Wednesday, 19 February 1969
Dáil Eireann Debate
That Dáil Éireann is of opinion that the present health services do  not meet the needs of the people, and that the method of financing them is unfair in the unjust burden which it imposes on ratepayers without regard to their ability to pay, and that as a matter of urgency existing services should be replaced by a comprehensive health service based upon insurance principles and which will provide without charge, and as of right, for all people within the scheme, full medical services with choice of doctor and free hospital, specialist and diagnostic services.
Health services at the moment are financed 50/50 by the Central Fund and by local rates. Medical services outside hospital are given only to those who can establish that they are poor within the definition in the Health Act. Hospital and specialist services are only given on charges to insured people, to persons whose means do not exceed the statutory figure and to farmers up to £50 valuation. This, in effect, means that thousands of taxpayers and thousands of ratepayers who pay for present health services are excluded from all benefit.
It is against that background that the Fine Gael motion must be considered. The Fine Gael motion and Fine Gael policy have been based on a very simple, clear belief. They are based on a belief in community organised effort, tempered by the principle that the community should supplement but should never supplant individual effort. We have always rejected the idea of a scheme financed exclusively from taxation. Such a State scheme— because that is what it would be— would be inimical to human dignity and would, in any event, be unworkable. Indeed, I do not believe that any responsible person or group of people in this country today would advocate such a scheme.
Fine Gael views were put forward in  this House in some detail on a motion tabled in 1961, debated in this House some months later, in April, 1961. That is eight years ago. At that time, in absolute complete detail, a workable scheme was put forward from these Benches. The Government tabled an amendment to the Fine Gael Health Motion of eight years ago. Their amendment was designed to set up a Select Committee. This Committee, I have no doubt, had as its object to commit the whole question of health reform into the political Limbo of forgotten things. I served on that Committee as did other Deputies in the present House. I think it is not unfair for me to say that years were wasted in an absolutely disgraceful manner by the then Minister for Health in an effort to establish that there was no public demand for a reform of our health services.
After three wasted years of service on that Committee I, on behalf of my Party, eventually circulated a document indicating our proposals for a reform in general medical services in this country. It was a detailed proposal. Every facet of what we were suggesting was carefully worked out. It was circulated to the members of the Select Committee. It was based on the principles of social insurance and that, a Cheann Comhairle, was the end of the Select Committee because they dissolved. But before they dissolved the then Taoiseach came into this House and he announced that a Fianna Fáil Government would never introduce a health scheme based on social insurance. It is an extraordinary thing that the many minutes of that Select Committee, which interviewed so many people, took evidence from so many organisations, have never been published and that the Committee ended its very useless life in 1965 without ever reporting and without ever considering the detailed memorandum submitted in my name on behalf of the Fine Gael Party.
After the collapse of that Committee we were back where we had been before. Deputy Seán MacEntee, who was Minister for Health, ceased to be Minister and he was succeeded by the late Deputy Donogh O'Malley. In 1966  a White Paper on the Health Services was circulated. It is a poor document. It contains some of our ideas but it clings to the poor law mentality of the Health Act of 1953. However, it represented some slight measure of reform. It was welcomed by us in that sense, not as showing any real step forward but as indicating at least some change of attitude by the Government. There it was in 1966, published, and we were promised this legislation in the autumn of 1966. We did not get it. Then we were promised legislation in the spring of 1967. We did not get it. Then we were promised legislation in 1968. We did not get it. Then, when the Dáil was meeting in the Mansion House to commemorate the 50th Anniversary of the First Dáil, the Government with such a disgraceful record in relation to this urgent matter of social reform made a gimmick of health services by introducing the First Stage of new health legislation. We were promised that at the first meeting of this Session of the Dáil in this House the legislation would be available to us. We have not got it. Fianna Fáil have made health a political issue for so long in this country——
Mr. T.F. O'Higgins: ——I would prove that those words are rubbish coming from the Minister. On every possible occasion health is used for political purposes. The only reason we are getting some proposals now from this mountain that has been in labour, this mouse that is going to be produced in 1969, is that this is an election year. That is the only reason. In the intervening wasted years poor, indigent, helpless people have had to suffer on trying to prove that they are paupers within the Victorian definition of the Poor Relief Act of over 100 years ago, trying to get medical cards,  queuing up in hospital clinics, where they are treated like so many members of a herd of cattle, having no dignity because of the way in which our community organises health services—all because the Fianna Fáil Government have not regarded health as being sufficiently important, except in an election year, to do anything about it. I say shame on the lot of them for what they have not done. Indeed, I will reserve whatever adjective I will apply to what they now propose, depending on the faith they keep with those who have been seeking so much for so long.
The plain fact is that progressive and acceptable standards in relation to health services in a Christian country can only be obtained through a scheme based on the principles of social insurance. That is as plain as a pikestaff. There is no alternative. Fianna Fáil know it and others know it also. There is no alternative to social insurance; to try to provide otherwise is to have health standards for our small community based on and dependent on the yearly Budget and on the exigencies of local rates. At this time each year there are headlines such as “Rates increase of 8s 11d, 9/- and 10/-”. There is pruning going on. The one advance that will never be tolerated, apparently, is an advance in the way we care for those who are sick and in need. People say there are hospitals for them; let them go into hospital. But they do not have regard to the fact that many sick people can be, and should be, treated in their own homes and have proper medical care in their own surroundings. That is not provided because of the manner in which our present health legislation is financed and because of the policies behind it.
