Ryan as Minister for Health, when he said that if it did not work he would bring in an amending measure, but this is an amending Bill which makes it worse. I am surprised at even the Minister for Health bringing in a Bill like this because in the past he supported the free no means test in regard to the mother and child proposals, but this is a long way from those provisions.
The Minister knows enough about health services to realise that the free services have given tremendous value for the money spent. Does he believe the money was not well spent and that we were over-extravagant in saving the lives of thousands of men, women and children as a result of these services?
“The Mother and Child Welfare Scheme, provided for in the 1947 Health Act, introduced by Dr. Ryan just before Fianna Fáil left office would have been brought into operaation in 1948 if Fianna Fáil had returned to power again, but two-and-a half years had since passed and we were still without that scheme.”
He went on to admit, and I agree with him in his admission, that the scheme would be a costly one as visualised by Fianna Fáil because they realised that the strength and hope of the nation lay in its children. That was in the days of the great ideals of the Fianna Fáil Party when they did not count the cost in lives saved and when the attitude was that money spent on health services was money well spent. We have the evidence before our eyes in Ireland in relation to the tuberculosis services; we have the evidence of the magnificent success of the national health scheme in Great Britain, in spite of the interference of civil servants and politicians. It is beyond my comprehension why the Minister should now take steps to introduce a Bill to raise the relatively petty sum of  £90,000, when the Budget provides over £100,000,000, in order to pare down the amenities provided under the 1953 Health Act.
This Health Act certainly needs amendment but not amendment in the way suggested here by the Minister. I do not know if there is any use in urging him to reconsider the measure. I do not suppose he will. While a lot of hardship and unhappiness for many people must flow from this Bill, I think it must have one valuable effect. It must make the people understand, and it must make our politicians understand and see clearly, that health services cannot be taken out of politics and that there are fundamental differences on the question of how health services should be administered. There is the point of view held by the Minister that health services should be paid for, but that the individual, if he cannot pay for them, must take the consequences that we impose by this outlandish pretence in a means test in order to gain access to the health services. Those who can pay for the good services must do so and those who cannot pay get the less good services and at times bad services. On the other side, the people will see the principle enshrined in our tuberculosis services which are completely free.
Dr. Browne: I bow to your ruling, Sir, but that has been the fundamental ailing in our health services in this country. I do not agree with Deputy O'Higgins that this is a final chapter. The people will consider the increasing effect of the inequities that will follow on the introduction of this Bill and they will turn more and more to the argument in favour of no means test and to the principle of free health services which they know will be fully effective for everyone, not only for the patients but also for the medical profession as well.
Dr. Esmonde: This Bill appears to me to be one of probably many Bills that will be introduced from time to  time in this House as a result of the previously futile legislation introduced here. Before dealing with the Bill, I should like to correct a statement made by the last two speakers that the legislation which is being introduced here to-day purports to save £90,000. I think that the amount involved is £180,000, as I understand from the Minister's statement. I think it is £90,000 which will be saved in the Central Fund and a further £90,000 from the local authorities.
In effect, what this Bill proposes to do is to increase the charge from 6/- to 10/- per day for those who heretofore came under Section 15 and under Section 14 of the 1953 Act. That sounds very simple, but the whole trouble in relation to the 1953 Act has been that we have not an overall decision in each county as to who is included under Section 15 and who under Section 14. The Minister has made it clear here to-day, and the former Minister for Health has thanked him for nothing, that he is not interfering with any of the free services that existed under Section 14 of the 1953 Act.
The difficulty we have to face is: who actually does come under Section 14 and who comes under Section 15? My principal objection to the 1953 Act was that it left the medical affairs of this country entirely in the hands of a local authority, of the county manager. The county manager in a county decides who is entitled to treatment under Section 14 and who is entitled to treatment under Section 15. I am making this point because this Bill deals largely with Section 14 and Section 15.
I have here a few of the latest figures which give some idea of the percentage that has been arrived at in different parts of the State in relation to those who are entitled to free treatment. In Longford, which I believe is not a particularly poor county, 48 per cent. of the citizens of that county are considered to be indigent patients. In other words, they come under Section 14. That is a fairly high percentage.
In Westmeath, which is also not a very poor county, 36 per cent. In North  Tipperary, 28 per cent.; South Tipperary, 36 per cent. In my own county, Wexford, 31.6 per cent. Incidentally, I should like to mention Leitrim. Leitrim is a poor county. I have not actually got the figures but I understand that the percentage there is extremely low—somewhere between 7 and 8 per cent. Does that not indicate to the Minister, to the Deputies on the other side of the House, to the Deputies of this House who were so enthusiastic about the 1953 Act, that there is something seriously wrong? Is this 1957 Act not the first instalment of many Bills which we shall have to try and rectify the chaos that is being created?
