Wednesday, 24 November 1965
Dáil Eireann Debate
Under the Social Welfare (Miscellaneous Provisions) Act, 1965, which was considered in this House as a Bill towards the end of the last session, the income limit for the inclusion of non-manual workers in the social insurance scheme was raised from £800 to £1,200 a year. This increase came into effect on 6th September and, without any further legislation, it extended eligibility for certain health services to the widened class of insured persons, and their dependants. The health services concerned are those known as the “middle income group” services and include the hospital and specialist services, the maternity and infant care service and the mental treatment service.
The purpose of this Bill is to make similar changes for the other categories included in the group of persons entitled to avail themselves of these services. Under section 15 of the Health Act, 1953, as amended in 1958, persons not in insurable employment but with a family income of less than £800 a year—I will from now on refer to these as the self-employed—are entitled to the services in question. So are farmers whose land, with the buildings, is valued at £50 or less. Dependants of those in these categories are also eligible. Justice obviously demands that the change in the insurance limit should be reflected in a corresponding change in the limit for the self-employed. Hence it is proposed by section 1 of the Bill to substitute a limit of £1,200 for the present limit of £800 for the self-employed.
It is also proposed to make another change as respects the self-employed which will eliminate a disadvantage from which they suffer at present in comparison with insured persons. In calculating the yearly means of a self-employed person, there is added to his own means, not only the means of his wife but also the greater part of the means of any unmarried son or daughter living in the household. We can well understand the motive behind this provision. Sons and daughters, particularly when they have, as yet, no family commitments of their own, should in ordinary charity be expected to help their parents in providing the necessaries of life, including medical treatment. However, in practical operation, this provision has given rise to anomalies and difficulties.
In the first place, I would emphasise that it applies only to the self-employed. An insured person, as such,  is eligible for these health services, irrespective of what his unmarried sons or daughters may be earning. Thus, you could have the position where a jobbing tradesman, working on his own account in a small way, would be excluded from eligibility because he had, say, two working sons living with him while they themselves, if working under a contract of employment, would be insured and would be eligible. Secondly, while we can all agree that sons and daughters should be willing to help their parents, it must be conceded that there are often circumstances when they would find it hard to do this for understandable reasons— for example, a girl might be saving to get married, or a boy might be attending a night course to get a qualification or degree at a technical institute or university, with the expense which that involves. Looking realistically at these factors, it seemed to me that it would be only equitable to change this rule for assessing the eligibility of a self-employed person, so that the means of the unmarried sons or daughters in the household would no longer be taken into account. Accordingly, subsection (3) of section 1 makes a change in section 15 of the 1953 Act so that, in future, only the person's means and any means his wife may have will be taken into account.
When we turn to the farmers, it is not quite as simple to decide what to do to keep them reasonably in line with the insured. In 1958, when the limits for insured persons and for self-employed were raised from £600 to £800 a year, no change at all was made in the limit for the eligibility for farmers. The reason for this was that what was being done then for the other limits merely represented a rough compensation for the fall in the value of money between 1953 and 1958. A man who had £600 a year in 1953 was, roughly speaking, as well off as one with £800 a year in 1958. Therefore, the object of the change in 1958 was merely to restore the limit for eligibility in real terms to what it was originally in 1953. It was not, therefore, necessary at that time to make any change for  the farmers since a £50 valuation farm was taken as being equated to an income of £600 in 1953, and, therefore, a farm of the same valuation would obviously be equated to an income of around £800 in 1958.
This time, however, it is different. The change in the income limit for insured persons and others from £800 to £1,200 a year does more than compensate for the fall in the value of money since 1958. If we were only to make such a compensation, then the limit would merely be increased from £800 to about £1,000 a year. The change to £1,200, therefore, represents an increase in real values of about 20 per cent. In justice, therefore, a similar increase is due for the farming community. Hence it is proposed to raise the valuation limit for farmers from £50 to £60.
Deputies may ask why we should now be making a real change in the criteria for eligibility for these services when this was not done in 1958. The answer is that, between 1953 and 1958, the relevant medical costs—and, in particular, hospital costs—did not change very much. In recent years, however, costs have gone up considerably. For example, the charge in a public ward in a Dublin teaching hospital has increased from 6 guineas to £17. 10.0. a week since 1961. The reasons for these large increases in cost are complex. They reflect increases in remuneration for hospital staff, the provision of better and more complicated equipment in institutions and general improvement in the scope and quality of services, as well as increasing prices.