Our views are clear. They are as clear now as they were when we first raised this matter in Dáil Éireann eight years ago. There is no other course for this country to embark on. I notice that the Labour Party have tabled an amendment to the Fine Gael motion. I have read this amendment but I have not heard it explained. It appears to me to be either unnecessary or an effort to provide in this country something of which we could never be  proud—a sectional approach in relation to health services.
The Labour amendment says that they want a comprehensive health service financed by the State from taxation and graded social welfare contributions from all earning members of the community. What do these words mean? If they mean a scheme financed by contributions from the State, from employers, from employees and from the self-employed that means social insurance and that means the Fine Gael policy. If that is what the Labour Party amendment means it would have been much better for them to have said that in this instance they stand squarely and honestly behind the Fine Gael motion and policy. If it does not mean that; if the insurance contributions should come from all earning members of the community and if that means merely those who are at the present moment paying social welfare contributions, then I ask where are the Labour Party going.
Are they seeking a difference from Fine Gael in so far as they are now advocating a proposal in which a privileged community is to be set up and in which it is not proposed to include the independent small shopkeeper, the small farmer, the pensioner, the widow, the widower and people who pay no social welfare contributions but who are still members of our community? I want to know where Labour stand. It would be much better if their motion means, as I think it was intended to mean — I know what the views of Deputy Kyne are—that they are agreeing with our proposals in relation to social insurance but, if that be so, let them be men enough to say it instead of wrapping up in a mass of verbiage some difference which means nothing. Our policy is clear. It is the clearest policy in relation to this matter in this country.
Mr. T.F. O'Higgins: There would be no trouble in introducing our scheme tomorrow. If the Minister does not do it, I have little doubt that, very shortly, a Fine Gael Minister for Health will have the honour of doing  it. We have raised this matter here again in an effort to focus public attention on this urgent social need which has, in my view, become a grave political wrong. I should like to see a social insurance scheme. I believe that by establishing it we would remove health out of national controversy. That is the way it should be. We will be doing far more for the 50 years of the existence of this Dáil and this Parliament by doing something worthwhile in establishing an Irish policy in relation to health and solving the grave problems which affect our society.
Mr. Kyne: Before I begin, A Cheann Comhairle, I should like a ruling from you as to whether I am to be permitted to move the amendment tabled by my Party, because I have been informed by one of the officials that you have decided not to accept it. If you have decided to allow it, I should like to move the amendment.
An Ceann Comhairle: At this stage, Deputy Kyne, I would point out that the amendment which is referred to was received by the Chair at 3.45 p.m. this afternoon. The Standing Orders provide for two days' notice or such shorter notice as the chair may permit. In this case, the motion to which the amendment is addressed was already under debate. It had been proposed and seconded and discussed in the House. The amendment could not, therefore, be regarded as coming within the provisions I have referred to and I am sorry, therefore, that I cannot allow it to be moved.
Much of the motion moved by Fine Gael, and which is now before the House, is welcomed by the Labour  Party. Indeed, any motion to improve the health services at any time during my time in Dáil Éireann has received the support of the Labour Party. I might mention for the benefit of Fine Gael that in 1953, when the present Health Services Act—the one that we work under—was before the House as a Bill, I had the honour to represent the Party and to welcome that as an improvement upon the existing Poor Law System.
It was there, even though it covered perhaps only 30 per cent of the people. If my memory serves me right—I will leave this to the Minister as I am sure he has read up the debates—Fine Gael were not in any way enamoured with the limited improvement then being made. I agree, it was limited, it is still limited, but I am glad to see the conversion of both Fianna Fáil and Fine Gael to the Labour Party's proposal.
Mr. Kyne: I have heard and read that Deputy O'Higgins stated that he had proposed this in 1961. All right, but the Labour Party had published a health scheme in 1956 and the Fine Gael health scheme of 1961 was a facsimile of the Labour Party's scheme. I should like to know from the Fine Gael Member who will be replying to the debate if there will be any money from taxation or will it be based on contributions?
That Dáil Éireann is of opinion that the present health services do not meet the needs of the people, and that the method of financing them is unfair in the unjust burden which it imposes on ratepayers without regard to their ability to pay, and that as a matter of urgency existing services should be replaced by  a comprehensive health service based upon insurance principles and which will provide without charge...
Mr. Kyne: It is not on insurance principles. Supposing you withdraw the ratepayers' share, who will finance that? That is roughly 45 per cent of the charges at the present moment. The employers do not contribute one-third to health. You are mixed up with social welfare. I am afraid you do not understand what you are talking about.