I may be accused by some Deputies —as I was in 1953, when I objected to this legislation—of being a reactionary. I am not. I foresaw endless muddle and troubles with regard to the decision as to who was entitled to the benefits and who was not. Anything I said then has, I think, been supported by the fact that the Minister has found it necessary to introduce this legislation.
The difficulty at the moment under health legislation is—I know it as a doctor and a Deputy because many cases come to me not only in my own constituency but in other constituencies as well—that people want to know if they are entitled to the treatment. The only answer you can give them is: “If the county manager says you are entitled to it then you are but if he says you are not entitled to it then you are not”. The result is that thousands of people all over Ireland, who were entitled to free treatment before, do not get it now and that thousands of people who could well afford to pay for treatment themselves are getting it free. That is the situation over which we have no control. I think it is a situation for which we cannot really blame the county managers as the original Bill—the parent Bill of the present Bill which we are discussing—is so involved that they do not know where they stand.
I now come to the question of the increased charges themselves. I take it that anyone who is not entitled to a blue card will be charged at the rate  of 10/- a day as against 6/- heretofore. I also understand that there is to be a ceiling charge for the middle income group—Section 15—of 7/6, maximum charge, for X-ray treatment. There is to be a charge for external patient treatment of 3/- for the first visit and 2/- for each subsequent visit. I think I am right in saying that the Minister made it quite clear that that charge is for specialist treatment for those who are now entitled to the benefits under Section 15, excluding maternity and infectious diseases, as well.
The Minister did not make quite clear how he proposes to collect that sum of money. It is a simple question but it is very pertinent to the issue. One of the things I dislike about State legislation—perhaps it is the only argument in favour of Deputy Dr. Browne's free-for-all medical services—is that in anything pertaining to the State you pile up the costs and the increased staffs.
The Minister must know that, in the short time in which he has been in the Department of Health, there has already been a demand for increased staffs from local authorities all over the country to deal with increased work under health legislation. When he is replying, I should like him to clarify how this money is to be collected. I shall give him a few instances.
A doctor sends a patient to a hospital for examination for specialist treatment. The patient goes there and it is discovered that an X-ray is necessary. Doctors are not men with a lot of time on hands. He examines the patient and decides that an X-ray is necessary. That patient has to pay 7/6. Who will collect that 7/6? Is the doctor to say: “I decide that you want an X-ray. Will you give me 7/6? Is that his job? Or is this going to be handed over to the administrative section to collect the money? When these Bills are drafted by whoever does so among the officials concerned, these little practical things do not come to mind to them very often.
Here is another instance. Suppose there is an accident—it may be trivial —which means that somebody is brought in off the street to an outpatient  department. We are told in this Bill that a person will be charged 3/- for specialist treatment. I take it that the reading of the Bill is that anyone who is taken into a hospital—and these local hospitals we have, be they in Dublin or in rural Ireland, are supposed to constitute specialist treatment—and who needs to be attended to there will have to pay 3/-. Who will collect the 3/-? Is the doctor to say: “I cannot treat you unless you give me 3/-?” It is quite reasonable that anybody who can pay 3/- should do so, but if you are suddenly brought into a hospital and somebody must collect the 3/-, who will do it? Are we to have more officials in local authority hospitals again for the purpose of seeing that the 3/- is paid?
There is another point in relation to which I should like some clarification. In his speech, the Minister said: “Suppose a person is referred to a specialist physician and he has to see the patient three times, the total charge will be 7/-, viz., 3/- for the initial visit plus 2/- for the second visit plus 2/- for the third visit.” Am I to take it that it will be 2/- for each visit? It is quite reasonable to assume that if a patient consults a physician he may have to pay some ten or 15 visits. I think any Deputy will accept that as being reasonable. If somebody has to collect 2/- from him on 15 occasions, in order to keep the book regular, to keep this service in existence, how will things work out? The point I am trying to make is that I am not quite sure from the Minister's speech whether there is any charge after the first three attendances. If there is, then I submit, in relation to the small sum of money that is being saved—£180,000 over all; £90,000 to the Central Fund and £90,000 to the local authorities—that the administration will cost nearly more than the money that will be saved.
I submit that this legislation is futile but I do not blame the present Minister for Health for it. He is not responsible for it. He is dealing with parent legislation which, in its time, was futile and he has inherited the baby.