As a result of these increasing costs, it has become more difficult even for persons who are quite well off to budget to meet the costs of hospital treatment. The Government considered, therefore, that it would be equitable to make some adjustment so that a higher proportion of the population could use the hospital and specialist services and the other relevant services under the Health Acts. Hence, under this Bill, the limit is to be raised to £1,200 a year and the adjustment I referred to is to be made for the farmers. The  effect of all these changes will be to increase the proportion of the population entitled to avail themselves of these services from an estimated 85 per cent to something over 90 per cent. I should stress that over 90 per cent of the population are not now getting entirely free medical services. The effect of these changes will be to increase the proportion of the population entitled to avail of these services from an estimated 85 per cent to something over 90 per cent.
I would like to inform the House that I have had discussions with representatives of the Irish Medical Association and of the Medical Union on the proposals in this Bill. The Association and the Union were understandably perturbed lest the changes should adversely affect some of their members, particularly those who, as well as participating in the health authority services, have private practice in the higher income group. I pointed out that at present it is not possible to know how exactly this change might affect their members, bearing in mind that many in the group now being brought into eligibility might prefer to continue to go to hospital as private patients. This should apply particularly to those covered by voluntary health insurance. I told the deputation that if, when the picture becomes clearer, it appears that they have been adversely affected, to a substantial extent, by the change, I will not be unsympathetic towards arranging some compensation by way of adjustment of their remuneration from public funds. Whether this will be necessary, and the extent to which it will be necessary, can only become known after the changes proposed in the Bill have been in operation for some time.
In a communication received within the last few days, the Irish Medical Association has told me that it was opposed to a comprehensive medical service on the principle that the profession would be expected to give free service to individuals who are capable of making provision for themselves without significant hardship and that this opposition applies equally to the extension as now proposed. It is as well that this statement of the policy  of the Association should be on the records of the House. I agree with the views of the Association in regard to the giving of free service to those able to provide it for themselves without hardship but I disagree with them that this principle is violated by the changing of the income limits proposed in the present Bill.
This Bill will not affect the fundamental pattern of the health services. It affects only the limit for eligibility for hospital services, including mental hospital services, the specialist services and the maternity and infant care service. However, in the light of recent references in the House to a free for all comprehensive service, I think that I should emphasise that when this Bill becomes law about 90 per cent of the population will be entitled to receive, from health authorities, full hospital care in public wards and complete out-patient specialist services. All medical fees, drugs, medicines, nursing, radiology, pathology and other services for such persons in public wards are paid for by the health authority. The only payment which may be required of such a person would be by way of the charges which the health authorities may make in certain cases.
These charges may be made only on persons in the middle income group and in no case can the charge for intern treatment be higher than 10/-a day. I would emphasise that this is a maximum charge which is made only in a small proportion of all the cases where charges are made. The charge for out-patient services also applies only to the middle income group and is at the rate of 7/6 for X-rays and 2/6 for other attendances. As many Deputies will know, from their own experiences, by far the greatest financial worry that can arise in medical care is in the arrangement of hospital treatment. As I have mentioned earlier, the cost of this treatment had increased very much in recent years and it is obviously necessary that the State should organise this comprehensive service for the very high proportion of our population which is entitled to it.
Because of the fact that the income limit for insured persons in non-manual  employment has increased already and that the increase for self-employed persons proposed in the Bill has not yet come into effect, there may be some confusion on the exact definition of the groups entitled to the hospital services at present. I am afraid that, until this Bill comes into operation, some such confusion seems inevitable but, when effect is given to the Bill, I propose to arrange that local health authorities will revise their information leaflets on these services so as to have available, to members of the public, up-to-date information on eligibility, on where the services are available locally and on how to go about using them.
This Bill will not, of course, affect in any way the present law on determining eligibility for what we describe as the lower income group health services. The most important of these is, of course, the general medical services provided through district medical officers. I have mentioned that this service, and the determination of the group eligible for it will be particularly dealt with in the proposed White Paper. I mention it now merely to emphasise that, for the present, there will be no change in the existing law which states that eligibility for that service is determinable by the local health authority, in each case.
I recommend this Bill to the House for a Second Reading. I hope Deputies will agree that it makes opportune and necessary adjustments in the standards of eligibility for the services with which it is concerned. I apologise to Deputies on the opposite side of the House that I did not have copies of my speech. I hope to have them shortly.