Mr. Kyne: I have. I am talking only on the motion and on what the mover of the motion said. The Labour Party, crazy and all as we are supposed to be, know that this insurance system on its own can never finance the health scheme. I think the Labour Party are much more honourable, straightforward and knowledgeable about health problems. We realise, having gained by experience, having seen the scheme working in Great Britain, that social welfare must be dealt with first; otherwise, it is like saying illness is caused by the effect of the failure of social welfare—trying to remove the effect of something without removing the cause. For instance, if a man is ill and feels he should go on sick benefit, because of the fact that under the present social welfare system he cannot afford to go sick, he remains at work until such time as his illness forces him out of employment, which means now a prolonged illness, very often a chronic illness, that forces him into hospital for the rest of his life. We must deal with social welfare first. In the outline of  health policy which the Labour Party have published we recognise this. We agree with the first part of the motion and then we suggest the deletion of all words after “comprehensive health service” and the substitution of “financed by the State from taxation and graded social welfare contributions from all earning members of the community”. Many people not covered by social welfare contributions are earning members of the community and should be made contribute. All farmers should also be made contribute, and so should everyone else, except widows and orphans receiving State benefits or people in institutions. We want to bring anyone who earns, irrespective of who he is, within the ambit of this scheme.
Mr. Kyne: They will contribute. Anyone who pays income tax; people in receipt of earnings from a company. Everyone will contribute. If I were simply transferring it from the ratepayers to the workers, I certainly would not sponsor that. The rating system is the fairest system up to this because rates are paid on factory premises. I am afraid this motion is put in deliberately to cash in on the fact that there is this outcry against rates going up.
Mr. Kyne: I should like to know what is meant by “within the scheme”. The motion says: “... without charge, and as of right, for all people within the scheme...” Who are the people outside the scheme? Does this not lead to class distinction? Does it not lead to a means test? I suggest that what Fine Gael really mean is all the middle income group.
Mr. Kyne: Perhaps in reply some Fine Gael Deputy will tell me what is meant by “within the scheme”. Does it cover all the people or does it not? We do not believe it covers all the people. If there is any group, even ten per cent in the upper income group, outside the scheme, then there must be a means test and there will be inquisitions. In our amendment we would catch everyone, and we would enable all the people to contribute, not only those who want to take benefit. If these people in the higher income group do not want the health services and are prepared to provide special services for themselves, that is their business. In Great Britain the Queen is as much entitled to health services as the ordinary worker. I should like to see everyone in this country who earns an income or receives payment in any way contributing on an equal basis. However, we want to go further, and I should like to know whether in Deputy O'Higgins's document there is provision for a flat contribution.
Mr. Kyne: Is it a graded contribution? Certainly, in the Labour Party outline of policy we believe in the graded contribution. Maybe there is some good in the Fine Gael policy or in the Fianna Fáil policy. In the Labour Party we are mainly interested in the health services. It does not matter whether it is a Fine Gael scheme or a Fianna Fáil scheme. The important thing is the improvement of the health services to relieve the sufferings of people in any category.
Mr. Kyne: It costs £40 million at the present day. It is estimated to cost £50 million in the coming year, as I understand it from reading the newspapers. Having excluded the contribution from the ratepayers, who is going to meet it in three equal portions? How much a week will that mean on the workman in addition to the 10/or 11/-?
Mr. T.F. O'Higgins: Roughly 2s 4d. The Deputy must not ask me a question based on false premises. The cost of the individual health services is not £40 million. That is the comprehensive health service for all the people.
Mr. Kyne: The Labour Party policy has already been published except for the fact that the health services cannot be taken separately from social welfare. It is cause and effect. The effect is sickness or illness; the cause is the failure of the State to provide individual wage earners or families with sufficient money to keep them in decent  health. This is the cause of the illness. This motion does not in any way deal with social welfare. In our Labour Party outline of a health policy we realised this. Perhaps we did not do so years ago, but things have progressed and people have improved. We certainly feel this can and will be done if and when a Labour Party Government comes. I cannot see how Fine Gael can implement their scheme even if they become the Government after the next election. Perhaps, they will form a Government that will implement and finance such a scheme, but I have grave doubts whether the scheme will be financed like that. If there is anyone outside the scheme in the country who is not eligible then we must have a means test and there is discrimination.
Mr. Kyne: Quoting from an Irish Times report I see that Deputy Ryan says that Fine Gael would oppose any proposal that retained objectionable features “such as a means test and class distinction”. If 90 per cent of the people were fully cared for, there is ten per cent somewhere.
Mr. Kyne: This is the difference between the Fine Gael and the Labour policies. You say they can come in. We say they must come in. If that group of ten per cent refused to come in, that is their own business. They refuse to avail of the services. That is all right so long as they pay for the services. That is the difference between Fine Gael and ourselves on this particular policy. This effect of poor social welfare benefits which is allied to health services very closely causes more mental illness in this country than anything I know of. Mental diseases are not always hereditary. This has been  proved by some of the leading psychologists in this country. The worry of a woman because her husband is unemployed, the worry of a man because he cannot get work, the worry on him because he cannot go into hospital and such things are the causes of the overcrowding of the mental hospitals in this country. Mental illness is caused by stress and strain due to uncertainty of employment, and the knowledge of the fact that if unemployed one gets very little, just enough to keep on the bread line, just enough for bread and butter to keep one alive.