I want to refer to the question of  mental hospitals. I was speaking quite recently to the superintendent of a mental hospital in this country. The position at the moment is that those who are responsible for paying for mental patients have to pay 6/- per day. I think everybody will realise that, unfortunately, mental treatment is not a thing that merely goes on for a few weeks. Very often it goes on for a couple of years. I ask the Minister in all sincerity was it considered, when this was being drafted into this Bill, that there are cases who stay for as long as five years in a mental hospital. Some people have to be paid for ad infinitum by their dependents. There are people with means of £400 a year regularly getting bills for £180. Is it seriously considered that this 10/- charge can be borne, when statistics will show the Minister that throughout the country hundreds of pounds, in fact, thousands of pounds, are owing to mental institutions which never can and never will be paid?
I think the Minister has inherited a difficult situation. I think we are spending a lot of money in the wrong way on health services in this country. It boils down to this. Unfortunately, this State as a whole over the last 20 years has not improved. If you are running anything under State jurisdiction and State control, you are running it in a most expensive way. That is the trouble at the moment. That is what we have been debating for the last couple of weeks. I would suggest that this is the wrong time to introduce this legislation.
I understand that at the moment there is a committee sitting on voluntary health insurance. I think a lot of us have come to realise that a voluntary contribution of some sort is very strongly indicated here, both for the benefit of the State and the finances of the State and for the good administration of medicine as a whole. It is a wrong time to introduce these charges. After all, the Exchequer is only benefiting over all to the extent of £180,000. Would it not have been better to have waited until the voluntary health insurance committee had produced its scheme? I know  many people will join that scheme. If it is properly run, it is the best answer.
If we are to have the best medical service for the Irish people, we want something that is good and absolutely free, so that they may go where they want and go to the man they want to attend. In other words, what we want is that there should be a free choice of hospital and a free choice of doctor. No doubt the Minister will answer me and say they have already a free choice of doctor. As far as maternity is concerned, that may well be. That is the only thing in the 1953 Act that is of any use. You can read it from end to end and everything else has been a total failure. If you have voluntary health insurance here, you will save far more money than the Minister is saving by this Bill to-day and you will have better services.
The Minister has not yet told us how he proposes to impose this extra charge. I suggest to him that he should consider some sort of stamp imposition. That will considerably cut out administrative expenses and will balance and regulate the matter. It will not result in a demand for extra staff. No matter what services you have and no matter what services you try to introduce, medical services, as I see them, should be for the benefit of those who require medical treatment and not for the purpose of increasing charges, increasing civil servants and increasing interference with the private lives of the people. If the Minister carries on for the time being with a stamp imposition and subsequently introduces a voluntary health insurance scheme, that will regulate the existing medical services, bring a better atmosphere into medical legislation here and give better service to the Irish people than they have had heretofore.
Mr. O'Malley: The opinion has got around that the Minister for Health has increased these charges to 10/-. As everyone in the House knows, this is, so to speak, permissive legislation. It just entitles the health authority, which is the county or city manager, taking the circumstances of individual cases into account, to charge up to 10/-, if he thinks these people are  capable of paying. That should be stressed. We have been attacked both by responsible members of the Opposition and in speeches made outside. These people should have had some sense of responsibility when they spoke to their constituents and to the people as a whole and suggested that Fianna Fáil was coming along now and making the poor people pay this exorbitant charge of 10/-.
Unfortunately, I did not envisage this Bill coming on to-day and consequently I have not many details. Speaking from memory—and my memory is correct from my experience of Limerick Corporation—I think we should ask ourselves why these measures were introduced to-day and why they are necessary. Was it for pleasure that the Minister for Health introduced this “appalling extra burden” as has been suggested by the Opposition? Did he get any satisfaction from it? From my experience of a local authority since 1955 and knowing what took place under the previous Government, I can only say that the Minister for Health has been very mild in his increases and in his suggestions for obtaining increased revenue.
I did not hear the previous speakers but none of the speakers on the Opposition side recall that it is not so long ago—about a year and two months ago, I think—since the previous Minister for Health, Deputy O'Higgins, sent an ultimatum to every local authority in the State under which increased charges had to be borne by the ratepayers. We all know that hitherto the deficiency in the case of voluntary hospitals, for example, was made up by payment from the Hospitals' Trust Fund. I do not argue the wisdom or otherwise of Deputy O'Higgins' decision, when he was Minister, to inform the local authorities that such a source of revenue would no longer be available to them.