Mr. T.J. Fitzpatrick: (Cavan): Particularly speaking, the object of this Bill appears to be to change the definition of the middle income group for the purposes of the Health and Mental Treatment Acts. I approve of the Bill. The proposal is to qualify for specialist and hospital services, etc., all people who are now insurable under the Social Welfare Acts, that is, all manual workers and non-manual  workers whose income does not exceed £1,200. That is clear and there is no problem about that.
The next category is self-employed persons. As the Minister has stated, the upper income limit there is being increased from £800 to £1,200. I agree with that, and it is clear enough. It is also proposed that in ascertaining the income of a self-employed person, the income of the person concerned together with the income of that person's spouse only will be taken into account, and the income of an unmarried son or daughter will be disregarded. That is a move in the right direction because heretofore the notional incomes of unmarried sons and daughters were calculated against the parents when in very many cases the parents were not reaping any benefit from those unmarried sons and daughters and indeed in some cases they were more a liability than an asset as regards income.
Before coming to category C, I should like to know from the Minister into which category a parent with a small income with a son on a farm with an £80 valuation will fall? Will that person—we will say a father who has transferred the farm with an £80 valuation to a son and retained an annuity of £200 a year or less—fall into category C? Or will the means of the son, the unmarried son in that case, be calculated against the parent?
Mr. T.J. Fitzpatrick: (Cavan): Because at the present time, as the Minister knows, a parent in receipt of an old age pension who is living with a married son on a farm, even a small farm, is not entitled to a health card in some counties because the means of the son are calculated against him.
Mr. T.J. Fitzpatrick: (Cavan): No. I am speaking about a health authority card. I know it does not come  within this Bill but in many counties a parent in receipt of an old age pension living with a son with a £20 valuation is not entitled to a medical card. That may be new to the Minister but it is a fact.
Mr. T.J. Fitzpatrick: (Cavan): I can assure the Minister that in some cases medical cards are issued on that basis. The next category is category C, that is, people in the opinion of the health authority, deriving their income wholly or mainly from farming. At the present time those whose poor law valuation does not exceed £50 fall within the middle income group, and the Bill proposes to increase the poor law valuation to £60. From now on farmers whose income does not exceed £60, with land and buildings, will fall within the middle income group and will be entitled to institutional and specialist services at reduced rates.
There is one thing in that definition with which I disagree. The poor law valuation which is taken into account at the present time and which will be taken into account when this Bill becomes law is not the poor law valuation of the land, which is really the earning factor, but the poor law valuation of land and buildings. I want to urge on the Minister that that provision is inequitable. It is inequitable not through the Minister's fault but because the present rating system and the present system of valuation are inequitable. It can be that a farmer with a farm with a poor law valuation, on land, of £50, with good outbuildings which were built 20 or 30 years ago but which, nevertheless, are quite substantial buildings with a poor law valuation of £9 and a total valuation of £50 will qualify for the benefits conferred by these various Acts. He has been lucky if he has got away with a small valuation on buildings. The rate collector has not drawn the attention of the county council to it and the council have not listed his buildings for valuation.
But the farmer with the same £50  valuation on land, living in the same parish, who is unfortunate or fortunate enough to add a bathroom and in some way to draw the attention of the rate collector or the county council to his house, has his buildings revalued and instead of having a £9 valuation, he has perhaps a £19 valuation, though his buildings are not in any way better and are perhaps less extensive. He could have a valuation of £19 and therefore be deprived of the benefits of these Acts, which means he has to pay through the nose for everything.
I urge on the Minister that until such time as we get a rational and equitable system of valuation for the purposes of the Rating Acts, the valuation of buildings should be disregarded. A very strong case can be made for that. As the Minister knows and as Deputies know, the valuation of land is static. It cannot be changed. It was valued under Griffiths Valuation about 100 years ago and there it stands and cannot be moved. By and large it is fair enough. However, the valuation of buildings can be changed at the whim of the rate collector whose duty it is to list buildings for valuation. In making this case, I speak from experience, from local knowledge and from general knowledge of rural Ireland. I say without fear of contradiction that there are buildings or sets of buildings throughout the country comparable in every respect and you might have a £5 valuation on one set and a £15 valuation on the other. Indeed it could be worse than that.
I presume the idea of taking the valuation of farmers into account is to try to arrive at the income of the farmers. By and large it is the land that produces the income. In certain exceptional cases buildings could produce an income. I cannot urge too strongly that a provision which takes the valuation of land and buildings into account in arriving at the means of a farmer is unjust, not so much on the ground that buildings cannot produce wealth but on the ground that there is no system whereby all comparable buildings carry the same valuation. That is the ground on which I base this argument, on which I ask the Minister to have  another look at this definition and exclude the poor law valuation of buildings in arriving at the income of farmers.