The Labour Party combine their health and social welfare policies and this is the only thing I can see as a means of ending this awful position. Like Fine Gael, we believe if this is done much of the sickness which causes hospitalisation in this country can be treated in the home. We have been laughed at for saying that medicine, drugs and prescriptions should be free. They are free in hospital so why should they not be free at home? People could be kept at home on medical prescriptions. We do not believe there should be any contribution for drugs. There is no contribution in hospital beyond the 10/- at the maximum, which varies down to very little. I heard from the Minister in a Parliamentary reply that the amount of money health authorities get in from the health services is trivial compared with the total health bill. I hope, with Deputy O'Higgins, that the long promised Health Services Bill will come in very shortly. I do not feel in any way aggrieved that the first stage of the Bill was introduced at the 50th Anniversary of the Dáil. It was very appropriate that this particular service which all support should have been mentioned there. If the Government are sincere and intend to carry it out, I feel that it is a tribute to the men of 1916 who fought for this to see that the Government are prepared to come along with this. I will await eagerly the White Paper on this. I give every man the benefit of believing he has the best intentions until proved otherwise.
Mr. Kyne: Or a year ago. We had no intention of cashing in on the health policy in this election year. Our policy has been in existence since 1956 and there have been many elections since then. I would recommend to the Minister and to Fine Gael to come as near as possible to our health and social welfare policy. We will all be in agreement then and give the people the service they deserve.
Mr. S.D. Barrett: I respect Deputy Kyne as I respect few Members of this House. It pains and amuses me in a tragic sort of way when I find the Labour Party coming in here trying to excuse themselves for not voting for this motion. Let us read it. Let Deputy Kyne and Deputy O'Connell read it. What one line of this motion is objectionable? We ask Deputy O'Connell and Deputy Kyne to subscribe to this. We and they are of the opinion that the health services do not meet the needs of the people. The motion reads:—
That Dáil Éireann is of opinion that the present health services do not meet the needs of the people, and that the method of financing them is unfair in the unjust burden which it imposes on ratepayers without regard to their ability to pay, and that as a matter of urgency existing services should be replaced by a comprehensive health service based upon insurance principles and which will provide without charge, and as of right, for all people within the scheme, full medical services with choice of doctor and free hospital, specialist and diagnostic services.
I am quite certain that the Labour Party were fully in favour of this motion until a recent change came over the spirit of their dreams. This motion—Deputy Kyne should read it —has been on the Order Paper of this House since January, 1968. Any Party who came along at 4 o'clock today to put in an amendment to this venerable motion is, therefore, at least under obligation to tell the House why, during the past 12 months, they were happy to sit there without raising their voices, without putting in an alternative motion, without putting in an  amendment. They are under obligation to explain this sudden spurt of activity by the Labour Party. Does it mean that Labour, even at the cost of the people on whose behalf we are pleading, are ready to indicate their absolute independence of all other Parties in the House?
Does it matter to the Labour Party whether this comprehensive health service should be implemented? We are simply asking them, as they had not the wit or the wisdom to put in an amendment or an alternative motion to the one to which we subscribe, in the name of the Irish people, on behalf of the deserving classes in the country, to vote for this motion.
If they do not do so they will be impugned at the bar of public opinion to which they have access at the moment—the opinion of the very people for whom we are pleading. I can tell Deputy Kyne that as a result of recent developments in his Party, the support of these people is dwindling— the people who subscribed to them at the polls. I say to Deputy Kyne that if his Party go on record as voting against this motion or abstaining from voting, they will suffer at the polls, and rightly so. I hope and devoutly wish that they will.
I appeal to Deputy Kyne and to those who sit with him to subscribe to the motion. There is nothing else they can do. There are two clear courses they can follow—to vote against the motion or to vote for it.
Mr. S.D. Barrett: I should be glad if Deputy Kyne on behalf of Labour would give one good reason, not to this House but to those who put them in Dáil Éireann, why they should abstain from voting for this motion. I should be glad if he would explain why they were apparently satisfied with this motion until 4 o'clock this afternoon; if he would explain why, up to that time today, the motion was quite satisfactory from the point of view of Labour. The motion states that the present health services do not meet the needs of the people. Nobody outside  Fianna Fáil could disagree with that. The Labour Party agreed with it. The motion states that the method of financing the health services is unfair in the unjust burden which it imposes on the ratepayers. Though Deputy Kyne may be happy that the present rating system is fair and equitable, I do not subscribe to it. I say that it is the most unfair and inequitable thing we have at the moment. It is not based on a person's earnings, his income, or anything else of that kind. It is based on a purely unimaginative system of putting a poor law valuation on a house, and whether the occupant of that house is a millionaire or a broken-down widow, the rates have to be paid no matter what the status is of the occupant. I do not know why Deputy Kyne should consider that the present rating system——
Mr. S.D. Barrett: ——the widow and the man of small means, the man who is living on small dividends. Many of them are actually penurised by the rates impost. This is unfair and I ask Deputy Kyne and his Party to subscribe to that, which is the exact proposal enshrined in our motion. In case Deputy Kyne is in any doubt whatsoever about it, implicit in the motion is that the fund for the health services will be met in the proportion of one-third from the employer, one-third from the employee and one-third from the State.