If my recollection is correct, and I think it is, this put a very heavy burden indeed on local authorities because they had to meet these extra charges in connection with the voluntary hospitals, which hitherto had their deficits met by the Hospitals'  Trust Fund. Now, these deficits have to be met by the local authority, the Limerick Corporation or the Cork County Council or whatever body it may be. We have heard very little about that very heavy impost on local authorities. We heard very little objection made by the Opposition when they were in Government and very little objection from the Labour Party.
This is a relatively small point, perhaps, but is it appreciated that, until Deputy O'Higgins became Minister for Health, the contribution to the B.C.G. vaccine scheme from the Exchequer was 50 per cent.? Deputy O'Higgins, in his wisdom, decided that he would scrap that and place the entire burden on the local authorities. There is no doubt but that the time has come at which both the ratepayers and the taxpayers have reached the limit of their capacity to pay. I have come to the conclusion that both members of this House and members of local authorities, possibly a relatively small proportion of them, are to a certain extent to blame for excessive health costs. When we, believing we are doing a good turn or obliging a constituent, recommend to the county or city manager that preferential or lenient treatment should be meted out to a particular individual in alleviation of his hospital bill, it is time that we shook ourselves up a bit and realised the snowball effect these representations are having in increasing State expenditure and the cost of local administration.
Only the other day I had occasion to lose my temper with a certain individual. He had a comparatively small bill of £37 from a hospital and he wanted to get it scrapped and have his treatment for nothing. That man's valuation was £158. It is all very well to say that he was automatically debarred but what worries me is the mentality of these people; evidently it is people like me, and others, who have been encouraging such individuals to look for a cut in the bill. That seems to be the normal thing to-day. It seems to have become accepted practice for members of local authorities to make  representations automatically to the health authority on behalf of so-and-so to have his bill for maintenance or specialist treatment reduced.
In the light of experience gained, the Health Act does, in my humble opinion, require revision. Back in 1952 when Deputy Dr. Ryan was introducing the Health Bill originally he said, in so many words, that amendment might be necessary in the light of experience gained. We have now reached that point and the health system of the State should now be reviewed constructively to the possible betterment of the financial position and with a view to more efficient working.
At one time I advocated a system of fixed income charges in relation to those who would benefit under certain sections. In this legislation we are amending a sub-section of Section 15. I realise that when the city or county manager adjudges each case on its merits, he cannot be tied to a hard and fast rule. It must be remembered, too, that circumstances vary considerably throughout the State and the cost of living can vary considerably in different constituencies. Some land is more productive than other land. Valuations may be identical but the yield and the output may not necessarily be the same at all and, therefore, it is very difficult to make a hard and fast rule.
The Minister has a difficult task before him. We have had to listen to the gross hypocrisy expounded by the Opposition; as usual, “the scurrilous Deputy MacEntee,” Minister for Health, is coming in here to take a lash at the poor unfortunate people. The people are sufficiently well educated and they have sufficient intelligence to appreciate the true facts when they are presented to them in a lucid mnaner. All the shouting and all the screaming of the Opposition about these relatively reasonable amendments will achieve little.
It is true the charges are being increased from 6/- per day to 10/- per day. I stressed the point that this is purely permissive and there may not be even five cases in one year—there may be 50 cases—in which the county  or city manager will levy the maximum rate of 10/- per day. The number of cases will be relatively small. It is left to the discretion of the county or city manager. It is both reasonable and just that, if a person can afford to pay, he should be made pay.
There is a dangerous mentality growing up to-day. Everyone wants something for nothing. Everyone wants something from the State. Everyone wants something without doing anything to earn it or without having any right to it. It is quite obvious that if that mentality gains ground there will be very little hope for the future. If that mentality is allowed to persist, then the sooner we chuck in making plans for the future of the nation the better, because we shall find ourselves building on a faulty foundation, in the pretence that everything in the garden is lovely: “I have no responsibility because the State will do this, that and the other for me. If I make representations to so-and-so he will get me a cut in the bill”.
I think this amendment is a reasonable one. Many county managers and city managers have expressed concern at the fact that in certain cases there was a statutory limitation on charging two guineas per week to people who were well able to afford it. This relatively simple amendment introduced by the Minister will enable the Minister for Health to alleviate hardship on other sections of the lower income group. The cost of the health services is rising annually and if the Minister for Health closed his eyes to the position God knows where it would end. This measure now shows he is actively aware of the acute position which exists. I am very reluctant to criticise or begrudge any professional success or fees, but the amount of fees earned by some doctors operating under the health scheme is one of the contributing causes to the high cost of health services to the State to-day.
It may not be generally realised that a dispensary doctor is far better off than any comparable professional man. I wonder if the public realise that a dispensary doctor is paid £1,000 a year and also gets free medicines and free drugs of the most expensive type,  perhaps. We know how expensive are these medicines, which are, so to speak, coming on the market now and being encouraged, the most modern types of medicine. The local authorities pay these doctors about £1,000 a year and supply them with free drugs.