Having said that, I approve of the provisions of the Bill. We could have a long discussion on the health services on the occasion of this Bill because it proposes to provide money to run the health services. However, we had a discussion on the health services during Private Members' Time in the past couple of weeks. We have heard the Minister—I was going to say “confess”: it would be a confession if he were responsible for the state of the health services at present; as an individual he is only a short time in the office of Minister for Health—admit that the health services were totally inadequate in many respects and that such things as the health card were a joke. There is no purpose, therefore, in having another long discussion at this stage on the shortcomings of the health services, particularly as we have been promised by the Minister a White Paper before Christmas. The Minister for Agriculture last year sent a Christmas card to practically everyone in the country. I am glad the Minister for Health, on assuming office, is going one better and sending us before Christmas, as he has promised, a White Paper setting out his proposals——
Mr. T.J. Fitzpatrick: (Cavan):——to abolish the present Health Act with, as Deputy Ryan says, all its works and pomps. On that basis I shall say nothing more about the health services, past, present or future. The Bill, as far as it goes, meets with my approval and now I await the White Paper on the health services which we hope will comply with the Fine Gael policy on them.
Mr. T.J. Fitzpatrick: (Cavan): He got it at the Select Committee and his predecessor neither accepted it nor produced anything in its place and the Government, in their wisdom, got rid of the Minister's predecessor who denounced our proposals. The Fine Gael policy on health services is a comprehensive one, based on insurance.
Mr. T.J. Fitzpatrick: (Cavan): Something similar to the Minister's middle-income grouping. As I say, when we see the Minister's White Paper on health, which we hope will come before Christmas, we shall have a better opportunity of judging it.
Mr. T.J. Fitzpatrick: (Cavan): Based on insurance. That is not free. That has been our policy. It is an extension of the very successful voluntary health insurance scheme introduced by Deputy T.F. O'Higgins and  denounced by the Minister's predecessor as unworkable, but now accepted by the Minister as a huge success.
Mr. T.J. Fitzpatrick: (Cavan): Of course he got it in writing and knows all about it. He is using it bit by bit. He has promised us free choice of doctor which we have been advocating for years and which his predecessor denounced and would not have anything to do with.
Mr. T.J. Fitzpatrick: (Cavan): I am sorry, Sir, but the Minister asks questions and if I do not answer, I shall be accused of being unable to answer. I am sure we shall have an opportunity of discussing the Minister's White Paper at length. I hope it is good and something that he will implement and not something that is being introduced to stall again.
Mr. Kyne: Needless to say, the Labour Party agree with this amendment of the Health Acts. Any improvement, however small and late, in the health services is always welcomed by us because it tends to move nearer to what the Labour Party always believed we should have, a comprehensive health scheme on an insurance basis——
Mr. Kyne: —— covering all the people in the country, not 85 or 90 per cent. I find it difficult to follow the Fine Gael health scheme which is without a means test and yet eliminates 15 per cent but is free for all. The Labour Party want an absolutely comprehensive health scheme to which all citizens contribute in some form and from which all receive equal benefit. There may have to be gradings according to ability to pay, as I think I mentioned in speaking last week, but the general object of our Party is to secure a complete, free-for-all health scheme. Any improvement such as this, little and late as it may be, is still welcome.
We accept the Minister as having a new and fresh idea as compared with his predecessor. He has promised this White Paper before Christmas and the only regret I have in connection with it is that he has indicated this should be a talking point. I hope this talking point or the discussion that will arise when the White Paper is issued will not go on and on as the Select Committee on the Health Services did. We shall not take very much part in it if there is to be any attempt to delay something really happening in health services in the foreseeable future.
I accept the Minister's good will; I think he is quite sincere and I believe that if it is left to him he will produce a very much improved health scheme but I fear what the Cabinet may say. There are only two things on which I want to comment and one is the IMA view which the Minister has indicated will be in opposition. If so, people like the IMA have been met before and will be met again. While organisations of all sorts are perfectly entitled to put forward their views the will of the Irish people must come before either the IMA or any other group and I am quite sure that if the Minister needs the support of the Labour Party in fighting any group that attempts to defeat the wishes of the House, he will get that support from us.