If Deputy Kyne were to show the interest he should show in the reasonable proposals now being put by the main Opposition Party in the Oireachtas in regard to health, he would reaslise—he should, and I am quite sure he does—that that is implicit in our proposals, that that undertaking is given unequivocally on behalf of our  Party. I challenge Deputy Kyne, I challenge the Labour Party not to vote for the motion. I challenge them to sit there and to say that it is not worth voting for, that it is wrong and should not be subscribed to. If they do so, in my submission—it is difficult to say what I want to say—it is indicative of the depth of weakness to which Labour have sunk in their new policy of dissociating themselves from any other Party in the State in the hope that some day they will become the Government. They will not become the Government by opposing decent, sensible motions like this. For these reasons they should change their minds. They know there is no sense in their amendment, which is useless subterfuge. Let them therefore do the decent, gentlemanly and generous thing and vote for the motion.
Minister for Health (Mr. S. Flanagan): First of all, I should like to thank Deputy Kyne for restoring the debate to the floor of the House and for taking it away from the realms of unreality into which it had been put by Deputy O'Higgins. Deputy Kyne mentioned stresses and strains resulting in people becoming psychiatric patients. Some of us, I am afraid, will soon become psychiatric patients under the stress and the strain of trying to find out what in reality is Fine Gael's policy in regard to health.
Mr. S. Flanagan: How will Fine Gael policy in regard to health be financed? Will they articulate for the benefit of the ordinary people of the country, of whom Deputy Barrett spoke, exactly how the Fine Gael health scheme will be financed? Indeed, I shall go further and say that it was a disappointing experience for me to listen to two of the best orators in the House, Deputies Ryan and O'Higgins, quite failing to come to grips with the problem of financing our health services, contenting themselves with florid statements about Fianna Fáil health legislation and about the alleged fact that it is a throw-back to the days of poor law relief.
 If it is, there were Governments here from 1923 to 1932, from 1948 to 1951 and from 1954 to 1957, in the last of which Deputy O'Higgins was a member as Minister for Health, and they had plenty of opportunity of altering the system which they now subject to poppycock obloquy. I had a rapid glance back to the debate of 1962 during Deputy O'Higgins' speech and for one thing he mentioned that a total of 800,000 people would have to be excluded from the ambit of the insurance scheme, being farmers under £15 valuation and——
Mr. S. Flanagan: ——other people in the poorer classes who could not be expected to contribute anything to the insurance scheme. The figure he gave was 800,000, although he made it clear that this was not necessarily the full total of people who would have to be excluded from any contribution to the insurance scheme. He said tonight, and I believe that this is in line with what he said previously, that the method of financing would be as to one part, anyway, from the taxpayer, but last night Deputy Ryan said that there should be created a social fund free of competition with any other money being found by the Minister for Finance. I hope that this accurately represents what Deputy Ryan did say, that this in effect should be an inviolate social fund devoted to health service only and that it should not be in competition with the other demands on the taxpayer. This is the note of what Deputy Ryan said. If that is the case it is a different thing from the scheme envisaged by Deputy O'Higgins. Tonight Deputy O'Higgins said that it would be a graduated contribution, whereas in his submission to the Health Council some time ago, he said it should be a flat-rate contribution.
Mr. T.F. O'Higgins: No, the Minister is misreading. Surely that is not so. I was referring to medical services and I contemplate there would be a graduated contribution in relation to the self-employed.
Mr. S. Flanagan: Well, then. “I think that the weekly contribution of  1/9d per week would be required from each employed person and from his employer and a weekly contribution of 2/- per week from all farmers and other self-employed” and that appears to me——
Mr. S. Flanagan: “May be necessary,” but basically this was a flat contribution. All I want to say about this is, while I have to sit here listening to abuse of Fianna Fáil because Fianna Fáil are still operating what is regarded as an unjust system that makes paupers of the people, that is all very well until Deputy O'Higgins and Deputy Ryan are in a position to make up their minds as to who is going to be involved in their scheme; whether or not, as Deputy Kyne asks, there is to be a means test and is it going to be a means test to distinguish the jet set from anybody else. If the jet set are to be included there has to be a means test. Would Fine Gael tell us now, would they accept the opportunity of their right to reply on this debate to say clearly, who is going to be excluded from the range of their scheme——
Mr. S. Flanagan: ——and who is going to be included? Obviously we have found out that a minimum of 800,000 of the poor and other classes will be excluded from any contribution towards the scheme. I am not against the insurance principle and I have made this clear before and if Deputy O'Higgins and Deputy Ryan say that this is not in line with what Deputy MacEntee said when he was Minister for Health that is all right with me; like Deputies in the Labour Party we  do not necessarily have the same attitude, each of us, and we do not have to have. As far as I am concerned I have no doctrinaire objection towards an insurance scheme.