Mr. O'Malley: No, Sir. With respect, I am replying to some of the suggestions of Deputy Dr. Browne and some members of the Opposition in regard to why the Minister had to bring in this “cruel measure” increasing the charge from 6/- to 10/- a day. I am reciting very briefly the contributory factors to the cost of health services and I am saying it will have to end. We must “cop ourselves on” or someone will have to “cop themselves on.”
Having got the £1,000 a year and the free drugs, I wonder if the people know—I did not, in my abysmal ignorance, know it until a few weeks ago—that these doctors can then also indulge in private practice? That is correct.
Mr. O'Malley: ——how free drugs can be advantageous—to be grammatical—to a dispensary doctor. They are so, simply because there is nothing to prevent—and here is where the abuse comes in—a dispensary doctor attending his private patients as he is entitled to do, and—I do not say he is entitled to do this—using free drugs supplied by the local authority, for the simple reason that if Deputy Dillon goes to look for the register to discover how these free drugs are utilised he will find to his horror and amazement that no register is kept.
Mr. O'Malley: There are no allegations, as such. These are statements of fact, and no statements are being made against people outside this House who cannot defend themselves. The statements I am making here are as a result of legislation enacted here——
Mr. O'Malley: I would not blame them in the least for looking a little glum when they have to listen to totally irrelevant interruptions by Deputy Dillon, who has been put in here to interrupt me until Deputy Cosgrave finishes his lunch. That is sticking out.
Before I was thrown off my track of thought, I had shown that we (a) inherited the position here on the 20th March last in which a line had been drawn for health expenditure for the future and where a policy had been initiated in the Department of Health  to prevent the whole matter of health expenditure going haywire. I had shown (b) that the previous Minister for Health, who, with his colleagues, is now so critical of the increase from 6/- to 10/- a day, came along and cut out the payment of the deficit from the Hospitals' Trust Fund to voluntary hospitals, with the result that that was thrown on to the local authorities and, of course, in the final analysis, the State had to find a contribution as well.
I have shown (c) that the cost of the B.C.G. schemes added to the burden. After all, Section 15 was debated in this House in July, 1952, I think. Even though it is called the Health Act, 1953, it was a Health Bill in 1952. Wages, salaries, costs of medicine, costs of food, coal, light and every conceivable thing have increased substantially since then. That has been added to, of course, by the imposition of a Coalition Government attempting to administer services in which they had no belief and no heart.
I thought some of the suggestions—I do not cast any aspersions on the Chair's ruling or position—would have been more relevant on the Estimate for the Department of Health. Here, we are just dealing with some specific points and I think, in the short time I have been speaking, I have shown in no uncertain manner that the Minister for Health has done an excellent job by explaining here very clearly the appalling burden which he inherited. It gives confidence to the public to know that he has at least come to the realisation that something must be done somewhere to cut down the ever increasing spiral of cost.
I also say, as I said earlier, that the whole workings of the health system now require reinvestigation. There is one very hard-hit section of the community—the Labour Party members might listen to me on this—and that is the lower income group. At the present time a medical card is issued to a member of the lower income group on the basis of his circumstances at the date of his application. That can mean that a man who is unemployed on Monday would be issued with a medical card and might get  work on the following Wednesday and work for the other 11 months and three weeks——
Mr. O'Malley: I am not criticising the measure; I am offering constructive criticism because, as a result of the position which I am describing, there are people who suffer. There are people who, through ignorance, may apply when they are working or people who have a good income, who are turned down and who subsequently may become unemployed and are not aware that they can reapply in their changed circumstances. Members of local authorities know that.
There is one very serious matter which the Minister might consider. It might be more relevant on the Estimate. People who have not a medical card are often faced, out of the blue, with an expensive type of medicine. The health authority, taking into consideration the circumstances of the person at the time of his application, may disallow it. The illness from which the applicant is suffering might be a very expensive illness, the cost of which the applicant would be unable to bear. I suggest that some provision should be made for such a case.
Mr. Kyne: Following immediately on Deputy O'Malley and having heard his amazing statement that it is his belief that dispensary doctors pilfer drugs supplied to them for use in the treatment of those in receipt of a medical card and use those drugs on private patients, I feel it necessary to say that, as far as my constituency is concerned—and I speak only for that constituency—and as far as the dispensary doctors in that constituency are concerned, I am quite sure that there is no truth in that allegation. Of other places I have no knowledge. Perhaps Deputy O'Malley knows what he is saying but, on behalf of the dispensary doctors in my area, who give excellent service to the poor and to the ordinary working man, I feel it necessary to say that I would find it very difficult to believe that they would stoop to the trick of depriving the people entitled to these drugs and using them on patients who pay them.