The Minister has indicated that with this amendment some 90 per cent of our  people will be covered for hospital services. That is a pretty good figure. Is it worthwhile leaving out the other ten per cent? Have we not almost full coverage for all citizens? Why are the Government baulking at covering the last ten per cent? The IMA said they object to giving these people treatment that they could afford for themselves. The Minister also said in his statement that many of those who are not now included in the 90 per cent may not avail of the services and is it not quite true that if you cover the whole population most of the ten per cent would not avail of the services? They would want private beds, private wards and a particular type of hospital and even a particular type of doctor. If you give complete free coverage in the health services it is quite possible that the ten per cent now left out would not avail of it.
I do not believe that the voluntary health scheme is anything wonderful. I have had experience of cases in which a person had the misfortune to become sick and the voluntary health organisation refused to cover this illness in the following year. I do not think it is a very good service or that anybody can suggest that it is. If a person is unfortunate enough to get some disease that is likely to recur he will not get cover or if he does, it will be at an excessive charge. It is something like the method used by insurance companies in the case of car risks—they charge excessive premiums or in some cases refuse cover altogether. I cannot understand why the Minister has baulked at the last ten per cent when now, by his own act, he has brought coverage up to 90 per cent.
The Labour Party will vote for this but we feel that enough is not being done and we intend, within the rules of the House, to put down a number of amendments in an effort to widen the scope of the Bill.
Dr. Gibbons: I feel this Bill has arisen by virtue of the fact that a certain section of people have lost benefit as a result of increases in wages and salaries. It now appears that health is one of those aspects of our lives in  which we expect much State help and we here and those outside the House are fully aware that health is very vital, so much so, that I think it behoves every Member of the House to support the Bill.
I should like to draw the attention of the House to another section of our people which will be affected by the Bill. Numerically it is a very small section, in no way vocal, but it is a very important section and plays a very important part in the health services. I refer to the consultants of our voluntary and public hospitals and I am glad that the Minister has not forgotten them. It is not necessary to tell the House that those people receive their remuneration, first from the hospital by virtue of the hospital appointment they hold. This is subsidised by the consultant's private practice and the latter is allowed because the hospital salary is so small that they need outside income to bring their salary in some way up to what is worthy of the calling of people of their skill and experience.
Practically all of them had to leave the country to acquire this skill and experience. All of them could have stayed in the foreign countries where they worked but they returned to this country, bringing their skill and experience with them. This is one of the most patriotic things an Irishman can do—to bring back his learning, dedication and skill to this country for the benefit of its people. We as individuals appreciate this very much. Deputies, who represent all the individuals of the country, should indicate to the Minister that, if the occasion arises, we would like to show our appreciation to them. The only way we can show it is by seeing that they do not lose financially by the extension of the medical services.
There is a lot of talk about health services and the improvement of health services. From what has been going on across the channel in the past few months, I feel you are going to reach a stage in this country at which you will find you have excellent services but may have no one to run them. Anybody interested in the problem should make himself acquainted with the terms offered to the doctors in  England at present. If we have to compete with those terms, the Minister and the Department of Health will be faced with a difficult problem.
Discussions about health services remind me at times of the farmer who found his work getting difficult and decided, if he bought a horse, it would be easier. He had not much experience of dealing with horses. When he got the horse, he found it was an excellent animal but it was dear to keep. Then he decided, if he could bring the horse down to a state where he would not have to feed him, he would be getting on excellently. He gradually reduced the diet offered to the horse. He was informing the neighbours every day that the experiment was working excellently but eventually he had to confess to them that, just when the experiment was a success, the horse died.
I have a feeling that is the position we must watch. We must make sure our horse does not die when our services are developed to a certain extent. I am aware of the anxiety of the Minister to produce a workable health scheme and I feel certain he will not forget any section of the people working it and using it.
Mr. Ryan: It is unfortunate we have to wait for cycles of five or seven years to bring the various ceilings for State benefits of one kind or another into line with current money values. What we need is some more comprehensive system so that, when there is a move forward in income rates, when there may be a national wages agreement or some recognised increase in income levels, the ceilings for social benefits, unemployment insurance and health services might likewise advance automatically. We were discussing earlier today and yesterday the provisions for workmen's compensation. We have the appalling situation where we have had to wait for many years to bring the paltry £4 10s. up to something having some relationship to current wages. That should not have been allowed to develop. Likewise here we should not have to wait seven years to raise the ceiling from £800 to £1,200. Although perhaps we are making some compensation  by moving forward a step further than the money values of 1958 might require, I somehow feel that, unless we overhaul the system and have a different approach to this problem, in another five or seven years, we will be behind time once again— unless in the meantime we have the kind of health service Fine Gael have been advocating for years, notwithstanding the Minister's statement that he does not know anything about it, or so he pretends. If his predecessor removed the Fine Gael memorandum from the Custom House, I trust he will be prosecuted under the Official Secrets Act for removing what had become a State document. The Department of Health should concern themselves more with that than engaging in propaganda of an undesirable kind such as they have in some respects in recent years. Then we might get the kind of health service the country requires.