Mr. S. Flanagan: I had the question of insurance examined in recent months by an inter-departmenttal committee and, unfortunately, insurance as such, within the real meaning of that word, simply does not present an easy, comprehensive solution to the problems with which we are presented in financing health services. To turn insurance in the comprehensive way suggested would involve a fundamental departure from the principle on which our health services are based——
Mr. S. Flanagan: ——which may be summarised that those who can afford to pay the taxation needed to finance the health services do so, and those who need to use the different services have entitlement to do so without regard to their taxability. However, neither Deputy Ryan nor Deputy O'Higgins, nor for that matter any other member of the Fine Gael Party, has ever gone deeply into the question of what insurance, within the real meaning of that word implies. Insurance, for one thing, implies that where the risk insured against matures the benefits contracted for are available to those who have paid the required premiums but people—and this is very important—who have not paid the premiums must themselves bear all the cost if the risk matures for them.
Mr. S. Flanagan: The normal concept of insurance in most cases also involves a limit to the liability of the insurer. Again, the premium paid, would, under a genuine insurance  scheme, have to be, at least in a general way, related to the risk, so that a person with dependents would have to pay higher contributions than a single person.
Mr. S. Flanagan: Is this so or is it not so? I merely wish the members of the Fine Gael Party to let us know what proportion of people they envisage as being included in their insurance scheme; what proportion of people they envisage as excluded from it and what proportion of people they envisage as excluded from contributing to the scheme. Finally, would they say how much they think it would cost the contributor per week, and when they refer to periodic payments, do they mean a week or a month, or what do they mean? What system of collection do Fine Gael envisage for farmers? What system of collection do they envisage for the self-employed? Do they know what the yield of, say, one per cent on the income of people contributing will be? I can tell them that one per cent of income in the middle income group would yield a total of £5 million a year.
If one is to assume that the people Fine Gael would not have contribute to the scheme, although they would be entitled to benefit from it, would be roughly on a par with the people now described as the lower income group, then do they envisage a ten per cent levy on all income in order to finance the health services at their present level, having regard to the fact that they apparently do not wish any part of the burden to remain on the back of the ratepayer?
Mr. S. Flanagan: ——your motion says that “the method of financing them is unfair in the unjust burden which it imposes on ratepayers without  regard to their ability to pay”. Let us know from Fine Gael how much of the burden you are prepared to put on the backs of the ratepayers and of how much you propose to relieve them. The people are entitled to know. If you ask for their votes on the basis of a policy on health they are entitled to the answers to all these questions which I claim are relevant. I also claim that it is wrong for a political party to ask for votes from the people without expounding their policy and how it is to be financed. It is one thing to cash in on the outcry against rates but, in fact, in real terms the ratepayer even now is not contributing 45 per cent of the cost of the present health service because further steps in general relief of rates by way of the agricultural grant have been taken in recent years so that, at present, every holding under £20 valuation is totally derated. As the House knows, the first £20 of holdings of higher valuation is also not rateable, so that the net effect of this increase in State assistance to the cost of the health services is that, over the country as a whole, three-quarters of the total cost of the service is now met in real terms from State funds and only 25 per cent of the cost in real terms is met by the ratepayer.
I do not say that the burden of the rates falls equally on everybody. I should be the last to say so because nobody appreciates better than I do the fact that what one ratepayer may have to find can vary very much from what his neighbour may have to find. But, taking the situation as a whole, when I say that in real terms the contribution of the rates to the total cost of the health services is only 25 per cent I think I can stand over that figure.
Deputy Ryan said that at present 70 per cent of the people must pay for everything themselves. This is highly misleading, to say the least, because apart from the 32 per cent of people who are in the so-called lower income group and who are entitled to a comprehensive free health service, though not yet, admittedly, with choice of doctor, the House well knows that people in the middle-income group have to pay only a very small amount  of money for hospital or specialist services at present.
Mr. S. Flanagan: That is all right. I accept that is so. I withdraw what I said: I misunderstood the Deputy in regard to this matter. I have figures from the Household Budget Survey carried out in 1965-66 in regard to average household expenditure on a number of items. For instance, while expenditure on tobacco, cigars and cigarettes came to 26/- and a fraction of a penny, entertainment to 8.60 shillings, drink to 15/-, the total of fees to doctors, dentists, opticians, medicines, drugs, hospitals and other medical expenses came to only 7.24 shillings. When you have regard to the fact that the hardship clause operates for people who have to pay too much for drugs it is, I think, clear that no person in the middle income group need suffer hardship. As Deputy Kyne pointed out, the actual overall figure for the amount collected from, say, the parents of mentally handicapped people going to hospital—this alleged 10/- per day— comes to something very tiny. Where drugs are concerned the hardship clause is being progressively operated more and more for those concerned so that to suggest that the middle income group under the present system is not getting a fair deal is incorrect.