 I do not intend to delay the House on this Bill. Everything that could be said has been said. If the Minister is correct in stating that only a small number will be affected and that there will be so small a saving, I am amazed that he went to the trouble of introducing the Bill at all. I can be forgiven if I have a doubt as to the smallness of the number and the smallness of the amount of money that will be saved. The figure of 17,000 quoted by the Minister appears to me to be ridiculous. As Deputy Corish has said, that would apply to a single constituency. I understand that in Waterford there is probably the highest medical card issue in Ireland. Even with that high rate of medical card issue, I believe the middle income group would amount to 60 per cent. of the entire population of the country. A figure of 17,000 seems to me a most unreal figure but perhaps the Minister has a reason for giving that figure.
To me the Bill means a demand that the working man, either for himself or for his dependent, will have to pay £1 8s. per week increased contribution in the case of illness. I have heard a Minister, if not the present Minister, say in this House, that at no time was a direction given by the Minister as to who should get a health card and who should not. That may be so. No definite amount has been fixed but it is well known to those who serve on local authorities that a scale of charges has been fixed by somebody, that, in a rural area, a single man who earns £4 10s. per week does not get a medical card. For a married man, 10/- is added and for each child under 16 or 14 years of age a further 7/6 may be added. There are charges fixed, if not by the Minister, certainly by the Managers' Association. There is a comprehensive rule on which it is based. This Bill means that a single man earning £4 10s. a week in rural Ireland, instead of having to pay 6/- per day for hospitalisation, will have to pay 10/- per day. The issue of medical cards, while decided by the manager in conjunction with the medical officer of health, is really a function of the home assistance officer who investigates the case. It is on  his say-so almost entirely that the decision is made.
A point that I would make is that in the case of a single man earning £4 10s. per week, or a married man earning £5 a week, in a rural community, that wage stops when the man is ill as a general rule. There are some good employers who continue to pay while their employee is ill. When his wages stop, the man is back to £2 10s. national health.
Mr. Kyne: I was just going to explain, if I had got an opportunity. Five pounds per week is not sufficient to enable a man to build up a reserve so that when he gets ill and his income is reduced he has a fund out of which he can pay even the 6/- per day, not to mention the 10/- per day, for either himself or his dependent. It would be more understandable if a proposal were made that some increased charge should be made in the case of a dependent but where a wage-earner is ill, in consequence of which his income is immediately reduced to whatever he is entitled to under his insurance scheme, it is amazing that he should now be called on to pay 66? per cent. over and above what he formerly would have to pay.
It is quite true, as has been indicated by the Minister, that this is a maximum payment but we are all well aware that the maximum payment becomes the minimum. I pride myself on the fact that County Waterford has as decent a medical service and as decent a county manager as any other county. I know of no case, unless a case where a prolonged illness could be proved, where a fee less than 6/- per day has been charged and I am sure that in future nothing less than 10/- per day will be charged for any illness not of a very prolonged nature. There are very few illnesses requiring specialist attention that will not require at least one extra specialist visit. There may be a number of visits required. The increase in that case to an ordinary worker in respect of a dependent will be £1 8s. plus 7/6, plus, perhaps,  3/- for the first specialist visit and a number of 2/- for subsequent visits, all added to the former 2 guineas per week.
I consider that as an attempt to balance the Budget at the expense of the people who can least afford to pay. I agree in the main with the case made by Deputy Dr. Browne. I do not think I could quarrel very much with him on many of the views he expressed on the means test and on the question of attendance by doctors on patients and the difficulties that lack of money might create for patients. I disagree completely however, with his suggestion that there should be a free-for-all medical service. The Labour Party has always advocated, and does so now, a contributory medical service scheme.
Deputy Dr. Browne pointed out that tuberculosis and other infectious diseases have disappeared. That is so. The reason should be obvious. Because of the danger to the community, people suffering from infectious diseases are induced to avail of the services. The Labour Party has always advocated and does so now that while a man is working and is in receipt of wages he should be required to pay, in proportion to the amount of his wages, a contribution, either in the form of stamps or in some other form, so that when he or some dependent of his falls ill he will be able to avail of a free medical service. This proposal is based somewhat on the Chinese system of paying the doctor to keep you well. We feel that while people are able to work they should contribute towards their treatment when they become ill later.