We in Fine Gael welcome some provisions of this Bill. For instance, we think it is a step forward to remove out of assessment the income which children of a family receive. We know that in practice the amount which junior members of a family hand over to the person in charge of the home is only a very small proportion of what is earned. I am glad to see a more realistic appreciation of this. As the Minister correctly pointed out in his introductory speech, we do not penalise insured persons in respect of the income of their dependants. Even if their family income should be double, treble or quadruple the insurable ceiling, we do not prohibit people from entering into or contributing to insurance by taking from the benefits of insurance. Such people are much better provided for because they are insured. Therefore, it is a step forward, even though rather late in the day, that we should not take the income of children into account in the present case.
It is fitting on an occasion such as this that we should be reminded of the tremendous increase in the cost of hospitalisation. Over a short period of four years, the cost of taking care of a person in a public ward has trebled. That  is not entirely attributable to the causes the Minister suggested. Even if it were attributable to them, it indicates how important it is to provide assistance towards meeting the cost of medical care outside of hospitals. We have one of the highest, if not the highest, hospitalisation rate in Europe. The reason is—the Minister knows this and I hope he will take cognisance of it in the preparation of his White Paper—we are putting people into hospital because it is possible under our archaic system to provide them with subsidy in respect of medical assistance received in hospital when we cannot do it outside of hospital.
The Voluntary Health Insurance scheme has been a resounding success, even though it was attacked not only by the Minister's predecessor but by the Minister and his colleagues in that Party when introduced. The Voluntary Health Insurance Board appreciate that, even under that excellent scheme, there has been a tendency to send people to hospital in order to receive some kind of assistance towards meeting medical costs, even though it might be possible to treat the people at home. But, if they had been treated at home, it would have required payment for each visit from the doctor and full payment for all drugs and medicines received. Conscientious doctors, concerned about the welfare of their patients and their ability to meet medical costs, have deliberately denied themselves the opportunity of earning money from sick people by sending them into hospital, where the money was received by other people.
As long as we maintain such a health service, we will have the same tendency. We had it in the voluntary health insurance scheme in which there has been the greatest goodwill and cooperation. The same thing is operating in our public health services and it is to be hoped that we will appreciate this and have a sensible health scheme. It is much cheaper to maintain people outside public institutions. That is common case. It is cheaper to maintain people at home and if we would provide subsidised medicines and drugs and medical care outside hospitals, we  would save the State a great deal and, at the same time, do a great service to sick people.
One would think from the Minister's presentation of the case that no levy is to be made on anybody. That is not so. It is not a question of 90 per cent of the people getting a free-for-all health service. They will be required to pay for it when they are sick and when the money is not coming in. They may have to pay less than £17.10.0 a week but they will be called on to pay 10/- a day when there is no money coming in.
Mr. Ryan: We are well aware of what such persons are required to pay. It may be that they are required to pay because there is a notional income coming in from their children but the fact is that these people are required to pay when they are sick and when their incomes are nil or are substantially reduced.
Mr. Ryan: Dublin is one of the worst areas in the country. Dublin has the smallest percentage of blue card holders in the country and you can have the case of a man whose income has been reduced from £15 a week to £5 a week being called on to pay 10/-per day while in hospital. It would not cost those people 10/- per day to live at home if they were in the full of their health but they are required to pay  that much in order to live when they are sick.
Mr. Ryan: I am concerned with the position in Dublin where the majority of insured persons are required to pay 10/- per day. It is the smaller percentage who are allowed to pay less than 10/-, if they have to pay any. If the Minister has figures for the rest of the country I would be anxious to see them. Take the case of Roscommon and Leitrim, two neighbouring counties.
Mr. Ryan: Roscommon and Leitrim are similar in wealth and the occupations of the people, but there is a tremendous difference in the percentage of blue card holders in each county. In one year the figure was three times greater in one than in the other.
Mr. Ryan: There may have been a levelling up but these figures were produced. If the Minister has not seen the Fine Gael policy on health, he would not have seen those figures in such detail but I will be glad to help him.