Deputy Ryan also mentioned the matter of payment of doctors. Here, again, there is a distinct difference between the view put forward by Deputy O'Higgins and that put forward by Deputy Ryan. Both were speaking on behalf of the Fine Gael Party. Deputy O'Higgins is on record as having said that “payment per item of service would probably be the most acceptable method to the medical profession. It has been adopted in both Australia and New Zealand but even in these countries it has its critics. In my view such a system of payment would require a large administrative machine to check abuses, would suffer from the grave defect that it would  provide no incentive to practise preventive medicine”.
Mr. S. Flanagan: That was some years ago. On the other hand, Deputy Ryan is now clearly on the side of the fee per item of service. May I say on this that basically I agree with Deputy O'Higgins's approach and I believe it would not be in the long-term interests of doctors to have to consult a long list of agreed charges? In other words, a fee per item of service would not be in the long-term interests of the doctors because they would be swamped by secretarial work and paper, not to mention that in any State where a fee per item of service operated without any contribution from the patient you would obviously need some system of administrative control. If there is anything professional people generally dislike, apart from too much paper work, it is too much administrative control.
In that connection Deputy Ryan said that in his opinion a fee per item of service would offer an incentive — human nature being what it is—to doctors to keep patients at home and to treat them there rather than have them sent to hospital, whereas a capitation service would be an inducement to them to send their patients away. May I put it this way? I hope that human nature is such that those who have taken the Hippocratic oath would be better and would have more integrity than to fail to treat at home a patient who could be treated there adequately by them instead of sending that patient to hospital. I hope this is so and that is a view I have expressed directly to representatives of the medical profession already.
The only other thing I wish to add in regard to this matter is that wherever the form of payment is on the fee per service basis as, for example, in New Zealand there is always some amount paid by the patient himself. There is no scheme of which I am aware in operation anywhere of a fee per item where there is not a direct charge on the patient, or some similar control. I think that in operating such a scheme  Deputy Ryan, if he were my successor, would find himself in serious difficulty.
Over the past few months, as the House probably knows, consultations have been taking place with representatives of the various hospitals and hospital groups in this city and elsewhere arising out of the recommendations of the Fitzgerald Report. May I take this opportunity of publicly thanking Professor Fitzgerald and each member of the council for all the work that they put into it and, indeed, for the progress that has been made since last July in laying the groundwork for the implementation in due course of the recommendations they made? I refer, obviously, mainly to the city of Dublin where these consultations have been going on continuously.
There are a few things I want to say. The impression has got abroad that it is my intention or the intention of my Department to take over the voluntary hospitals and convert them into State institutions. There is also the impression abroad that, aside from the voluntary hospitals, the Department of Health or myself is interested in exercising progressively greater control over hospitals generally.
With regard to voluntary hospitals I wish to say categorically, clearly and finally that there is no question whatsoever of the Department of Health or myself attempting to take over the voluntary hospitals and, indeed, there is no change so far as I am concerned in the basic policy laid down in the White Paper in 1966 in their regard. Any impression to the contrary that has got abroad is the result of some sort of misunderstanding but certainly does not reflect my situation or that of my Department. I hope that by saying what I have said I will put an end to speculation and rumour in this regard.
Obviously, the implementation of the Report recommendations will involve a radical change in the structure of hospital services generally in the city of Dublin. You cannot reduce the number of acute hospitals from the  present number finally to four without having considerable structural alterations in the process. All I can say is that, again, all these changes will have to be worked out only in consultation with the representatives of the hospitals and the various groups of hospitals and that no doctrinaire approach on my part or on the part of my Department will prevent that consultation from being completely successful.
With regard to the country, may I say that I am not prepared to have the recommendations of that report treated as political issues in regard to any hospital, no matter where it is and, if people try to make it a political issue, then the report will simply be, so far as the country is concerned, still another pious expression of hope?
I was interested that Deputy Ryan was so keen on the preventive aspect of medicine and I thoroughly agree with him and, indeed, would draw his attention to the fact that this has been more and more the policy of my Department in recent years and would say that, as far as we are concerned, interest in the preventive aspect of medicine will be intensified.
Whether this or, indeed, the Fine Gael scheme as suggested by Deputy Ryan would have the result of reducing very substantially the enormous number of working days—14 million, he says—which are lost through illness annually in this country is something I cannot say, although I would point out that where illness has to be certified for social welfare benefits, obviously, the patient concerned is already under medical care if the illness has to be certified.
There is one final matter. As I said at the beginning, I was thankful to Deputy Kyne for having taken a certain line in this debate, and, indeed, as far as I am concerned, my only interest and concern is that this enormous bill be met in the best possible way. Frankly, I do not believe that the present system is one which people themselves regard as putting them in the pauper class. So far as choice of doctor is concerned, this is obviously desirable, not merely from the patient's point of view but from a strictly social and human aspect; but  I do not think the average person in the country who applies for a medical card regards himself as being a pauper and Members of the House who receive letters from those who have been turned down for medical cards would, I think, agree with me that they get no such impression from their constituents.