Mr. MacEntee: Perhaps I should begin with Deputy Dr. Browne's contribution. He takes issue with this Bill on the general principle that health services should be free for everybody—not only for the poor people who are unable to provide for themselves when illness or disease strikes them, but also for persons who might be described as rich and wealthy. I think that is a very broad statement though correct in the main of Deputy Dr. Browne's position. The  reason he gives in support of that position is rather a striking one. He contends that because you pay in hospitals you get better care and treatment than if you did not pay. I think that is a fair summary of the argument he uses to support his view that there should be a free-for-all medical service.
In the first place, I do not think it is true that people who do not pay, whether in dispensaries or hospitals, are not treated as well as they would be if they were in a position to pay. If Deputy Dr. Browne's contention were true in that respect, if he maintains that everybody should receive equality of treatment on a certain scale or standard, it would not mean that we would have a better medical service. The logical conclusion to be drawn from his argument would not be that we would have better medical services but that whatever services we have, whether good or bad, would have the outstanding merit, in his eyes, of being free to all.
I think it is much more rational to take the view that those who can afford to contribute to the cost of our medical services, those who can contribute towards the cost of their own treatment and that of their dependents, should be asked to do so, so that the State and the local authorities would be in a better position to provide better services for everybody—for those who can contribute to their maintenance and for those, the larger section of the community, who cannot afford to pay anything. That is the difference between Deputy Dr. Browne and myself in regard to the health services.
Broadly speaking, I do not think anybody who does not require it should be given anything for nothing. It is interesting to find Deputies, who during the Budget debate said that we should not give increased children's allowances in a general way, now changing their attitude and saying we should provide free medical services for all. Deputy Dr. Browne was good enough to quote from a speech which I delivered in 1950 in regard to the Mother and Child Services. There is nothing inconsistent between what I said then and my action in introducing this Bill  to-day, because there is nothing in this Bill which in any way affects the Mother and Child Services. I felt very strongly then, as I do now, that we should make Mother and Child Services available to everybody provided we can do it equitably and fairly. When I saw what the consequences were likely to be of an undue extension of free services, I said in 1951, when Deputy Dr. Browne was fighting his election campaign in my constituency and I was questioned whether I believed in a Mother and Child Scheme free of charge, that I should like to see that if it were possible but that the practical circumstances would not permit it to be done in fairness and justice. I said I would prefer to have a Mother and Child Service operated in some form than not to have one operating at all. My experience has compelled me to the view that I do not believe in a completely universal free Mother and Child Service except to the limited extent it is available in our present health legislation.
It was suggested by a number of Deputies that this is a mean and petty Bill, that the amount involved was only £180,000 as Deputy Dr. Esmonde correctly pointed out. This is one of the efforts being made, not merely in my Department but in every other Department, towards lessening the burden of future expenditure upon the community as a whole. It is because of the fact that there is a statutory limit fixed to the charges which may be made under Section 15 of the Health Act that this Bill had to be presented to amend the Health Act. We are determined to save, if we possibly can, at least £3,500,000 in addition to the other economies which were set out by the Minister for Finance in his Budget statement. This is part of the campaign to fit the burden of the State services fairly to the backs of the people and to allow the mass of the people who in general have to pay a pretty large proportion of the cost of these services, some relief by asking those who can afford to contribute something in return for what they are getting, to make that contribution.
Deputy Corish expressed the view, and Deputy Kyne followed him, that  there must be some understatement in the figure of 17,000 which I mentioned. There may be an understatement but it is not a very significant understatement. It is the best estimate we can make and I think that both Deputy Corish and Deputy Kyne forgot that it is not, after all, the number of people who are in the middle income group, it is not the total number in that group, who will be affected by the provisions of this Bill, but only those who have to avail of the services. When you weed out all those who will not have to avail of the services you can see that my figure is a reasonable one and is based upon a reasonable assumption.
Deputy Corish asked me to break down certain figures which I quoted. I am not able to do that at the moment but, undoubtedly, the Deputy will be in a position to raise that matter on the Estimate and I will be glad to give him whatever information is at my disposal.
Deputy Esmonde raised a question about the method of collecting fees. I want to assure the Deputy that fees are not going to be collected in cash, certainly not by the doctors. When the Order is made it will be accompanied by regulations. The Order will be laid on the Table of the House and we will have an opportunity then of clearly setting out the charges and how they will be collected. It was suggested that they might be collected by means of stamps. The practicability of that is already being investigated. Deputy Esmonde also raised the question of accident cases and of certain other particular types of cases. Accident cases will be dealt with as emergency cases and at the outset, at any rate, there will be no question of any charge for specialist services. I do not think there will be any great difficulty arising in that connection.