Mr. O'Malley: I have a note here which says that health authorities have an option to make a charge or not in any particular case and to decide on the amount of any charge made within the 10/- per day limit. It has been estimated that in a recent year no charge was made in the case of 60 per cent of people in the middle income group and that only half of those in the remaining 40 per cent were charged more than 5/- a day.
Mr. Ryan: Will the Minister now extract for me the figures for Roscommon and Leitrim and I will bow to him if I am wrong? These averages mean nothing. They are no comfort to a man who is dying and has to deny himself the necessary medical treatment because he cannot afford it. It is no comfort to him to know that on the national average more people are doing better than he is. That is the kind of thing that sickens me. We are told that various figures are not important because various averages can be extracted. They are of the greatest significance to any person suffering pain and who cannot afford necessary medical assistance. I am concerned with human beings and not with national averages or national percentages or the variations in the interpretation of the law as between  one area and another. We are concerned with human beings and all Irish men and women, as human beings, not because they belong to any county, are entitled to the best that society can give them.
I shall now deal with the question of the Minister's fundamental approach to the health service. He says he agrees with the views of the Irish Medical Association which have been expressed to him. I quote from the Minister's brief:
In a communication received within the last few days, the Irish Medical Association has told me that it was opposed to a comprehensive medical service on the principle that the profession would be expected to give free service to individuals who are capable of making provision for themselves without significant hardship and that this opposition applies equally to the extension as now proposed.
The Minister says that he agrees in principle with the Medical Association but the Minister contends that the extension that is suggested in this particular piece of legislation will not offend against that principle.
We feel that society has a clear obligation by the application of modern sophisticated techniques to collect from people who can afford to pay a reasonable contribution so that all people who are ill or injured can call upon the society to which they have made contribution to assist them when they need medical benefit. We make no apology to the Minister or the Medical Association or anybody else for that fundamental approach of ours. We do not think it is degrading, we do not think it is injuring the self-respect of individuals, to develop here a society in which all will help everybody, in which all will work together so that the weakest can have the same medical benefit as the strongest whenever the afflictions to which we all are heir come upon them.
May we emphasise that Pope John XXIII emphasised the moral obligation that rests on all societies to apply these techniques? If the Minister  wishes to take his stand with those who are opposed to the development here of a society of mutual help he will be deservedly in a minority whenever our society appreciates this obligation and does something to fulfil it.
One does not wish to extend this debate beyond the immediate purposes of this Bill except to the extent that the Minister in his opening statement may have provoked such discussion. We in Fine Gael are glad that this Bill is going as far as it does go. We wish it would go very much farther but, as it is a small step, even a tottering and unsteady step, towards the just society in which we believe, we are generally in favour of it.
Dr. O'Connell: We of the Labour Party, of course, welcome this Bill wholeheartedly. There is some confusion in the House as to what is meant by a comprehensive health service. The Labour Party mean by a comprehensive health service, which we would like to see introduced, a service which would be paid for directly out of the Exchequer. Fianna Fáil have one idea of a comprehensive health service; Fine Gael have another. We of the Labour Party say that a comprehensive health service is a health service where the full facilities of the medical services are available to everyone in the country and the charge is a direct charge on the Exchequer. That is what we understand by a comprehensive health service which, of course, as I have said, we would like to see introduced. This Bill is, in a very small way, leaning towards that. It represents an extension of the existing inadequate health service. I see that the Irish Medical Association is opposed to it.
Dr. O'Connell: I do not know what the Irish Medical Association have in mind but the Minister has said that the Irish Medical Association has told  him that it was opposed to a comprehensive medical service on the principle that the profession would be expected to give free service. The profession would never be expected to give free service.
Dr. O'Connell: They are opposed to a comprehensive medical service because the profession would be expected to give free service. In the comprehensive medical service in England, no doctor gives free service to anyone. The doctors are paid.
Mr. O'Malley: “To individuals who are capable of making provision for themselves without significant hardship”. The words “without significant hardship” are used and there is no use in putting a full stop after the word “themselves”.
Dr. O'Connell: The Irish Medical Association is opposed to a comprehensive medical service on the principle that the profession would be expected to give free service to individuals who are capable of making provision for themselves without significant hardship. If there were a comprehensive medical service in this country, the Minister would be receiving medical service.