Finally, in regard to the Labour Party health policy, I would obviously much prefer the Labour Party approach to either the Fianna Fáil or the Fine Gael appoach. When I say that I say it with this reservation, that in the present state of our economy it is unrealistic to try to have a comprehensive health service which — I hope I am not misrepresenting the Labour viewpoint —would remove entirely the ratepayers' contribution and put it all on the taxpayer to expand to 100 per cent the people entitled, as in Great Britain, to a free comprehensive service. As Deputy Kyne mentioned, the Queen is just as entitled as any of her subjects. To try to do it in the present state of our economy is, I believe, unrealistic. I believe that it will be unrealistic in the foreseeable future if only because of the fantastic direct cost on the taxpayer.
Realising this situation, we have felt all down the years and have said in the White Paper that, not merely from the point of view of realism but from other points of view, the elderly, the poor, the unemployed, people suffering from chronic illness, people living on small farms and so forth must be looked after and that the others must pay.
If only Fine Gael would have accurately articulated for the benefit of the House how their scheme would operate, then this motion would have served a considerable purpose. In the meantime, I can only say that I believe that our approach is right. I believe that, while the service is not perfect, it is good and improving and that we intend to continue to improve it under the Health Bill which will be introduced very soon.
Dr. O'Connell: I do not want to indulge in semantics over this motion but, of course, we were right in the  amendment that we proposed in so far as we were in doubt as to what Fine Gael meant when they said “a comprehensive health service based upon insurance principles”. This was very vague and ambiguous. It did not include additional funds from central taxation and we know that a comprehensive health service operating upon insurance alone would be impracticable. We are a little dubious about the phrase “which will provide without charge, and as of right, for all people within the scheme...”. To us that is very ambiguous, implying a health service which was merely an extension of the Voluntary Health Insurance Scheme. That would be utterly unacceptable to us. We want a comprehensive health service paid for from central taxation and an insurance scheme which will operate by means of graded contributions under a combined social welfare scheme.
We should not haggle over words. The main thing is that the Minister has dragged his feet for two years and has done nothing about introducing this new health scheme. This scheme, of course, merely offers a choice of doctor to 30 per cent, and only 30 per cent, of the people. It offers nothing else. The Minister has not said when this scheme will be put into operation. He promised it last year and the year before. He promised recently that the Second Stage would be taken on 18th February and he now says it will be taken in another two weeks. I believe he has no intention of bringing this scheme into operation but he wants to dangle the scheme as bait in the forthcoming election.
Dr. O'Connell: The Minister carried on negotiations with the medical profession for months, fruitless negotiations. He asked that discussions be held in private. What was the reason? He never gave any proper reason why the discussions had to be held in private. These matters concern the public and they should be discussed in public. The Minister tries to give the impression that the position in relation to the present health scheme is quite rosy.
 I can tell him it is anything but rosy. The position is really bad for those who are deprived of medical cards. One man received an increase of 8/3d and he had his medical card withdrawn. He asked, if he returned the 8/3d, could he have the medical card renewed. We all know the humiliation of people who must sit in queues in cold dispensaries. The Minister has given no indication when these dispensaries will be abolished. I think the people are wise to the position; they know Fianna Fáil will not introduce this health scheme in the foreseeable future. When will it be implemented?
Dr. O'Connell: The Minister said that a year ago. There is, too, the humiliation suffered by those who must apply for a medical card. Forms must be brought to employers for details of earnings and everyone knows they are seeking this medical card.
Dr. O'Connell: It is humiliating. It should be abolished without delay. The Minister thinks the capitation rate operates successfully in Britain. He forgets that the capitation rate operates there for the entire population. A recent study in Britain has shown that the application of the capitation rate to the equivalent group here would require a capitation rate payable in this country of five times the British rate. The Minister is trying to compare the system in Britain, which operates for the entire population, with his own system, which will operate for no more than 30 per cent of the population. He has stated it will not operate for more than 30 per cent. I think the capitation rate will encourage more and more hospitalisation since it will not be possible for doctors to operate good medicine because of the enormous demands that will be made on their time. The Minister would be well advised to make proposals which will permit of good medicine operated in ideal conditions.
I hope the Minister will implement the Fitzgerald Report in full since he is so keen to praise it. We will give every support to a comprehensive health service, financed from central funds in conjunction with graded contributions under the social welfare system from all earners in the community. This will exclude pensioners and those who have no means. We believe such a system could operate most successfully. We had doubts about the feasibility of the Fine Gael motion and the means suggested by them. If they excluded the jet set we would not approve the system. They should be included; they should pay their contribution. What they do after that is their own business. If they do not want to avail of the scheme that is their affair, but they should make their contribution like everyone else.
Mr. Dowling: There is an everincreasing demand and need for better services. Systems become out of date and need careful attention and examination in order to bring them up to date and give equality to all sections of our community and, in particular, do justice to the weaker sections. In my opinion, this motion is a cleansing  of conscience on the part of the Fine Gael Party. As a member of Dublin Health Authority and of Dublin Corporation I have seen the activities of the Fine Gael group. It is not so long ago since members of the Fine Gael Party on the Dublin Corporation sought a reduction in the health estimate——
Mr. Dowling: ——a reduction in the health estimate which would have meant we would have less money for the sick, less money for the disabled, less money for the unemployed, less money for the widows and orphans who would be looking for some of these services from the Dublin Health Authority.
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