I come now to Deputy O'Higgins, and I must say that I was really astonished when I heard Deputy O'Higgins contend that Fine Gael had been quite consistent in endeavouring to get health out of politics. I remember, not merely did they oppose the 1953 Act, not merely did they oppose the 1947 Act, but, going further back,  they opposed the 1946 Bill, the Health and Sanitary Services Bill, which included the main provisions of the 1947 Act. There is a consistent record of political opposition on Fine Gael's part to any attempt to improve the health services of the country. I suppose audacity is sometimes an admirable quality, but it may betray itself, when it expects that the people have such short memories that they have forgotten the attitude which Deputy O'Higgins and his Party adopted in regard to the development of health services in this country. Their attitude has been one of political opposition and, I might say so, unprincipled opposition to it. If, due to the political associations and alignments which they were compelled to make in 1948 and 1954, they have retracted their previous declarations in relation to this question, and have put certain of the health services into operation, I do not think they did so because they wanted to withdraw the question of the health of the people out of the political arena. Instead, they did it because they waned to maintain themselves in place and in power. They did what their allies compelled them to do.
I am sorry that on the first occasion on which I have to replace Deputy Tom O'Higgins on these benches, I should have had to make that statement. I would not have made it if I did not believe that the Deputy's speech was a closely woven tissue of misrepresentations of what was left behind by himself when he left office.
Mr. MacEntee: Deputy O'Higgins said—no doubt he thought it was a very good phrase—that for the first time in the history of the State money is being asked from the sick. Does Deputy O'Higgins remember the Paying Patients' Regulations? Does he remember that they required persons using local authority hospitals to pay for the cost if they could afford to do so? Does he not remember that? What is in the 1953 Act about which he is boasting? What is in Section 15 except the principle that those who can afford to pay in a hospital will be asked to pay?
Mr. MacEntee: It is impossible to argue with a man who does not know the difference between payments, who tries to draw a fine distinction between payments for services rendered and taxes. This is not a tax Bill.
Mr. MacEntee: Is the Deputy trying to induce the people to believe that, when the petrol tax went up, as it did under the Government of which the Deputy was a member, and the transport services were given permission to increase their fares accordingly by the Minister for Industry and Commerce at the time, the then Minister for Industry and Commerce was imposing a tax? He was doing nothing of the sort. There is the greatest difference in the world between a charge for a service and a tax, which is something exacted for the benefit of the community——
Mr. MacEntee: ——but not for a specific service—for the State services as a whole. There is no use in Deputy O'Higgins trying to confuse the issue by referring to this service as a tax. I am leaving that out——
Mr. MacEntee: I am sorry that the former Minister who just left the Ministry of Health should come in here and ask the people to believe that this is the first time money is being asked from the sick. Everybody who has had any association with local authority health services up to 1953 knows that, under the Paying Patients' Regulations, patients in local hospitals were required to pay what they could afford. That is the position and always has been——
Mr. MacEntee: Not to all of them. I happen to know. I was Minister for Local Government and Public Health  when these additional services were provided. They were provided simply because there happened to be a surplus in the National Health Insurance Fund at that time——
Mr. MacEntee: Deputy O'Higgins also said that every insured person was entitled to free hospital and specialist services. These services were not available to insured persons unless they satisfied certain conditions——
Mr. MacEntee: Yes, I know. Why did the Deputy not say that? That is not what the Deputy said when speaking. He knows now he is being caught, so he is mending his hand. Instead of speaking as a responsible member of the House, he spoke as if he were down at the crossroads where there would not be any person to repudiate what he was saying. Now he is mending his hand just the same as he tried to mend it in relation to the question of paying patients. It is true you require to be three years insured. You must have 156 contributions paid before you can get free hospital and specialist services——
Mr. MacEntee: I am sorry I did not hear the Deputy say they were entitled to it for six weeks. I heard him mention certain figures. He mentioned not only 400,000; he mentioned 800,000. I did not hear him say—it might be due to some defect in my hearing—six weeks. I did not hear him bring out that very important fact.
Mr. MacEntee: I did not hear the Deputy say that a certain number of insured persons, those who were three years in benefit, were entitled to hospital and specialist services for a limited period of six weeks. As I have already pointed out, they were entitled to this only so long as the funds were there to provide them. More important than anything else is the fact that these benefits applied only to the insured persons themselves and not to their dependents——
Mr. MacEntee: The insured persons themselves did receive the hospital treatment and were entitled to the specialist services, but the others were not—the dependents were not. This position is quite changed under the 1953 Act.
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