Dr. O'Connell: The Minister would not be receiving it free from the medical profession. He would in actual fact be paying for it. I cannot see anything logical in that statement that has been quoted. An income of £1,200 per annum is not a very big income nowadays having regard to the high cost of living. Imagine a man who must go to hospital and pay £17 10s. per week  out of an income of £24 a week. It would cripple him financially. Imagine a man with two children in hospital for the removal of tonsils, as commonly happens, paying 14 guineas a week. Those who are not covered by the existing service must pay 14 guineas for a child over one month. That is why I say the extension of the income limit for the purposes of the existing health services to £1,200 a year is overdue because the cost of hospital service is prohibitive and it is impossible for the group on the fringe to provide medical services for themselves.
For years past the Voluntatry Health Insurance Board have opposed giving any benefits to persons who would like to remain at home. Their rule was that in order to avail of the service, insured persons must go into hospital. As a doctor, I fought them on this issue for three years. Now, suddenly, when they see this extension of the medical service, they rush into print and say they will offer benefits to persons who remain at home because they are afraid of losing this group who will benefit under the health services. A few years ago they told me it was impossible to do it. Now they are prepared to help out. They think they could do it now because they know that otherwise they will lose the group of people who will benefit under this extension. The voluntary health insurance scheme certainly needs overhauling.
I welcome the change in the rule for assessing eligibility of a self-employed person so that the means of unmarried sons or daughters in the household would no longer be taken into account. We have this problem arising time and again. It is not a question of what a son or daughter earns; it is what actually goes into the home that matters. This morning I went to see a patient who is in quite bad circumstances. He could not get a medical card because he has two sons working. They each contribute £2 10s. towards their keep. There is no law under which they can be compelled to pay more. It is, perhaps, unfortunate that they do not realise their responsibilities; but that is the general pattern. A son may  earn £12 per week, but that does not mean that he gives up £12 per week at home.
We approve of this provision. It is said that the Irish Medical Association is opposed to it. There are a great many general practitioners in the Association and, for my part, I cannot understand why general practitioners could be opposed to it. It will not affect them. They will not lose anything by it. Perhaps some consultants will, but then the Voluntary Health Insurance helps those. It would be too much to ask a man earning £24 a week to go privately to a surgeon and pay the cost of an operation or specialist services. I think it would be very difficult for such a man to meet an expense like that unless he had voluntary health insurance. And voluntary health insurance helps the consultant. The general medical practitioners, who form the majority in the Irish Medical Association, will not, I believe, be adversely affected by this extension.
This is a move in the right direction. We welcome it. We would wish it went a little further. I believe the Minister honestly wants a comprehensive health service, though I was inclined to think differently at one stage. I do not think a comprehensive health service would involve any tremendous charge on the Exchequer.
Mr. O'Malley: Fine Gael call an insurance scheme a comprehensive health service. When the Labour Party talk about a comprehensive health service, they mean a free-for-all. Fine Gael use the same expression——
Dr. O'Connell: We do not think insurance contributions would be sufficient to cover the comprehensive scheme we have in mind. We believe a comprehensive health service should be a direct charge on the Exchequer, as it is in Britain. I refer to the scheme introduced by Aneurin Bevan. That is the ideal. Any abuses that might arise initially could be overcome, as they have been overcome in Britain. When there is talk about dissatisfaction with the health services in Britain, it must be remembered that it is not the people who are dissatisfied. That is most important. The health services are available free to everyone in Britain. They are paid for by the Exchequer and the more you have, the more you pay. That is the way it should be. That is what we mean by a comprehensive health service. We do not think insurance contributions could pay for it. The Labour Party would never agree that insurance contributions would pay for such a service. We believe it should be a charge on the Exchequer. When we speak of a comprehensive health service, we mean a free health service for everyone.
Mr. O'Malley: I do not propose to deal with all the points raised, but there is just one matter I should like to stress. It is in reference to a point raised by both Deputy O'Connell and Deputy Ryan. The cost of hospital treatment has increased considerably,  but it should be borne in mind that, even though a man may have an income of over £1,200 a year, the charge for maintaining him in hospital can be at a substantially reduced rate. The provision is there in the 1953 Health Act, section 15 (d). There have been cases in which people over the limit have suffered very grave, and sometimes continuing, hardship from the point of view of costs. The possibility is that in the future people with £1,300, £1,400, £1,500, £1,600 a year, and maybe more, will be able to prove undue hardship under section 15 (d) which says:
Persons not specified in the foregoing paragraph who, in the opinion of the health authority, would be unable without undue hardship to provide institutional and specialist services for themselves or their dependants.
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